August 2009 volume 25 number 08 Colorectal Cancer in Georgia Introduction Colorectal cancer is a collective term for cancers of the colon and rectum. Since these cancers share many common features, they are often grouped as colorectal cancer. The colon and rectum are parts of the digestive system. Together, they form a long, muscular tube called the large intestine. The colon is the first 4 to 5 feet of the large intestine and the last 4 to 5 inches is the rectum. Colorectal cancers develop slowly over a period of several years. Most of them begin as a polyp, a growth of tissue protruding into the center of the colon or rectum. Polyps are also known as adenomas. Removing the polyp early may prevent it from becoming cancerous. Over 95 percent of colorectal cancers are adenocarcinomas, which arise from cells that line the inside of the colon and the rectum. Colorectal cancer affects both men and women and often occurs in people over 50 years of age. It is the third most commonly diagnosed cancer and cause of cancer death among Georgia men and women (Table 1). The Georgia Comprehensive Cancer Registry estimates that over 3,700 new cases of colorectal cancer will be diagnosed in 2009 and about 1,300 Georgians will die from this disease. Risk factor behavior data were obtained from the Behavioral Risk Factor Surveillance System, a state-based surveillance system administered by the Georgia Department of Community Health, Division of Public Health, in collaboration with the CDC. Incidence and Mortality The overall age-adjusted colorectal cancer incidence rate, 2002-2006, in Georgia, is 49 per 100,000 for males and females combined. The overall age-adjusted colorectal cancer mortality rate, 2002-2006, is 18 per 100,000 in males and females combined. Males are 40% more likely to be diagnosed with colorectal cancer than females (age-adjusted rate 59/100,000 vs. 42/100,000) Males are 47% more likely to die of colorectal cancer than females (age-adjusted rate 22/100,000 vs.15/100,000) In Georgia and the United States (U.S.), black males are more likely than white males to be diagnosed with colorectal cancer. Similarly, black females are more likely than white females to be diagnosed with this disease (Figure 1) Black males are more likely than white males to die from colorectal cancer in Georgia and the U.S. Similarly, black females are more likely than white females to die from this disease (Figure 2) Top 5 causes of Cancer Incidence Top 5 Causes of Cancer Mortality Males Females Males Females Prostate Breast Lung & bronchus Lung & Bronchus Lung & Bronchus Lung & Bronchus Prostate Breast Colorectal Colorectal Colorectal Colorectal Bladder Uterus Pancreas Pancreas Melanoma Melanoma Leukemia Ovary Rate per 100,000 Figure 1. Age-adjusted Incidence Rate by race and sex, 2002-2006 100 Georgia 2002-2006 United States 2002-2006 69 68 50 57 58 53 52 39 43 Methods The number of cancer cases and incidence rates for the state of Georgia were obtained from the Georgia Comprehensive Cancer Registry (GCCR). The GCCR is a population-based cancer registry that includes all cancer cases diagnosed in Georgia residents since January 1, 1995. GCCR collects, analyzes, uses and disseminates data on cancer. This information is used to assist state agencies, health care providers, and Georgia citizens to monitor cancer incidence trends, plan and implement cancer control and prevention activities, develop public and professional education programs, and stimulate scientific cancer research. The number of cancer deaths and mortality rates for the state of Georgia were obtained from the Georgia Division of Public Health, Vital Records Branch. 0 Black Males White Males Black Females White Females Figure 2. Age-adjusted Mortality Rate by race and sex, 2002-2006 100 Georgia 2002-2006 United States 2002-2006 Rate per 100,000 50 30 31 0 Black Males 20 21 21 22 13 15 White Males Black Females White Females The Georgia Epidemiology Report via e-mail , see last page for details. Please visit, http://health.state.ga.us/epi/manuals/ger.asp for all current and past pdf issues of the GER. Figure 3. Rural-Urban counties, Georgia 2003 Figure 4. Age-adjusted Colorectal Cancer Incidence and Mortality Rate by Geography, Georgia, 2002-2006 Incidence 100 Males Females Rate per 100,000 50 44 33 35 24 43 35 39 27 0 Urban Black 100 Urban White Rural Black Mortality Males Females Rural White Rate per 100,000 50 30 21 21 14 3301 210 22 14 Rural-urban classification of Georgia counties is fromFtihgeuUre.S5. . Age-Specific Col0orectal Cancer Incidence and Mortality Rates by Sex, Georgia 200 Department of Agriculture, Economic Research Service. The Urban Black Urban White Rural Black Rural White classification is based on the county's population and its proximity to a metropolitan county. Figure 5. Age-Specific Colorectal Cancer IncidencMeaalnedsMortality Rates by Sex, Georgia 200 Urban vs. Rural Georgia Based on definitions from the U.S. Department of Agriculture, Georgia has 89 rural counties and 70 urban counties (Figure 3). The Georgia Comprehensive Cancer Registry further analyzed the colorectal cancer incidence and mortality by rural/urban location (Figure 4). Colorectal cancer incidence and mortality rates are significantly higher among urban black males and females than among urban white males and females Incidence and mortality rates are not significantly different between rural black males and rural white males Incidence and mortality rates are significantly higher among rural black females than among rural white females Rate per 100,000Rate per 100,000 Figu50r0e 5. Age-Specific CInocliodreenccetal CMoarntaclietyr Incidence and Mortality Rates by Sex, Georgia 2002-2006 400 373 Males 300 271 500 Incidence Mortality 217 200 Males 168 400 100 300 21 0 22 7 77 23 107 373 58 271 217 200 0-39 40-49 50-59 16680-69 70-79 80+ 107 100 77 58 21 0 22 7 23 Females 0-39 40-49 50-59 60-69 70-79 80+ Age at Diagnosis 500 In Georgia the incidence and mortality rates of colorectal cancer increase with age for both males and females (Figure 5) 400 Incidence Mortality FeFmemaaleless Rate per 100,000Rate per 100,000 The risk of being diagnosed with colorectal cancer increases 300 267 sharply between ages 50-59 years for both males and females 500 200 Incidence Mortality 194 147 Similarly, the risk of dying from colorectal cancer increases sharply between ages 50-59 years for both males and females 400 100 300 21 0 19 6 58 16 109 34 79 267 Fewer than 65 cases and 35 deaths due to colorectal cancer 200 0-39 40-49 50-59 60-69 19740-79 8104+7 occur each year in individuals less than 40 years of age 109 100 -2 - 21 0 19 6 58 16 34 79 0-39 40-49 50-59 60-69 70-79 80+ gure 6. Colorectal Cancer Five-Year Survival Rates by Sex, Race and Stage, United States, 999-2005 Figure 6. Colorectal Cancer Five-Year Survival Rates by Sex, Race and Stage, United States, 1999-2005 100 91 91 Males 65 65 70 69 Females 50 Figure 7. Percent of Adults age 50+, who ever had a Sigmoidoscopy/Colonoscopy, by Sex, Georgia 2002-2008 100 56 57 50 Percent Percent 11 12 0 All Stages Localized Regional Distant 0 Males Females 100 92859187 White Males Black Males 66 66 56 57 70 70 White Females 63 63 Black Females 50 Figure 8. Percent of Adults age 50+, who had a Fecal Occult Blood Test (FOBT) in the past 12 months, by Sex, Georgia 2002-2008 100 51 50 42 Percent Percent 11 7 13 9 0 All Stages Localized Regional Distant 0 Males Females Survival Early detection saves lives. Individuals diagnosed at an early stage (localized) have a better chance of surviving five years after diagnosis than those diagnosed at a later stage (Regional and Distant) (Figure 6). Overall, five-year survival rate is 65% for both males and females for all stages. However, when detected at a localized stage the five-year survival rate increases to 91% Overall, the five-year survival rates for white males and females (66% each) for all stages are higher than those for blacks (56% for males, 57% for females) Black males and females diagnosed at a localized stage have a lower five-year survival rate than do their white counterparts (85% and 87% vs. 92% and 91% respectively) Five-year survival rates drop significantly for all individuals when diagnosed at a distant stage Screening and Detection Treatment is more likely to be successful if colorectal cancers are detected early. Several screening tests are available to detect the disease. Most people who develop colorectal cancer do not have identifiable risk factors, and are considered to be at average risk. The American Cancer Society recommends that people at an average risk for colorectal cancer should begin screening at age 50. Screening options Tests that find polyps and cancer: Flexible Sigmoidoscopy every 5 years; Double contrast barium enema every 5 years; CT colonography (virtual colonoscopy) every 5 years; or Colonoscopy every 10 years. Tests that mainly find cancer: Fecal occult blood test every year (FOBT)* ; Fecal immunochemical test every year (FIT)*; and Stool DNA test (sDNA), interval uncertain. *For FOBT or FIT used as a screening test, the take-home multiple sample method should be used. People at increased risk of developing colorectal cancer include those with personal or family history of colorectal cancer, those with colorectal cancer symptoms, or those who already have inflammatory bowel disease or certain genetic conditions. It is recommended that people at increased risk begin screening at an earlier age; undergo screening more frequently; and receive specialized medical care (Centers for Disease Control and Prevention www.cdc.gov/pcd/issues/2008/ apr/07_0206.htm). Based on the Georgia Behavioral Risk Factor Surveillance System (BRFSS) data from 2002-2008: The overall percent of screening by sigmoidoscopy /colonoscopy is similar for both men and women 50 years of age and older (Figure 7) Among adults aged 50 years of age and older, a significantly higher percentage of males than females reported having received a Fecal Occult Blood test in the past 12 months (Figure 8) -3 - Mortality Trends The age-adjusted colorectal cancer mortality rate has been decreasing in the rate decreased by 2.2% for both black and white males the U.S. and Georgia. However, the annual average decrease is different Mortality rates among white females have been generally lower by race and sex (Figures 9 and 10). than those in black females, both in Georgia and in the U.S. FFirgoumre199.8A0geto-a2d0ju0s5t,etdhCeoUlo.Sre. ccotalloCreacntcael rcaMnocretralmityorRtaatleityamraotneg Males by RacFer,oGmeo1r9g8ia0(t1o98200-02050t6h)evcso. lUonreitcetdalSctaantecser(1m98o0r-t2a0li0t5y)rate decreased decreased at an average rate of 0.2% annually for black males and by 0.7% for U.S. black females and 2% for U.S. white females, 1.96 % for white males whereas in Georgia there was a slight increase of 0.5% among 50In Georgia from US Black Males 1980 to 2006, the US White Males colorectal cancer mortality GA BlackblMacaklefesmales aGndAdWechrietaeseMoafle1s.2% among white females rate increased at an annual average rate of 1.9% for black males 40while it decreased by 0.76% for white males Since 2000, there has been a decrease in colorectal cancer mortality among females for both U.S and Georgia (2.4% in U.S. Rate per 100,000 Since 2000, the colorectal cancer mortality rate decreased by 3% black females, 3.7% in U.S. white females vs. 3.3% in Georgia 30for U.S. black males and 3.5% for U.S. white males; in Georgia black females and 1.7% in Georgia white females) Figure 9. Age-adjusted Colorectal Cancer Mortality Rate among Males by Race, Georgia (1980-2006) vs. United States (1980-2005) 20 Figure 9. Age-adjusted Colorectal Cancer Mortality Rate among Males by Race, Georgia (1980-2006) vs. U.S. (1980-2005) 50 US Black Males US White Males GA Black Males GA White Males 10 40 0 30 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 Rate per 100,000 20 10 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 0 Figure 10. Age-adjusted Colorectal Cancer Mortality Rate among Females by Race, Georgia (1980-2006) vs. United States (1980-2005) Figure 10. Age-adjusted Colorectal Cancer Mortality Rate among Females by Race, Georgia (1980-2006) vs. U.S. (1980-2005) 50 US Black Females US White Females GA Black Females GA White Females Rate per 100,000 40 3F0igure 10. Age-adjusted Colorectal Cancer Mortality Rate among Females by Race, Georgia (1980-2006) vs. United States (1980-2005) 20 10 50 US Black Females US White Females GA Black Females GA White Females 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 Rate per 100,000 0 40 30 Definitio2n0 malignant cancer either (1) has extended beyond the limits of the organ Age-adjusted rate: A rate calculated in a manner that allows for of origin directly into surrounding organs or tissue, or (2) involves the com10parison of rates derived from populations with different age regional lymph nodes by way of lymphatic system, or (3) has both regional structures Cancer0incidence rate: The number of new cancer cases occurring extension and involvement of regional lymph nodes. Distant stage includes malignant cancer that has spread to parts of the body remote 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 in a population during a specified period of time. Often expressed per from the primary tumor either by direct extension, or by metastasis to 100,000 population distant organs or tissues, or via the lymphatic system to distant lymph Cancer mortality rate: The number of cancer deaths occurring in nodes a population during a specified period of time. Often expressed per Rural-Urban Classification: The rural urban classification of Georgia 100,000 population counties was based on the 2003 Rural-Urban Continuum Codes from the Risk factor: A behavior, characteristic, or finding on clinical United States Department of Agriculture, Economic Research Service. examination that is consistently associated with increased probability of Information about the Rural-Urban Continuum Codes can be retrieved a disease or complications from the disease from http://www.ers.usda.gov/Data/RuralUrbanContinuumCodes/ Cancer Stages: Local stage includes an invasive malignant cancer confined entirely to the organ of origin. Regional stage is where the This article was written by Deepali Rane, MBBS, MPH, Rana Bayakly, MPH, Aimee Pragle, MPH. Division of Public Health http://health.state.ga.us Please send comments to: gaepinfo@dhr.state.ga.us Rhonda M. Medows, M.D., F.A.A.F.P. Acting Director, State Health Officer Cherie Drenzek, D.V.M., M.S. Director, Acute Disease Epi Section Georgia Epidemiology Report Editorial Board Carol A. Hoban, M.P.H., Ph.D. Editor Kathryn E. Arnold, M.D. Cherie Drenzek, D.V.M., M.S. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer Two Peachtree St., N.W., Atlanta, GA 30303-3186 Phone: (404) 657-2588 | Fax: (404) 657-7517 The Georgia Epidemiology Report Epidemiology Section Two Peachtree St., NW Atlanta, GA 30303-3186 Providers can contact Public Health IMMEDIATELY 24 hours a day, 7 days a week, by calling: 1-866-PUB-HLTH (1-866-782-4584) to report immediately notifiable diseases and public health emergencies August 2009 Due to the rising costs of printing and mailing the GER to over 30,000 subscribers, we are switching to an electronic version of the GER. The electronic version will be available as a portable document format (pdf ) file on the Division of Public Health web site, http://www.health.state.ga.us/epi/manuals/ger.asp. We will send an e-mail notification to all subscribers when the monthly GER has been posted to the web site. This will enable us to continue distributing the GER to all of our subscribers. We have also created an electronic database where GER subscribers may log on to request an electronic subscription to the GER, enter their current e-mail address for the GER electronic notification, update their contact information, or cancel their electronic subscription. To access this database, please visit this website, https:// sendss.state.ga.us/ger, and follow the instructions when prompted. We look forward to continuing to provide you with important public health information in Georgia. Volume25Number08 Reported Cases of Selected Notifiable Diseases in Georgia, Profile* for May 2009 Selected Notifiable Diseases Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis Total Reported for May 2009 2009 71 3010 29 1 49 1101 6 3 7 6 6 5 0 7 0 171 65 4 65 46 57 0 31 Previous 3 Months Total Ending in May 2007 2008 2009 161 155 187 11051 11061 10743 37 72 88 2 6 5 141 137 173 4489 3963 3502 40 32 47 22 11 9 33 38 34 12 10 11 2 9 9 3 6 12 0 2 0 3 3 37 0 0 0 296 379 370 489 401 159 26 38 42 130 164 188 114 149 174 313 396 202 3 6 1 134 139 100 Previous 12 Months Total Ending in May 2007 2008 2009 587 698 724 41763 42825 42576 272 272 302 37 48 44 689 712 812 19706 17213 15648 124 137 148 69 57 45 180 169 173 49 39 48 9 19 38 18 25 26 3 2 1 28 15 61 0 0 0 1940 2051 2329 1702 1576 761 108 118 175 530 677 805 422 493 621 1075 1354 1101 9 16 8 516 478 422 * The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia. ** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis. AIDS Profile Update Report Period Latest 12 Months Disease Total Cases Reported* Classification <13yrs >=13yrs Total HIV, non-AIDS 12 2,896 2,908 Percent Female MSM 26 31 Risk Group Distribution % IDU MSM&IDU HS Unknown Perinatal White 2 1 4 62 <1 24 Race Distribution % Black Hispanic Other 71 4 <1 7/08-06/09 AIDS 1 1,692 1,693 22 34 3 1 6 57 <1 25 68 5 <1 Five Years Ago:** HIV, non-AIDS 43 2,116 2,159 31 33 10 4 12 40 <1 20 75 3 <1 07/04-06/05 AIDS 8 1,524 1,532 26 34 7 3 13 43 <1 19 76 4 <1 Cumulative: HIV, non-AIDS 226 13,796 13,908 31 29 5 2 10 54 <1 21 74 4 1 07/81-06/09 AIDS 240 34,304 34,544 20 43 14 5 14 24 <1 30 66 3 <1 Yrs - Age at diagnosis in years MSM - Men having sex with men IDU - Injection drug users HS - Heterosexual * Case totals are accumulated by date of report to the Epidemiology Section ** Due to a change in the surveillance system, case counts may be artificially low during this time period ***HIV, non-AIDS was not collected until 12/31/2003 - 4 -