Georgia Mueller

Population Cancer Risks Associated with Coal Mining: A Systematic Review

Background Coal is produced across 25 states and provides 42% of US energy. With production expected to increase 7.6% by 2035, proximate populations remain at risk of exposure to carcinogenic coal products such as silica dust and organic compounds. It is unclear if population exposure is associated with increased risk, or even which cancers have been studied in this regard. Methods We performed a systematic review of English-language manuscripts published since 1980 to determine if coal mining exposure was associated with increased cancer risk (incidence and mortality). Results Of 34 studies identified, 27 studied coal mining as an occupational exposure (coal miner cohort or as a retrospective risk factor) but only seven explored health effects in surrounding populations. Overall, risk assessments were reported for 20 cancer site categories, but their results and frequency varied considerably. Incidence and mortality risk assessments were: negative (no increase) for 12 sites; positive for 1 site; and discordant for 7 sites (e.g. lung, gastric). However, 10 sites had only a single study reporting incidence risk (4 sites had none), and 11 sites had only a single study reporting mortality risk (2 sites had none). The ecological study data were particularly meager, reporting assessments for only 9 sites. While mortality assessments were reported for each, 6 had only a single report and only 2 sites had reported incidence assessments. Conclusions The reported assessments are too meager, and at times contradictory, to make definitive conclusions about population cancer risk due to coal mining. However, the preponderance of this and other data support many of Hill’s criteria for causation. The paucity of data regarding population exposure and risk, the widespread geographical extent of coal mining activity, and the continuing importance of coal for US energy, warrant further studies of population exposure and risk.

Impact of County Rurality and Urologist Density on Urological Cancer Mortality in Illinois

PURPOSE The urology work force is contracting at a time when service demand is increasing due to demographic changes, especially in rural areas. We investigated the impact of rural status and urologist density on kidney and renal pelvis, bladder and prostate cancer mortality at the county level in Illinois. MATERIALS AND METHODS We stratified the 102 Illinois counties by 2003 RUCCs as urban (36, RUCCs 1 to 3) and rural (66, RUCCs 4 to 9). Area Health Resource Files were used for county demographic data and urologist density. County level age adjusted mortality rates from 1990 to 2010 were derived from National Center for Health Statistics data using SEER*Stat. We examined the associations of urological cancer mortality rates with rural status and urologist density. RESULTS Average urologist density significantly differed between rural and urban counties (1.9 vs 3.4/100,000 population, p < 0.01). The kidney and renal pelvis cancer mortality rate in rural counties was higher than in urban counties while that of prostate cancer was lower (4.9 vs 4.3 and 28.7 vs 32.2/100,000 population, respectively, each p < 0.01). Urologist density correlated with the mortality rate of kidney and renal pelvis cancer (Pearson coefficient -0.33, p < 0.01) but not with the bladder or prostate cancer mortality rate. Multiple regression analysis revealed that rurality and lower urologist density (p = 0.01 and < 0.05) were significantly associated with higher kidney and renal pelvis cancer mortality. CONCLUSIONS Rural residence and low urologist density were associated with increased kidney and renal pelvis cancer mortality on the county level in Illinois. Further expansion and testing of evidence-based telemedicine is warranted because remote technical consultation is now technologically feasible, effective, inexpensive and satisfactory to patients.

Delivering kidney cancer care in rural Central and Southern Illinois: a telemedicine approach

There is a growing body of experience and research suggesting that telemedicine (video conferencing, smart phones and online patient portals) could be the solution to addressing gaps in the provision of specialised healthcare in rural areas. The proposed role of telemedicine in providing needed services in hard to reach areas is not new. The United States Telecommunication Act of 1996 provided the initial traction for telemedicine by removing important economic and legal obstacles regarding the use of technology in healthcare delivery. This initial ruling has been supplemented by the availability of federal funding to support efforts aimed at developing telemedicine in underserved areas. In this paper, we explore one aspect of disease disparity pertinent to rural Illinois (kidney cancer incidence and mortality) and describe how we are planning to use an existing telemedicine program at Southern Illinois University School of Medicine (SIUSOM) to improve kidney cancer (Kca) care in rural Illinois. This represents an example of the possible role of telemedicine in addressing healthcare disparities in rural areas/communities and provides a description of general challenges and barriers to the implementation and maintenance of such systems.

Manuscript title: Geospatial analysis of Cancer risk and residential proximity to coal mines in Illinois

BACKGROUND Studies have indicated a population-level association between coal mining and cancer incidence and mortality, but few studies specifically examined residential proximity to this exposure using spatial analysis. We utilized a Geographic Information Systems (GIS) approach to perform spatial and statistical analyses to test two coal mining exposure variables and their associations with cancer incidence and mortality in Illinois--the fourth highest coal producing state in the United States. METHODS Data included age-adjusted county-level cancer incidence and mortality for five cancers: all malignant, lung, colorectal, breast (female) and prostate. Coal mining exposure was defined by two variables: coal production group and distance-weighted exposure. Spatial analyses were performed to identify spatial clustering. Correlation and stepwise regression analyses were performed to explore the relationship between cancer incidence and mortality and coal mining exposures. Covariates considered in regression analyses included socioeconomic deprivation, former/current smoking prevalence, race, and rurality. RESULTS Global spatial autocorrelation indicated significant spatial clustering of incidence, mortality and aggregated coal production. Distance-weighted exposure was significantly correlated with coal production group, age-adjusted all cancer incidence and age-adjusted all cancer mortality. Regression analyses indicated an association between recent coal production and colorectal cancer incidence (p=0.009) and mortality (p=0.035) and prostate cancer mortality (p=0.047). Distance weighted exposure was associated with lung cancer incidence (p=0.004) and mortality (p<0.001), and all cancer mortality (p<0.001). CONCLUSION Coal production, incidence and mortality are spatially clustered in Illinois. Exposures to coal mining were associated with elevated risk of multiple cancers, most notably lung and colorectal. The environmental impact of the mining industry is substantial, and exposure of individuals residing near coal mines to known carcinogens is plausible. Future studies are needed to further elucidate the population exposure dynamics of coal mining, and should be explored using individual-level exposures and cancer outcomes.

Intrastate Variations in Rural Cancer Risk and Incidence: An Illinois Case Study.

CONTEXT Although rural-urban cancer disparities have been explored with some depth, disparities within seemingly homogeneous rural areas have received limited attention. However, exploration of intrarural cancer incidence may have important public health implications for risk assessment, cancer control, and resource allocation. OBJECTIVE The objective of this study was to explore intrastate rural cancer risk and incidence differences within Illinois. DESIGN Illinoiss 83 rural counties were categorized into northern, central, and southern regions (IL-N, IL-C, and IL-S, respectively). Chi-square test for independence and analysis of variance calculations were performed to assess regional differences in demographic characteristics, socioeconomic deprivation, smoking history, obesity, cancer-screening adherence, and density of general practitioners. Age-adjusted incidence rates were calculated for 5 cancer categories: all cancers combined, lung, colorectal, breast (female), and prostate cancers. Unadjusted and adjusted incidence rate ratios (IRRs) were calculated to evaluate regional differences in rates for each cancer category. RESULTS Socioeconomic deprivation varied by region: 4.5%, 6.9%, and 40.6% of IL-N, IL-C, and IL-S counties, respectively (P < .001). Smoking history also significantly differed by region. Mean former/current smoking prevalence in IL-N, IL-C, and IL-S counties was 46.4%, 48.2%, and 51.4%, respectively (P = .006). In unadjusted analysis, IL-C (IRR = 1.12; 95% confidence interval [CI], 1.02-1.23) and IL-S (IRR = 1.24; 95% CI, 1.13-1.35) had increased lung cancer incidence compared with IL-N. Elevated risk remained in IL-S after adjusting for relevant factors such as smoking and socioeconomic deprivation (IRR = 1.14; 95% CI, 1.04-1.26). CONCLUSIONS Socioeconomic deprivation, health behaviors, and lung cancer incidence varied across rural regions. Our findings underscore the importance of identifying cancer risk heterogeneity, even within a state, to effectively target risk factor reduction and cancer control interventions.

The Constant Shape Parameter Assumption in Weibull Regression

ABSTRACT The usual assumption in Weibull regression is that the scale parameter is a function of the predictor variables, and the shape parameter is constant. We consider the problem of estimating parameters in the presence of a nonconstant shape parameter and the effect of assuming a constant shape parameter when it really is not constant. We consider both classical and Bayesian methods of estimation. The misspecification of a constant shape parameter can lead to a loss of power for tests regarding the slope parameters. We find that prediction intervals can be inaccurate when the shape parameter is incorrectly assumed to be constant.

MP74-06 THE PRIVATES STUDY: PAIN RATES IN VASECTOMY AND TESTING TO ENSURE STERILITY

INTRODUCTION AND OBJECTIVES: Literature on post vasectomy pain rates and complications is disparate. Also, sterility implications of the updated AUA Guidelines on post vasectomy semen analysis is not yet known. METHODS: Four year, single surgeon (TSK) retrospective review of office vasectomies. Surgical and demographic data, semen analyses (SA), and patient post-procedure clinic contacts were assessed. RESULTS: We had 303 subjects with average age 38 years and a mean follow up of 1140 days. 9% of patients called with complaints and scheduled postoperative visits. Complaints included incisional concerns (3%, 9/303), scrotal pain (3%), epididymal fullness (1%) and infection (1%). Two percent of patients required a second visit for post-vasectomy pain (PVP) and one patient (with pre-procedure pain) returned 3 times. Two per cent (5/303) refilled narcotics while 4% were prescribed NSAIDs. No patients had PVP refractory to NSAIDs. Only 62% of men provided any required post-vasectomy SA. A phone call to the office for any reason increased the likelihood that a man would provide the SA (p<0.001). Using the new AUA vasectomy guidelines, 94% would have been cleared after the first sample, 99% after the 2nd sample and 100% after the 3rd sample. CONCLUSIONS: Men undergoing vasectomy can safely be told they are at a very low risk for refractory PVP, the need for narcotic refills, and secondary procedures of any kind. Using the new AUA guidelines, only 6% of men require a second SA to ensure sterility.

Abstract A40: The “Mini-Report”: Use of CBPR to create a practical tool to address lung cancer disparities in rural communities

Community Based Participatory Research (CBPR) principles were used to build an academic-community partnership to address lung cancer disparities in the Healthy Southern Illinois Delta Network (HSIDN), which includes 7 community coalitions in the southernmost 16 counties in Illinois. These counties are rural and medically underserved, and compared to IL as a whole, experience notably higher rates of smoking (27.1% vs. 16.9%), and lung cancer incidence (87.8 vs. 72.6/100,000) and mortality (66.8 vs. 54.4/100,000). By involving community members in all aspects of the research process and data dissemination, health disparity factors are more effectively identified and addressed. Our goal was to translate epidemiological data into community-specific lung cancer and behavioral risk factor “mini-reports” which could be used at the local level for education, resource allocation, and targeted intervention development. Methods: The partnership included an academic medical institution, a governmental agency, two community partners, and the HSIDN. Three work groups formed as part of the partnership infrastructure and two were vital in the development of these mini reports. The data work group (DWG) included members from the academic and governmental agency partners and was responsible for creating the reports. The CBPR work group included academic and community partners and was invaluable in providing feedback on report content, structure and intended audience suitability. Initial draft reports were based upon input from a partnership summit and DWG discussions. Draft report feedback tools were distributed to all coalition leaders in the HSIDN to assess content, display, motivation to action, and cultural appropriateness. The partnership9s steering committee also provided feedback to refine the mini-reports for use at the community level. Results: The DWG finalized two mini reports, both of which compared coalition-specific data to IL as a whole. The first report described the local cancer burden and included cancer incidence, mortality, survival by stage, population demographics, and lung cancer risk factors (e.g. smoking rates). The second report characterized the at-risk populations (e.g. veterans, those below poverty level) within the coalitions and included smoking rates by gender, youth smoking rates, and data on the effect of statewide smoke free laws on smoking rates and attitudes. Both reports used a mix of narrative text, bullet points, graphs, tables, and graphics. Feedback from the HSIDN coalition leaders indicated the reports effectively described the cancer burden and the content, relevancy, and usefulness of the reports was appropriate. HSIDN leaders noted a wide range of future uses for these reports. Discussion: These mini-reports translated epidemiological data for use at the community level for educational and other purposes. HSIDN use the reports for development of strategic planning, input in state-required community health plans, implementation of smoke-free initiatives, and grant writing. The creation process can serve as a template for other academic-community partnerships aiming to address cancer disparities using CBPR principles. The partnership successfully developed a series of coalition level reports to describe the local lung cancer burden and characterize risk factors to help coalitions create interventions to address disparities. The process of report creation, refinement and local dissemination was successful due to engagement of all partners (academic, government and community) and utilization of their expertise to ensure the reports could be used effectively in their communities. This in turn contributes to partnership sustainability by establishing trust for future efforts. Citation Format: Georgia Mueller, Whitney Zahnd, Kyle Garner, Ruth Heitkamp, Wiley Jenkins, Michael Boehler, Diane Land, David Steward. The “Mini-Report”: Use of CBPR to create a practical tool to address lung cancer disparities in rural communities. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A40. doi:10.1158/1538-7755.DISP13-A40

Abstract B95: Barriers to completion of a free colorectal cancer screening program in a low-income population

Colorectal cancer (CRC) is the fourth most common cancer in the US. Screening is effective to prevent and detect CRC, but is underutilized in underserved populations. We assessed a free CRC screening program intended for the underserved population in central Illinois to determine what factors (demographics, medical history, risk factors, perceived barriers, rurality) prevented eligible patients from completing CRC screening. Methods: Potential participants were recruited to the Vince Demuzio Colorectal Screening Initiative via postcard mailing, media advertising and physician referral from July 2010 to June 2012. Interested participants called a toll-free number for an eligibility assessment, which required: being due for a CRC screening, age of 50-64 years, uninsured/underinsured, ≤250% of the federal poverty level, and residence in the 22 county (1 urban and 21 rural counties) catchment area. Eligible participants then completed a questionnaire via phone about their demographics, screening history, risk factors, and screening barriers, and were sent documents to sign for enrollment. Once signed documents were returned, patients chose to complete a fecal occult blood test (FOBT) or schedule a pre screening appointment and colonoscopy at 1 of 13 participating local hospitals. Analysis of 22 factors associated with screening was performed comparing residency (rural vs. urban) and screening completion (completers vs. non-completers) using Fisher9s exact tests and independent t-tests. Results: There were 352 eligible participants, and they were: 86 % white, 57% female, 90% with at least a high school education, 60 % rural and 37 % current smokers. 245 participants (69.6%) completed CRC screenings (233 colonoscopies and 12 FOBTs). Ultimately, 107 (30.4%) eligible individuals did not complete screening due to the following: unreturned enrollment documents (54), loss to follow-up or withdrawal (44), did not return FOBT card (4) or were later deemed ineligible (5). Overall, rural participants were more likely than urban to be female (66.2% vs.44.4%, p Conclusions: Despite meeting eligibility criteria, roughly a third of interested patients did not receive CRC screening. Rural NC differed from urban NC. Rural NC were more often female, white (anticipated in rural Illinois) and reported procedure discomfort as a screening barrier. However, most examined patient-related factors did not differ between groups and stratifications. Patient anecdotes indicated that more efficient processes, such as reduction in enrollment and screening steps and assistance with scheduling, may improve completion rates. Also, efforts should be made to both address gender and race differences that might impact screening in rural populations and develop better survey tools to identify screening barriers. Citation Format: Whitney Zahnd, David Steward, Wiley Jenkins, Jennifer Andoh, Georgia Mueller, Sandra Puczynski. Barriers to completion of a free colorectal cancer screening program in a low-income population. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B95. doi:10.1158/1538-7755.DISP13-B95

Abstract 2526: Coal mining and cancer risk: important gaps in public health knowledge.

Coal fueled 42% of electricity generation in the US in 2011 with >1 billion tons mined across 27 states. Considering that 33% of petroleum used in the US comes from Arab States and Venezuela, coal will remain a critical component of US energy policy with national production expected to increase 7.6% by 2035. Given the large spatial extent of coal bearing formations, substantial proportions of the population are now, with more likely to be, exposed to coal mining (CM) activities, e.g. dust from mining and processing, leachates from mine tailings, and smoke from coal combustion. While CM activities are known to release carcinogens such as crystalline silica dust, polyaromatic hydrocarbons, and trace elements (e.g. Cd, As), a systematic review of literature published since 1980 regarding resultant impacts upon cancer rates in potentially exposed populations is equivocal. Occupational studies are designed to provide data concerning the effects of acute or long term exposure. Of 11 such studies identified, 7 found an increased risk of cancer in coal miners (digestive/gastric, lung, all cancers) but 4 found no increased risk (gastric, lung, all cancers). Another 17 studies compared miners to other populations, or examined CM as a risk factor. Nine found associations between CM and increased cancer risk (bladder, gastric, larynx, lung, nasal, all cancers), but 8 found no increased risk (gastric, lung). Finally, 6 studies were identified which examined associations between CM and cancer in the general population. Three found associations between community cancer rates and CM, with those living near CM at increased risk (male colorectal, lung), 2 used spatial statistics to identify cancer clusters associated with CM (breast, lung, respiratory, all cancers), and 1 used community surveys to identify increased self-reported cancer in mining areas. While the strength of these latter studies is limited by weaknesses inherent in ecological and cross-sectional designs, evidence exists to support the biological plausibility that populations near CM activities are at increased risk. Environmental studies have shown that lignite bed leachates are associated with renal pelvic cancer and induce kidney cell culture proliferation; rodents captured from CM areas had greater DNA damage than non-exposed controls; and crystalline silica may be found in coal at high levels and released by burning. In sum, the data are too weak to conclude there is an increased risk of cancer to the general population, to identify which specific populations suffer that risk, or indicate which mitigation strategies may be effectively implemented. While prospective cohort studies might provide such data, the long lag time between exposure and cancer may preclude practicality and other measures of exposure (e.g. toenail clippings, wind patterns) and potential pre-cancerous cellular conditions (e.g. DNA methylation, histone modifications) should be investigated as interim outcomes. Citation Format: Wiley D. Jenkins, Georgia Mueller, W. Jay Christian. Coal mining and cancer risk: important gaps in public health knowledge. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2526. doi:10.1158/1538-7445.AM2013-2526