Incidence of Primary Liver Cancer in American Indians and Alaska Natives

Transcription

1 Incidence of Primary Liver Cancer in American Indians and Alaska Natives Stephanie C. Melkonian, PhD Epidemiologist Epidemiology and Applied Research Branch NAACCR Annual Conference June 21, 2017

2 Overview Liver cancer incidence in the US Cancer Disparities in AI/AN population Racial misclassification and linkage of cancer registries to Indian Health Service (IHS) patient registration database David Espey, Melissa Jim Liver Cancer Incidence in AI/AN How do liver cancer incidence rates in the AI/AN population compared to the white population? How do incidence rates vary by geographic region? Is the prevalence of behavioral risk factors correlated with liver cancer incidence rates in this population? Conclusions & Recommendations

3 Liver Cancer Etiology and Risk Factors Recent data shows highest increase of incidence rates in liver cancer HBV/HCV account for 60% of HCC cases globally Other risk factors include: Cirrhosis excessive alcohol consumption Obesity Non-alcoholic fatty liver disease (NAFLD) Diabetes Highest rates observed among AI/AN (18.7/100,000 compared to 10.3/100,000 NHW) National rates may not tell the whole story for AI/AN incidence

4 Cancer Disparities in AI/AN population Regional cancer disparities are often masked when rates are aggregated across regions and cancer type E.g. recent study showed rates of all malignant cancers in men as 487.8/100,000 in AI/AN versus 546.4/100,000 in whites Regional rates ranged from /100,000 AI/AN; /100,000 white Top 10 leading causes of cancer differ between AI/AN and white, and by region Liver cancer is a top 10 cause of cancer in all regions for AI/AN population; ranked #14 for whites

5 Indian Health Service Linkage: NPCR & SEER Race misclassification of AI/AN occurs in cancer surveillance & vital statistics databases- varies by state Alaska Northern Plains Link administrative records from IHS with records from central cancer registries CDC- National Program of Cancer Registries (NPCR) NCI- Surveillance, Epidemiology, and End Results (SEER) Pacific Coast Coast Hawaii Southwest East Identify AI/AN cases misclassified as non- Native IncludedExcluded State CHSDA* County Southern Plains *Contract Health Service Delivery Areas

6 Methods- Liver Cancer Incidence AI/AN vs white, Cancer Cases Primary liver cancer (no metastases) NPCR +SEER linked with IHS Patient Registration Databases Microscopically confirmed cases CHSDA Counties only (unless otherwise specified) Non-Hispanic White/Non-Hispanic AI/AN Statistical Analysis Age-adjusted incidence rates per 100,000 (19 age groups) 2000 US Standard population Trends estimated using joinpoint regression Incidence rates, rate ratios, 95% CIs calculated using SEER*Stat Behavioral Risk Factor Surveillance System (BRFSS) used to estimate risk factor prevalence (Overweight/Obese, smoking, diabetes, alcohol consumption, hypertension) Pearson correlation coefficients use to evaluate correlation between liver cancer incidence rates and risk factor prevalence

7 Liver Cancer Incidence Rates, CHSDA Overall liver cancer incidence rates: 11.5 (AI/AN) vs 4.8 (white) 20.4 Pacific Coast 10.3 East 8.1 Northern Plains and Southwest 5.8 East

8 Liver Cancer Incidence by Age - Rates of liver cancer were higher in AI/AN across all age groups compared to whites overall, in the Southwest and the Pacific Coast % of AI/AN liver cancer cases occur under the age of 60 (compared to 34.6% in Whites) Rates increase at younger ages for AI/AN male - Rate ratios (AI/AN: white) ranged from White female AI/AN Female White Male AI/AN Male RELIABLE TRUSTED SCIENTIFIC DCPC

9 Liver Cancer Stage and Histology 76.2 % HCC in AI/AN (69.2% in Whites) Lower percentage of localized disease in AI/AN population Percent distribution of distant disease was highest in Alaska and Southwest Rate ratios for regional disease ranged from 1.2 ( Alaska) to 4.4 (Northern Plains) Rate Ratios for distant disease ranged from 1.8 (Northern Plains) to 2.6 (Alaska)

10 Liver Cancer Incidence Trends Rate per 100, AI/AN Female White Female AI/AN Male White Male Liver cancer rates increased for both populations and genders Annual Percent Change (APC) was 5% for AI/AN; 3.6% whites Highest APC in Southern Plains (8.1%) and Pacific Coast (6.6%) APCs consistent for males and females separately

11 Liver Cancer Incidence and Prevalence of Drinking- BRFSS (AI/AN CHSDA counties) Liver cancer Incidence/100,000 Persons Pearson Correlation Coefficient =0.84 P=0.001 Pacific Coast (men) Northern Plains (men) Southwest (men) Souther Plains (men) Alaska (men) East (men) Northern Plains (women) Southwest (women) Southern Plains (women) Pacific Coast (women) Alaska (women) East (women) Percent Binge Drinking

12 Liver Cancer Incidence and Prevalence of Obesity- BRFSS (AI/AN CHSDA counties) Liver Cancer Incidence/100,000 Persons Pearson Correlation Coefficient =0.79 P=0.002 Pacific Coast (men) Northern Plains (men) East (men) Southern Plains (men) Southwest (men) Alaska (men) Northern Plains (women) Pacific Coast Southwest (women) (women) Southern Plains (women) Alaska (men) East (women) Percent Overweight/Obese

13 Limitations Efforts to reduce racial misclassification (linkage to IHS) only take into account federally recognized tribes Does not capture individuals who are not eligible for IHS services or have not previous accessed IHS services Exclusion of Hispanic individuals may disproportionately impact certain regions Phone survey data may be problematic in AI/AN populations Correlations are hypothesis generating only

14 Summary AI/AN population has higher liver cancer incidence rates than white population Highest rates in AI/AN men Substantial variation by IHS region (highest rates in Pacific Coast) AI/AN has higher risk factor burden than general population Compared to national average, AI/AN persons have 2X higher rate of HCV Higher prevalence of obesity (34% versus 23% for men, 35% versus 21% for women) Smoking prevalence is double in AI/AN population Interaction between higher rates of HBV/HCV infection and risk factors such as drinking/obesity/smoking may play a role in cirrhosis and higher liver cancer rates AI/AN individuals diagnosed with later stage disease Access to care issues in this population are both financial and geographic

15 Future Directions Focus on primary prevention, including vaccination for HBV, screening for HCV Development and promotion of culturally appropriate programs to address obesity, diabetes, tobacco use (Good Health and Wellness in Indian Country) Address issues of access to care (collaborations with Project Echo)

16 Thank You Melissa A. Jim (CDC) Study supported by CDC and IHS Brigg Reilley (Northwest Portland Area Indian Health Board) Jennifer Erdrich (Cedars-Sinai) Zahava Berkowitz (CDC) Charles Wiggins (University of New Mexico) Donald Haverkamp (CDC) Mary White (CDC) Special thanks to Brian McMahon, Brenna Simons-Petrusa and Sarah H. Nash (Artic Native Tribal Health Consortium)

17 Go to the official federal source of cancer prevention information: Follow DCPC The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.