Priority-Setting Data: California Specific Program Goal 06/20/14 - - PowerPoint PPT Presentation

Priority-Setting Data: California Specific Program Goal 06/20/14

Overview of 2015 Priority-Setting Process

• 1. Review the CBCRP mission statement and reaffirm the

program’s foundation of long-term outcomes.

• 2. Review and revise the priority criteria and generate data

collection questions.

• 3. Gather and analyze pertinent data as indicated by

the priority criteria and data collection questions.

• 4. Identify and make decisions on long-term (5 years) priorities

through a data-driven, group decision-making process.

• 5. Incorporate priority decisions into CBCRP operational plans

and award cycles.

Timeline for the 2015 Priority-Setting Process

6/13 10/13 1/14 4/14 6/14 9/14 12/14 3/15 Responsive X Translation X Capacity Building X Public Health Outcomes X

Disparities

X

California Specific

X

Innovation X Collaboration X Non-Duplicative X Policy X Decision-making Retreat X

Program Goal

• Program Goal for California Specific:

fund research that utilizes resources particular to California and/or addresses a breast cancer need that is specific but not necessarily unique to the burden of breast cancer in California

What do we Mean by California Specific?

• Investigates populations that are rare in other

parts of the country or take advantage of the diversity of California;

• Addresses policies specific to California and/or

health care systems in California;

• Addresses topics of particular interest to

Californians; and/or

• Utilizes unique CA resources (e.g. cohorts)

Information Questions

Question 1. What is the current burden of breast cancer in California? Question 2. What are the current gaps and opportunities in disparities research, prevention research, and environmental links to breast cancer, with a particular emphasis on CA specific research and opportunities? Question 3. What investment has the Program made in CA specific research? Question 4 Specifically, what role has the SRI/CBCPI set aside had in CBCRP's investment in California-specific research?

BURDEN OF BREAST CANCER IN CA

Question 1:

CCR Basic Statistics

• Incidence & Mortality Rates Female Breast Cancer

– Statewide w/ considerations

• Race/Ethnicity

– Non Hispanic White [NHW] – Non Hispanic Black [Black] – Hispanic [HISP] – Asian/Pacific Islander [API] – American Indian/Alaskan Native [AI/AN] [*Misclassifcation]

• County of residence at time of diagnosis
• Stage at time of diagnosis (SEER Summary Stage)
• Urban/Rural categorization (County Level)

CCR Basic Statistics

• Population Data Sources:

– California Cancer Registry (CCR) published reports varying years – NCI SEERStatTM Data Files

• SEER 18 Registry File 2000-2011, November 2013 Submission
• American Community Health Survey 2010 (County Level Attributes)
• Rural Urban Commuter Codes 2013 (County Level)
• NCHS Mortality Data, Aggregated by NCI into 3-5 Yr Periods

– CCR on-line Query System (2007-2011, October 2013)

• Age-Adjusted Rates (AAR) per 100,000

– Calculated 2000 Std U.S. Population

• Descriptive statistics

– Females only, malignant cases (except as stated) – Majority rates presented for 2007-2011 (except as stated) – Stage (SEER Summary Stage 2000)

Overall CA Breast Cancer Incidence Rates, 2007-2011

141.5 127.7 93.2 91.8 122.4 33.3 28.7 19.8 28.7 29.1 20 40 60 80 100 120 140 160 Non Hispanic White Non Hispanic Black Hispanic Asian Pacific Islander All Races Combined Age Adjusted Incidence Rate per 100000 Invasive In Situ Calculated from NCI SEERStat SEER 18 Registries w/ Katrina Correction, November 2013 Submission

Overall CA Incidence & Mortality Age Adjusted Rate, 2007-2011: Age & Race/Ethnicity

< Age 50 Incidence Age 50+ Incidence Total Incidence Mortality NH White 47.2 388.5 141.5 23.4 Black 43.3 348.5 127.7 33.2 Hispanic 33.3 250.1 93.2 17.0 Asian/PI 39.4 229.1 91.8 13.2 AI/AN* 9.9 112.6 38.3 * All Races Combined 40.8 335.9 122.4 21.4

Age adjusted incidence rate per 100,000 (2000 U.S. Std Population) *AI/AN identification via medical record considered misreported (no other AI/AN rates reported in following slides). Calculated from NCI SEERStat, SEER 18 Registry File w/ Katrina Correction, November 2013 Submission

Overall CA Incidence Age Adjusted Rate, 1988-2010: Trends by Race/Ethnicity

60.0 80.0 100.0 120.0 140.0 160.0 NHW Black Hispanic API

AAR per 100,000

Extracted from CCR annual rate data at http://www.ccrcal.org/pdf/AnnualReport/1988-2010_BREAST.pdf

Overall CA Mortality Age Adjusted Rate, 1988-2010: Trends by Race/Ethnicity

AAR per 100,000 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 NHW Black Hispanic API

Extracted from CCR annual rate data at http://www.ccrcal.org/pdf/AnnualReport/1988-2010_BREAST.pdf

Overall CA Invasive Incidence 2007-2011: Geography (County), All Races Combined

Overall CA Mortality AAR 2007-2011: Geography (County), All Races Combined

Overall CA Invasive Incidence AAR 2007-2011: Geography (County), by Race/Ethnicity: NHW

Overall CA Invasive Incidence AAR 2007-2010: Geography (County), by Race/Ethnicity, NH Black

Overall CA Invasive Incidence AAR 2007-2010: Geography (County), by Race/Ethnicity, Hispanic

Overall CA Invasive Incidence AAR 2007-2010: Geography (County), by Race/Ethnicity, API

Percent of CA Cancer Cases, 2007-2011: by Summary Stage & Age Group

0% 20% 40% 60% 80% 100% 65+ 45-64 20-44 In Situ Local Reg Distant Unk

Calculated from NCI SEERStat SEER 18 Registries w/ Katrina Correction, November 2013 Submission

Percent of CA Cancer Cases, 2007-2011: by Summary Stage & Race/Ethnicity

0% 20% 40% 60% 80% 100% NHW Black Hispanic API In Situ Local Reg Distant Unk

Calculated from NCI SEERStat SEER 18 Registries w/ Katrina Correction, November 2013 Submission

Overall CA Incidence AAR 2007-2011: Summary Stage at Dx & Race/Ethnicity

10 20 30 40 50 60 70 80 90 100 NH White Black Hispanic Asian/PI Total Age Adjusted Incidence Rate per 100,000

In Situ Localized Regional (Ext +/or LN) Distant Unstaged

Calculated from NCI SEERStat SEER 18 Registries w/ Katrina Correction, November 2013 Submission

Overall CA Incidence AAR 2007-2011: Summary Stage at Dx & Race/Ethnicity

In Situ Localized Regional (Ext +/or LN) Distant Unstaged NH White 33.3 91.2 41.5 6.6 2.2 Black 28.7 71.3 44.0 9.9 2.9 Hispanic 19.8 53.6 32.3 5.6 2.0 Asian/PI 28.7 59.2 27.2 4.2 1.5 All Races Combined 29.1 76.8 37.2 6.2 2.3

Calculated from NCI SEERStat SEER 18 Registries w/ Katrina Correction, November 2013 Submission

Overall CA Incidence Age Adjusted Rate, 2000-2011: Trends by Race/Ethnicity, Advanced Stage, Ages 50+

40 60 80 100 120 140 160 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 NHW Black Hispanic API

AAR per 100,000

NCI SEERStat data available statewide for California with cases diagnosed as of 1/1/2000 Calculated from NCI SEERStat SEER 18 Registries w/ Katrina Correction, November 2013 Submission

Overall Incidence AAR 2005-2009: Age 20+ Years Advanced Stage at Dx & Geography (MSSA)

“Late Stage” : Summary Stage Regional/Distant MSSA = Medical Service Study Area Morris CR, et al. Cancer Stage at Diagnosis, 2013. Sacramento, CA: California Department of Public Health, California Cancer Registry, June 2013.

Overall CA Incidence AAR 2007-2011: Urban/Rural (County)

Calculated from NCI SEERStat SEER 18 Registry w/ Katrina Correction, November 2013 Urban/Rural: Counties aggregated per 2013 RUCA codes w/ ‘Adj’ = adjacent to ‘Metro’ area

122.6 121 120.8 125.7 124.1 120.7 108.1 95 100 105 110 115 120 125 130 Metro >1M Metro>250K Metro <250K Urban>20K Urban 2.5- 20K Adj Urban 2.5- 20K Rural <2.5K AAR per 100,000

Overall CA Incidence AAR 2007-2011: Summary Stage at Dx & Urban/Rural (County)

Calculated from NCI SEERStat SEER 18 Registry w/ Katrina Correction, November 2013 Urban/Rural: Counties aggregated per 2013 RUCA codes w/ ‘Adj’ = adjacent to ‘Metro’ area

10 20 30 40 50 60 70 80 90 In Situ Local Reg Distant Unk

Metro >1M Metro>250K Metro <250K Urban>20K Urban 2.5-20K Adj Urban 2.5-20K Rural <2.5K

AAR per 100,000

*

Overall CA Incidence AAR 2007-2011: Race/Ethnicity & Urban/Rural (County)

49.3 46.3 45.0 39.4 41.1 45.5 39.2 37.3 37.6 41.4 53.8 46.8 53.9

10 20 30 40 50 60 Metro >1M Metro>250K Metro <250K Urban>20K Urban 2.5-20K Adj Urban 2.5-20K Rural <2.5K NHW Hisp AAR per 100,000

*

Calculated from NCI SEERStat SEER 18 Registries w/ Katrina Correction, November 2013 Submission Urban/Rural: Counties aggregated per RUCA codes w/ ‘Adj’ = adjacent to ‘Metro’ area

Overall CA Incidence AAR 2007-2011: Socioeconomic Status (County: Household Median)

134.7 139.1 147.3 162.5 20 40 60 80 100 120 140 160 180

<$44,000 $44-$50,099 $50.1-$64,000 >$64,000

AAR per 100,000

Calculated from NCI SEERStat SEER 18 Registries w/ Katrina Correction, November 2013 Submission SES: Median Household Income at County Level, Quartiles derived from NCI SEERStat County Attributes File, American Community Health Survey 2010

Overall CA Incidence AAR 2007-2011: SES (County: Household Median) & Race

20 40 60 80 100 120 140 160 180 200 <$44,000 $44-$50,099 $50.1-$64,000 >$64,000 NHW Black HISP API

AAR per 100,000

Calculated from NCI SEERStat SEER 18 Registries w/ Katrina Correction, November 2013 Submission SES: Median Household Income at County Level, Quartiles derived from NCI SEERStat County Attributes File, American Community Health Survey 2010

Overall CA Mortality AAR 2006-2010: SES (County: Household Median) & Race

5 10 15 20 25 30 35 40 45 <$44,000 $44-$50,099 $50.1-$64,000 >$64,000 NHW Black HISP API

AAR per 100,000

Data from NCHS and calculated from NCI SEERStat All Cause of Death, Aggregated County File, Total U.S. 1990-2010, w/ Katrina/Rita Population Adjustments *NCHS/NCI SEERStat data files w/ County Attributes, Race Recode and Origin Code (Hispanic/NonHisp)

Burden of Breast Cancer in California: Summary

• Descriptive population level statistics continue to illustrate that a substantial

variation in breast cancer incidence/mortality continues across California – Overall, incidence & mortality race/ethnic differential patterns continue statewide (NHW, B, Hispanic, API) – Race/ethnicity differential increases for some single county based attributes, e.g. SES trends (less pronounced Hispanics vs. NHW), non-metro

• vs. metro status (higher non-metro rates Hispanics)

– Advanced stage continues increased statewide with Hispanics and NH Blacks (% and rates) – Association with single county level attributes and late stage vary by race

• Rates for in situ and localized disease decline metro-urban-rural
• Rates distant and unknown stage increase metro-urban-rural

Surveillance data serves as tool for tracking population-level disparities

Burden of Breast Cancer in California: Summary

• Continued interplay of these and other factors, environmental

and otherwise, integrate to influence incidence, stage of diagnosis, treatment and survival

• Individual-level observational studies and analysis required:

– to acquire complete individual detail on access and clinical metrics (such as insurance, comorbidity) that influence stage, treatment and survival – to acquire complete individual detail on factors that influence life course exposure(residence and occupation) and social/cultural impacts on disease development, survival and prevention Enable targeted research and prevention strategies capable of better accounting for the multiple contributing factors from the physical and social environment

GAPS AND OPPORTUNITIES IN CA SPECIFIC RESEARCH: DISPARITIES, PREVENTION AND ENVIRONMENTAL LINKS

Question 2:

Research Targeting the Relationship between Breast Cancer Disparities and the Environment

• Research funding for prevention in general, and avoidable

environmental exposures specifically, represents a small fraction of the total available resources

– <7% NCI budget allocated to “cancer prevention & control” – Federal interagency review of breast cancer research (2013)

• 10-11% NIH/DOD focus on environmental health
• No other federal agency supports substantial research on the

environmental causes

• International Cancer Research Partnership (ICRP)

– Research investment in breast cancer prevention 2008-2013 at 3- 4% worldwide – <2% exploring exogenous factors such as chemicals

CBCRP: Development Process CBCPI

CBCRP: Development Process CBCPI

• CBCRP SRI Research identified a broader spectrum of factors

in the physical/social environment that influence breast cancer disparities

– Integrated into the 2007 “Gaps” document integrated state-of- the-science on 23 topics

• CBCPI Process aims to build on earlier work around the

intersection of the physical environment (e.g., chemicals, pollutants), disparities (e.g., racism and other injustices), and the social/services environment (e.g., neighborhood socio- demographics, food environment)

– 2012 “Gaps” Supplemental literature scans provided update on the 23 topics – Overall, “Gaps” update found most of the environment and disparities research gaps identified in 2007 remain unanswered

CBCRP: Development Process CBCPI

CBCPI Process (as outlined previous slide)

• Identify and eliminate environmental causes of breast cancer.
• Identify and eliminate disparities/inequities in the burden of breast

cancer in California.

• Population-level interventions (including policy research) on known
• r suspected breast cancer risk factors and protective measures.
• Targeted interventions for high-risk individuals, including new

methods for identifying or assessing risk.

Current Gaps & Opportunities for Breast Cancer Research – Environment, Disparities & Prevention

“Follow-on” Topics (from Earlier SRI Funding Rounds):

• Integrated Approach Breast Cancer among Immigrants

(Behavior, Social and Physical Environment)

• Making Chemicals Testing Relevant to Breast Cancer
• Ecological Model of Breast Cancer Causation and Prevention

Current Gaps & Opportunities for Breast Cancer Research – Environment, Disparities & Prevention

SRI Principal Investigators Input:

• Proof of concept that environmental chemical exposure during

critical periods of development can induce or promote breast cancer in humans?

• Early life or founding generation exposures make you more

vulnerable to subsequent environmental exposures?

• Key modifiable risk factors and conditions suggested by complex

modeling systems?

• Invest in an existing cohort / cross-disciplinary research teams as

the best scientific approaches to address the research questions

Current Gaps & Opportunities for Breast Cancer Research – Environment, Disparities & Prevention

Strategy Team Members (SC/SA) Input:

• Invest in an intergenerational cohort study, i.e., analyze how

mother, daughter, and granddaughter respond to chemical exposures; and

• Examine the relationship between environmental exposures and

disparities across social class/race/ethnicity and incorporate a life course perspective / time dimension

• Improve utilization of animal studies to better indicate human

relevant environmental agents

• Develop exposure assessment methods for suspected chemicals

and their metabolites

Current Gaps & Opportunities for Breast Cancer Research – Environment, Disparities & Prevention

External Experts on Cancer Prevention Input:

• Trans-disciplinary research teams, or “team science”
• Improving knowledge

– Windows of susceptibility relative to breast cancer risk – Identifying pathways controlling breast density – in utero environmental exposures – Integration of animal and human models for mammary development

• Breast cancer risk from a variety of environmental exposures

– including stress, endocrine disrupting chemicals, ionizing radiation

• Disparities in breast cancer incidence related to race, ethnicity,

ancestry, and/or immigration status.

Current Gaps & Opportunities for Breast Cancer Research – Environment, Disparities & Prevention

Stakeholders Input:

• Geographic and temporal disparities in exposure to environmental

chemical / social stressors, and to range of cultural influences on breast cancer

• Relationship between disparities in breast cancer relative to

– Environmental and workplace exposure to chemicals – Social stressors and cultural influences – Social determinants of health – Geography, underserved and vulnerable populations – Concurrent exposures

• Policy related research questions

– Impact chemical policy on exposure and prevention – Impact policy on breast cancer risk factors and incidence – Economic, housing, and education interventions

INVESTMENT IN CA SPECIFIC RESEARCH

Question 3:

CA Specific Research: CBCRP Investment

Cycles 1-14 Cycles 15-19 Total $ Invested $29.8 Million $30.4 Million Average per year $2.1 Million $6 Million % of total investment 17% 57%

Cycle 15: 2009 first year of the 30% set aside for SRI

Investment by Priority Area: Cycles 1-14

Community Impact 56% Etiology & Prevention 27% Detection & Treatment 17%

CA Specific Grants by Priority Area: Cycles 1-14

By Dollars Invested

Investment by Priority Area: Cycles 15-19

Community Impact 25% Etiology & Prevention 67% Detection & Treatment 8%

CA Specific Grants by Priority Area: Cycles 15-19

By Dollars Invested

Investment by Priority Area: Cycles 15-19

E&P/Disparities 44% Etiology and Prevention 22% Disparities 17% Sociocultural 8% Treatment 8% Policy 1%

CA Specific Grants by Priority Area: More Details

By Dollars Invested

Investment by Institution & Investigator

• 19 Unique institutions funded
• 45 projects/50 grants*
• 13 of 19 in Northern California
• 13 academic and 6 community Institutions
• 40 unique PIs funded
• >1 grant: Anna Wu, Peggy Reynolds, Scarlett

Gomez, Anna Napoles, Marilyn Kwan, Barbara Cohn

* Most CRC projects have 2 institutions/grants funded by not all

Investment by Award Type

SRI/CBCPI 70% CRC 14% Translational 12% IDEAs 5% Postdoc 0%

CBCRP CA Specific Grants Cycles 15-19 by Dollars

Themes by Award Type

• SRI/CBCPI: by design research funded is CA

Specific

• CRC: 10/17 awards since Cycle 15, focus is

shifting to etiology and prevention, disparities

• Translation:4/8 have been CA specific
• IDEAS: just 7/67 since Cycle 15– utilizing CA

cohorts, CA policy

Conclusions: CA Specific Research-CBCRP Investment

• SRI/CBCPI has significantly increased CBCRP’s

investment in CA Specific research

– Focus on etiology and prevention, as well as disparities

• Since 2009, CBCRP has invested over $30million

in CA specific

– $20 million from SRI/CBCPI

• CRC awards also represent a large portion

– CRIBS training helped boost applications/CA Specific

• Translational and IDEAs also contribute, lesser

extent

• Funded a variety of PIs and types of institutions.

CONTRIBUTION OF SRI/CBCPI

Question 4:

CBCRP Investment in Special Research Initiatives

Both Disparities/En viro 52%

Enviro

28% Disparities 20%

Dollars Invested Cycles 15-19 Total: $21,198,646

Contribution of SRI/CBCPI to CA Specific Research in CBCRP Portfolio

• Almost all SRI/CBCPI Projects are California Specific

Examples

• 1. The Immigrant Experience and Breast Cancer Risk in

Asians

• 2. California Chemicals Policy and Breast Cancer
• 3. Cancer Mapping: Making Spatial Modeling work for

Communities

• 4. Persistent Organic Pollutants and Breast Cancer Risk
• 5. Women Firefighters Biomonitoring Collective

Conclusions: Unique Contribution of SRI/CBCPI

• The SRI/CBCPI has been the leading driver in

the increase of California-specific research funded by the CBCRP.

• Almost all of the SRI/CBCPI projects have been

California specific and have given the Program the opportunity to fund unique, California specific projects that would not have been supported by the Program previously with investigator-initiated funding mechanisms.

Recommendations

• Continue SRI/CBCPI set-aside focusing on disparities,

environmental links to breast cancer, and prevention.

• Continue funding CRC Awards
• Continue supporting outreach and training
• pportunities for CRC awards with special emphasis on

increasing applications in the disparities, environment and prevention areas.

• Continue to look for and encourage researchers to

focus on CA specific research, including IDEA investigators.

• Determine whether disparities exist that are unique to

populations in California (e.g. Filipinas) and support research into these areas.