Did 9/11 Cause Cancer? The Role of the State Cancer Registry in Answering the Question

Transcription

1 Did 9/11 Cause Cancer? The Role of the State Cancer Registry in Answering the Question AR Kahn, MJ Schymura, B Qiao New York State Cancer Registry NAACCR Annual Conference, Pittsburgh, PA, June 13, 2018

2 July 13, What I shall address Short background of the 9/11 attack Government Responses Public Perception of Cancer and 9/11 Health Studies New York State Cancer Registry s Role

3 3 The second tower of the World Trade Center explodes into flames after being hit by an airplane, New York September 11, 2001 with the Brooklyn Bridge in the foreground. REUTERS/Sara K. Schwittek

4 4 While New York City smoldered, thousands inhaled and swallowed hazardous debris. Huffpost 09/09/2016

5 July 13, Federal Emergency Management Agency Response to 9/11 Emergency services Over 3,400 human and 600 animal patients treated Housing assistance including temporary relocation Debris removal 115,756 tons moved to Staten Island landfill Directed ATSDR to collaborate with NYC s Department of Health and Mental Hygiene (DOHMH) on the World Trade Center Health Registry (WTCHR)

6 July 13, Chemical Exposures Aerosolized dust Asbestos, heavy metals, polycyclic aromatic hydrocarbons, polychlorinated biphenyls, polychlorinated furans, and dioxins Toxic fumes Burning jet fuel, diesel fuel Most exposures, including asbestos, did not exceed NIOSH recommended exposure limits (REL) or OSHA permissible exposure limits BUT two samples of benzene exceeded the REL Occupational Exposures to Air Contaminants at the World Trade Center Disaster Site --- New York, September--October, MMWR: May 31, 2002/51(21);453-6

7 7 However: The upper limit for the expected number of asbestosrelated cancers is less than one case over the lifetime of the population for the risk model that is specific for fibertypes.. JOEM, August 2005

8 July 13, Early WTC Worker and Volunteer Medical Screening Program Funded by NIOSH, begun July, 2002 Free medical assessments, clinical referrals, and health education Finding: new-onset or worsened respiratory symptoms: 851 had persistent symptoms E.g., wheezing, shortness of breath, congestion, sore throat, blocked ear, stuffy nose, nosebleeds Physical Health Status of World Trade Center Rescue and Recovery Workers and Volunteers - -- New York City, July August 2004.MMWR September 10, 2004/53(35);

9 July 13, First Report from New York City s World Trade Center Health Registry (WTCHR) Data collected 9/5/ /20/2004 Plan: follow 71,437 participants for 20 years Effects: injury, respiratory symptoms, heartburn, headaches, serious psychological distress, skin rash, hearing loss, stroke, anxiety or other emotional problem (ORs ) Centers for Disease Control and Prevention. Surveillance for World Trade Center disaster health effects among survivors of collapsed and damaged buildings. In: Surveillance Summaries, April 7, MMWR 2006;55(No. SS-2).

10 July 13, /11 Commission on How to Prevent Islamist Terrorism Stand as an example of moral leadership in the world our vision can offer a better future. Support for public education and economic openness Communicate American ideals in the Islamic world stronger public diplomacy

11 July 13, NYSCR Got Involved March, 2007: NYSCR invited to meeting that included three groups, WTCHR,FDNY, Mount Sinai s GRC NYSCR urged collaboration : NYSCR linked to each separate cohort multiple times Separate publications

12 July 13, Multiple Myeloma Case Series Report from Mt. Sinai Study Center 2009 Study Period: 9/11/2001 9/10/2007 Eight cases identified among respondents (6.8 expected) Four cases among persons <45 MolineJM,HerbertR,CrowleyL,etal.Multiple Myeloma in World Trade Center Responders: a case series..joccupenvironmed.2009;51(8):

13 July 13, FDNY Early results Type of Cancer Observed/Expected SIR Confidence Interval Lung 6/ * Malignant Melanoma 33/ * Prostate 73/ Bladder 11/ Thyroid 12/6 2.17* NHL 20/ Multiple Myeloma <5/ All sites 242/ Zeig-Owens R, Webber MP, Hall CB, Schwartz T, Jaber N, Weakley J, Rohan TE, Cohen HW, Derman O, Aldrich TK, Kelly K, Prezant DJ [2011]. Early Assessment of Cancer Outcomes in New York City Firefighters After the 9/11 Attacks: An Observational Cohort Study. Lancet. 378(9794):

14 July 13, MSSM GRC Early results Type of Cancer Observed/Expected SIR Confidence Interval Lung 18/ * Malignant Melanoma 12/ Prostate 82/ Bladder 15/ Thyroid 26/ * NHL 13/ Multiple Myeloma <= NA Samara Solan et al. Cancer Incidence in World Trade Center Rescue and Recovery Workers, Environmental Health Perspectives. 121(6)June, 2013.

15 July 13, WTCHR Later results Type of Cancer Observed/Expected SIR Confidence Interval Lung 42/ * Malignant Melanoma 37/ * Prostate 223/ * Bladder 30/ Thyroid 37/ * NHL 27/ Multiple Myeloma 12/ All Sites Combined 685/ * Jiehui Li, et. al. Ten-Year Cancer Incidence in Rescue/Recovery Workers and Civilians Exposed to the September 11, 2001 Terrorist Attacks on the World Trade Center. American journal of Industrial Medicine 59: , 2016.

16 July 13, James Zadroga 9/11 Health and Compensation Act of 2010 Sec. 3301: Establishment of World Trade Center Health Program Sec. 3304: Uniform data collection and analysis Sec. 3311: Identification of responders and provision of WTC-related monitoring services Sec. 3312: Treatment for WTC-related health conditions Sec. 3341: Research regarding certain health conditions related to 9/11 attacks Has been extended to cover conditions until 2090

17 17 NIOSH s World Trade Center Health Program 1. World Trade Center Health Registry (WTCHR) New York City Department of Health and Mental Hygiene 71,000+ enrollees 31,000 rescue/recovery/cleanup workers 43,000 local residents/passers-by/workers/students 2. WTC Worker and Volunteer Medical Screening Program (GRC) Mount Sinai Irving J. Selikoff Center for Occupational and Environmental Medicine 22,000+ responders 3. FDNY Responder Health Program (FDNY) Active and Retired FDNY employees who responded to the 9/11 attacks

18 July 13, Criteria for WTC-Related Health Conditions Strength of association (includes magnitude of effect and statistical significance) Consistency of findings across studies Biological gradient or dose-response relationship Biological plausibility and coherence with known facts

19 July 13, From the News Media 9/11's delayed legacy: cancer for many of the rescue workers (The Guardian, 11/11/2009) Of all the illnesses people fear might be caused by toxic dust from the World Trade Center, nothing scares people like cancer. (NBC News, 3/27/2010) 9/11 s Second Wave: Cancer and Other Diseases Linked to the 2001 Attacks Are Surging (Newsweek, 9/7/16) 5,400 diagnosed with cancers linked to September 11 attacks (CNN, 8/15/2016) 9/11 responders might be sick and not even know why (Chicago Tribune, 9/8/2016) Forgotten victims of 9/11 are developing cancer at alarming rates (The Hill, 12/07/2017)

20 July 13, Justification for Broad Cancer Coverage Due to the long latency period between exposure and cancer diagnosis for most types of cancer, many epidemiological studies of cancer associated with particular exposures are produced years after a given exposure event. Waiting for definitive, scientifically-unassailable epidemiologic results before adding types of cancer to the List would prevent treatment of currently-enrolled WTC responders and survivors. Federal Register / Vol. 77, No. 177 / Wednesday, September 12, 2012 / Rules and Regulations

21 July 13, Covered Cancers Childhood Cancers Blood and Lymphoid Digestive System Eye and Orbit Female Breast Female Reproductive Head and Neck Respiratory System Skin (MM and other) Soft Tissue Thyroid Urinary System* Mesothelioma Rare Cancers *Includes Prostate

22 July 13, It Only Took Nine Years

23 July 13, Incidence, Latency, and Survival of Cancer Following World Trade Center Exposure NIOSH Cooperative Agreement U01 OH Charles B. Hall and Paolo Boffetta, Principal Investigators James Cone (NYC DOHMH) and Maria Schymura (NYSCR), site Principal Investigators New Study will combine the three cohorts Will examine cancer incidence, latency, and survival following World Trade Center exposure

24 July 13, Selected Cancer Incidence Results Cancer site N FDNY (PY=61,884) N WTCHR (PY=41,280) N WTC GRC (PY=153,077) All sites (0.98 to 1.25) (0.99 to 1.30) (0.94 to 1.18) Lung (0.20 to 0.86) (0.35 to 1.12) (0.37 to 0.98) Melanoma (1.08 to 2.18) (0.63 to 2.43) (0.52 to 1.77) Prostate (1.20 to 1.85) (1.11 to 1.82) (0.98 to 1.53) Thyroid (1.86 to 5.08) (1.07 to 3.45) (2.04 to 4.57) NHL (1.03 to 2.42) (0.57 to 2.06) (0.45 to 1.45) Multiple Myeloma (0.56 to 3.97) (1.15 to 5.88) (N/A) Boffetta et al., 2016; based on Zeig-Owens et al., 2011; Li et al., 2012; Solan et al., 2013

25 July 13, NYSCR Role in the Study Each of the three WTC rescue/recovery cohorts will send individually identified data to New York State Cancer Registry (NYSCR). We will match the three cohorts to each other to identify duplicates and will create a deduplicated, combined dataset. We will send the combined dataset to other state cancer registries for linkage and conduct linkage to our own database. We will create a limited dataset for analyses. We will calculate person-time and SIRs, using NYSCR for the reference population. We will be involved in the interpretation of results and in manuscript preparation.

26 Raw records N=79,062 Consolidated N=69,143 July 13, Overlap of Cohorts FDNY only N=12,764 FDNY/WTCHR: 3,155 FDNY/GRC: 217 WTCHR/GRC: 6,377 FDNY/WTCHR/GRC: 85 GRC only N=26,748 WTCHR only N=19,797

27 July 13, State Cancer Registries Involved Arizona California Connecticut Florida Massachusetts New Jersey New York North Carolina Ohio Pennsylvania Texas Virginia Washington

28 July 13, Cancer Registry Matches so Far State Number of Tumors Duplicates with NY Connecticut 58 9 Massachusetts 19 1 New York 6,239 Not Applicable North Carolina Ohio 23 0 Texas 25 0 Virginia 36 3 TOTAL

29 July 13, Next Steps Send cohort file to remaining states Deduplicate the matched results Calculate person-time for each cohort member Create de-identified analytic file and provide to study centers Collaborate on analysis and results

30 30 Did 9/11 Cause* Cancer? 9/11 has, in fact, resulted in increases in some reported cancer rates in the exposed population. As the honest broker, the NYSCR provides technical and analytic support as well as the benefits of our NAACCR perspective. *It depends on what your definition of cause is.

31 July 13, One World Trade Center, seen with the Brooklyn Bridge in the foreground, stands at a patriotic 1,776 feet tall /09/11/911-fifteenheartbreaking-years-later/

32 July 13, Websites of Interest hr847enr.pdf

33 July 13, Acknowledgements This work is supported in part by the Centers for Disease Control and Prevention s National Program of Cancer Registries through cooperative agreement 6NU58DP awarded to the New York State Department of Health. This work is also supported by NIOSH and by the New York State Department of Health. The contents are solely the responsibility of the New York State Department of Health and do not necessarily represent the official views of the Centers for Disease Control and Prevention. Did 9/11 Cause Cancer? AND Thanks to You, the NAACCR Community We really are all in this together