Thyroid Cancer Investigation Update

Transcription

1 Thyroid Cancer Investigation Update Department of Environmental Quality Department of Health and Human Services NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

2 Agenda I. Partner organizations II. Overview of the NC Central Cancer Registry III. What do we know about thyroid cancer? IV. Background on cancer clusters V. Iredell County: What has been done and what have we found? VI. Next steps NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

3 Partner Organizations NC DEQ Division of Water Resources Division of Air Quality Division of Waste Management NC DHHS Central Cancer Registry Epidemiology Section Others as needed Local health departments Academic partners NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

4 Overview of the NC Central Cancer Registry (CCR) Collects data from hospitals, doctors, laboratories and death certificates Sole repository of complete cancer incidence data for the State of North Carolina Performs statewide analyses on all 27 major cancer types County-level analyses follows the recommendations of the NC Comprehensive Cancer Control Plan which includes the 5 most common cancers plus cervical cancer: Lung/bronchus, female breast, prostate, colorectal and melanoma plus cervical CCR data are routinely shared with approved research partners NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

5 Overview of the NC Central Cancer Registry (CCR) NC s CCR functions similarly to other states, and meets/exceeds national standards Member of the North American Association of Central Cancer Registries (NAACCR) Professional organization that develops and promotes uniform data standards for cancer registration NC awarded Gold Standard for the past 10 years, the highest level for complete, accurate, and timely registry data In 2018, NC was recognized by the CDC as one of 17 Registries of Excellence for achieving the highest level of data quality NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

6 What do we know about Thyroid Cancer? Thyroid cancer rates are increasing statewide, nationally, and globally NC thyroid cancer rate is 39 th in the US ( ) Papillary thyroid cancer (PTC) is the most common of all thyroid cancers Ionizing radiation is the only confirmed cause of thyroid cancer in humans NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

7 Number of Cancer Cases/Deaths per 100,000 Persons Thyroid Cancer Incidence and Death Rates United States and North Carolina, US Incidence Rates NC Death Rates Source: U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool, based on November 2017 submission data ( ): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; June 2018 NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

8 Source: U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool, based on November 2017 submission data ( ): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; June 2018 NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

9 Thyroid Cancer Screening U.S. Preventive Services Task Force recommends against screening for thyroid cancer in asymptomatic adults (Grade D: Harms outweigh benefits) Does not apply to patients with signs/symptoms that could be consistent with thyroid cancer Does not apply to persons at increased risk e.g. History of exposure to ionizing radiation Inherited genetic syndrome associated with thyroid cancer First-degree relative with a history of thyroid cancer JAMA May 9, 2017 Volume 317, Number 18 NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

10 Cancer Cluster Investigations: Challenges Environmental exposures are complex and change over time Limited/no data in cancer registries on potential exposures e.g. occupations, behaviors Residence at time of diagnosis might not reflect residence at time of potentially relevant exposures Timing of disease development Often years-decades between exposure and diagnosis Small numbers large fluctuations in rates Challenge with defining cases, drawing geographic boundaries NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

11 Cancer Cluster Investigations in the United States, Critical Reviews in Toxicology, 2012; 42(6): NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

12 Iredell County: What has been done and what have we found? In 2017, Iredell County residents and local health department requested DHHS analysis of thyroid cancer rates DHHS investigated with DEQ and drafted report summarizing: Analysis of thyroid cancer rates from cancer registry Statewide All counties Specific regions in Iredell County Review of scientific literature Examination of existing environmental monitoring data NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

13 Iredell County: What has been done and what have we found? DHHS-CCR working with health care providers to ensure complete reporting of thyroid cancer in Registry DHHS-CCR shared data for all cancers types ( ) with Duke University Researchers to inform their research. Results of this work can be used to generate hypotheses specific to environmental exposures of interest and inform further research studies DHHS shared new resource from CDC with more county level data DHHS consulting with academic and federal partners to explore possible collaboration NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

14 Incidence Rate (Number of Cancer Cases per 100,000 Persons) Iredell County: What has been done and what have we found? Rates for papillary thyroid cancer in Iredell County were comparable to NC in but higher in Southeast and Southwest for Rate of Papillary Thyroid Cancer Iredell County, Northern Iredell Central Iredell Southeastern Iredell Southwestern Iredell North Carolina NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

15 Thyroid Cancer Diagnosis Rates across North Carolina NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

16 Iredell County: What has been done and what have we found? Only ionizing radiation is clearly linked to thyroid cancer No radionuclide samples exceeded investigative action limits around the McGuire Nuclear Site No specific chemicals known to cause thyroid cancer Identified small number of chemicals (target analyte list) with potential to increase the risk of PTC Many factors can contribute to differences in rates Changes in medical practices, such as increased screening Changes in population NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

17 NC Department of Environmental Quality Provide science-based environmental stewardship for the health and prosperity of ALL North Carolinians Divisions represented here: Air Quality Water Resources Waste Management NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

18 Division of Water Quality Ensures safe drinking water by issuing pollution control permits, monitoring permit compliance, evaluating environmental water quantity and quality, and carrying out enforcement actions for violations of environmental regulations. NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

19 Water Monitoring Results DEQ s Division of Water Resources (DWR) identified 38 drinking water systems in the and zip codes in southern Iredell County: DEQ reviewed monitoring records for releases of contaminants with potential to increase the risk of thyroid cancer 31 Community Water Systems - monitor for radionuclides Drinking water systems with radionuclide MCL exceedances: 1 facility: 1 sample in 2010 with (Radium Radium-228) above the MCL 1 facility: 9 samples from with Uranium above the MCL 1 facility: 21 samples from with Uranium above the MCL The DWR also reviewed wastewater monitoring data for other permitted facilities in its programs in the and zip codes in southern Iredell County: No wastewater treatment plants or pre-treatment facilities were identified with detectable discharges of the regulated chemicals on the thyroid cancer target analyte list NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

20 Division of Air Quality Operates a statewide air quality monitoring network to measure the level of pollutants in the outdoor air, develops and implements plans to meet future air quality initiatives, assures compliance with air quality rules, and educates, informs and assists the public with regard to air quality issues such as the air quality forecast. NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

21 Air Emissions Monitoring Results DEQ s Division of Air Quality (DAQ) reviewed air emissions records in the and zip codes in southern Iredell County: 19 facilities with air emission records in those zip codes 10/19 facilities emit 2 chemicals with potential to increase the risk of thyroid cancer Benzene Formaldehyde Both are common environmental contaminants released from many sources NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

22 Division of Waste Management Ensures that underground storage tanks are managed properly, waste is handled, stored, transported and disposed of properly and that existing contamination that exceeds regulatory standards is controlled to minimize risk to people s health or the environment. NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

23 Waste Management Program Monitoring The Division of Waste Management (DWM) reviewed monitoring data for landfills and other regulated facilities under its programs in Iredell County. Inactive Hazardous Sites 36 facilities identified 1 - Benzene detected above state groundwater regulatory level Pre-regulatory Landfill (PRLF) program facilities 9 sites identified 1 - Benzene detection above state groundwater regulatory level Underground Storage Tank (UST) program 145 UST or AST incidents reported since Benzene detected above state groundwater regulatory level and remain open cleanups. NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

24 Next Steps Convene panel of state and national experts in thyroid cancer to: Include epidemiologists, clinicians, researchers, others Review existing data about thyroid cancer broadly, in Iredell and statewide Provide recommendations to state and local officials for investigation and response NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

25 Next Steps Examine thyroid cancer in other counties above the state rate Continue surveillance Monitor geographic variations over time Continue working with hospitals and clinicians to confirm reporting for all cases Collaborate with researchers and others investigating potential causes for thyroid cancer in Iredell and other counties NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

26 Next Steps Continue to review monitoring data Continue to provide data and support to others involved in this investigation With input from experts, consider expanding cancer analyses at the county level Continue outreach and communication with local and statewide stakeholders NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,

27 Questions? NCDHHS, NCDEQ Thyroid Cancer Investigation Update March 21,