INVESTIGATION OF CHILDHOOD ACUTE MYELOID LEUKEMIA IN THE AREA OF THE VILLAGE OF CLYDE, WAYNE AND SENECA COUNTIES, NEW YORK

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1 INVESTIGATION OF CHILDHOOD ACUTE MYELOID LEUKEMIA IN THE AREA OF THE VILLAGE OF CLYDE, WAYNE AND SENECA COUNTIES, NEW YORK Prepared by the Cancer Surveillance Program Bureau of Chronic Disease Epidemiology and Surveillance New York State Department of Health with the assistance of New York State Cancer Registry staff and the Bureau of Environmental Exposure Investigation For further information contact: Aura L. Weinstein, M.P.H. Director, Cancer Surveillance Program 6/08

2 INVESTIGATION OF CHILDHOOD ACUTE MYELOID LEUKEMIA IN THE AREA OF THE VILLAGE OF CLYDE, WAYNE AND SENECA COUNTIES, NEW YORK Background The Cancer Surveillance Program of the New York State Department of Health, Bureau of Chronic Disease Epidemiology and Surveillance, responds to concerns over cancer in communities throughout New York State. In January of 1998, the Cancer Surveillance Program was contacted by a resident of southern Wayne County who reported what she believed to be an unusual number of children in her area who had recently been diagnosed with acute myeloid leukemia (AML). Although leukemia is the most frequently diagnosed type of cancer in children, approximately three quarters of cases are of the acute lymphocytic subtype; cases of acute myeloid leukemia are fairly rare in children. The children reported to have AML all lived in the area of the Village of Clyde in Wayne County or in a neighboring section of Seneca County, and were diagnosed within a two-year period. The Cancer Surveillance Program reviewed information provided by the resident and attempted to confirm the reported diagnoses through available information sources. These sources included the New York State Cancer Registry, which contains information on all cases of cancer diagnosed or treated in New York State, as required by law, and the death certificate files of the New York State vital records system. These data sources confirmed an unusual occurrence of AML among the children, who lived within an approximately ten-mile area in a sparsely populated section of Wayne and Seneca Counties. Hospital medical records were then obtained which further confirmed the precise diagnoses for all the children. Based on this confirmation, it was decided to conduct a follow-up to learn more about the unusual occurrence of childhood AML in the Clyde area. Follow-up activities included 1) a search of Cancer Registry files to identify any additional cases of childhood AML or other unusual patterns of blood cancers among residents of the Clyde area; 2) examination of the individual characteristics of the children confirmed to have developed AML (or people with any other unusual blood cancers that may be identified) to obtain detailed information on their personal and family medical histories and any other factors that might have influenced their risk; and 3) review of available environmental information to identify any potential for unusual environmental exposures in the area. This report presents the results of these follow-up activities. 1

3 Search for additional cases Methods The source of information on blood cancers among residents of the Clyde area was the New York State Cancer Registry. As noted in the background section, the Cancer Registry contains information on all cases of cancer diagnosed or treated in New York State, as mandated by law. The computerized Cancer Registry files are continuously updated to reflect information gained from multiple reports on the same cancer. At the time this follow-up began, cancer incidence data were considered official through 2004, with information on cancer cases updated as of April Variation in cancer incidence among different geographic areas reflects not only true differences in cancer occurrence, but also differences in how cancer is diagnosed, treated, and recorded in different areas of the state. The completeness and accuracy of the Cancer Registry depend upon reporting from hospitals, laboratories, managed care organizations and other sources. The Cancer Registry has been certified as more than 95% complete by the North American Association of Central Cancer Registries. In addition, the Cancer Registry has received gold certification from the Association for the past seven years, the highest certification given to central cancer registries (1). Leukemia, lymphoma and multiple myeloma are all cancers of the blood or bloodforming system. While their patterns of spread within the body are different, lymphomas, multiple myeloma and the lymphocytic types of leukemia involve the same class of white blood cell (2). Since it is plausible that these diseases may have similar causes, all three classes of blood cancers were examined as a first step to ensure that the confirmed cases of childhood AML were not part of a larger pattern. To identify additional blood cancers diagnosed among residents of the Clyde area, we selected ZIP Codes in Wayne and Seneca Counties that contained people living within five miles of the children originally confirmed with AML. These ZIP Codes include (Clyde), (Waterloo), (Seneca Falls), (Lyons), (North Rose), (Wolcott) and (Savannah). ZIP Code serves the Village of Clyde as well as the majority of the Town of Galen, in which the Village is located, and portions of the Towns of Rose to the north and Savannah to the east and the Town of Junius to the south in Seneca County. ZIP Codes and are located in Seneca County directly south of Clyde, and extend south through the Towns of Waterloo, Seneca Falls and Fayette, including the Villages of Waterloo and Seneca Falls. ZIP Codes 14489, 14516, and border ZIP Code on the west, north, northeast and east, respectively (see map). Cancer Registry records were searched for people living in these ZIP Codes who were diagnosed with leukemia, lymphoma or multiple myeloma since The year 1990 is the earliest year for which address data for this part of New York have been deemed to be of sufficient accuracy and completeness for this purpose. 2

4 Expected numbers of each blood cancer and total blood cancers were calculated for people of all ages and for children ages 0-19 separately to compare with the actual numbers identified. The time period selected for this comparison was , the latest year for which Cancer Registry data were considered official at the time cases were identified. To compute the expected numbers, age-specific incidence rates for each cancer (leukemia, lymphoma and multiple myeloma) for a standard population were applied to the populations of the seven ZIP Codes in nine age groups (four five-year age groups for the childhood comparison). The standard population for this study was chosen as New York State, exclusive of New York City. Population estimates for the ZIP Codes for the years were obtained from Claritas, Inc., a commercial vendor. The probability that chance alone could explain a difference between the observed number of cancer cases compared to the expected number was evaluated based on the Poisson distribution (3). (In statistics, the Poisson distribution describes a process where a rare event occurs in a large population.) If the probability of obtaining an excess or deficit of the given size solely by chance was or less, the result was considered to be statistically significant. Non-significant excesses or deficits were considered to represent random variations in patterns of disease. Findings A total of 329 blood cancers were diagnosed among residents of the seven ZIP Codes during the 15-year period In comparison, we calculated that, based on rates for New York State, exclusive of New York City, and the estimated populations of the seven ZIP Codes for this time period, we would expect to see 314 blood cancers diagnosed. The number that was actually diagnosed was slightly higher than the number expected, but the difference was not statistically significant, meaning that it was within the range that frequently occurs due to chance. The 329 blood cancers diagnosed in the 15 years of the study translates to an average of 21.9 diagnoses a year. Table 1. shows that numbers of cancers diagnosed in any one year ranged from 12 to 29. Numbers increased from the time period to the time period , declined somewhat over the next three years, then rose back to their earlier level in Additional cancers were identified in 2005; the number of these additional cancers was within the range diagnosed in previous years. (Since data for this year are not yet official, the exact number cannot be provided.) The greatest numbers of blood cancer diagnoses occurred in residents of ZIP Codes and 13165, which have the largest populations of the seven ZIP Codes. The smallest numbers of diagnoses, averaging about one a year, occurred in ZIP Codes and 14516, which have the smallest populations (Table 2.). The 95 diagnoses occurring in ZIP Code was greater than the 78 expected, and the 64 diagnoses in ZIP Code was less than the 3

5 81 expected, but neither of these differences, nor the differences in any of the other ZIP Codes, was statistically significant. Specific types of blood cancers diagnosed in the seven ZIP Codes between 1990 and 2004 included 116 leukemias, 172 lymphomas, and 41 multiple myelomas (see Table 3.); additional diagnoses of each cancer were identified in The number of each of the blood cancers actually diagnosed was not significantly different from the number expected. Looking at specific types of leukemia, acute myeloid leukemia (AML), with 37 cases diagnosed, and chronic lymphocytic leukemia, with 31 cases, were, as usually observed, the most frequently diagnosed. Cancers in children This study was initiated as a result of a report of an apparently high number of children with a less common type of leukemia. When children were looked at separately, a total of 15 children ages 0-19 in the study area were found to have been diagnosed with some type of blood cancer between 1990 and Calculations show that 13 children would have been expected to be diagnosed with some type of blood cancer during this time. This difference was not statistically significant. When the different blood cancers were looked at separately, the majority of children were diagnosed with some type of leukemia, which is the most frequently diagnosed type of childhood cancer. A small number of children with lymphomas was also found. (To protect patient confidentiality, in what follows exact numbers will not be provided when these numbers are small enough to permit someone with local knowledge either to identify an individual with cancer, or to infer additional information about an individual already known to have cancer. This generally applies for numbers of five or fewer.) The number of children diagnosed with leukemia was greater than the number expected and the number of children diagnosed with lymphomas was less than the number expected, but neither of these differences was statistically significant. The number of children in any one ZIP Code diagnosed with any type of blood cancer was less than six, and the number actually diagnosed was similar to the number expected for all ZIP Codes. Looking more closely at the childhood leukemias, as expected, the majority were cases of acute lymphocytic leukemia (ALL), the most frequently diagnosed type of leukemia in children. The proportion of leukemia cases that were of the AML subtype was, however, greater than the proportion usually found, which is 15-20%. The children with AML included those originally reported to us, plus one or more additional children with characteristics similar to those originally reported. This small number of additional children with AML were in the same age range as the originally reported children and were diagnosed within one year. Plotting the addresses of the children with AML on a map of the area showed that the additional children lived within a short distance (within two miles) of at least one of the original children. We then examined the home addresses at the time of diagnosis for all children diagnosed with any blood cancer between 1990 and We found that the addresses 4

6 generally followed the population, with several children living in the more densely populated area in and around the Villages of Waterloo and Seneca Falls in Seneca County and other addresses widely scattered in the more rural areas. Other than the children originally reported with AML and the children with AML identified from the Cancer Registry, any other children living in the vicinity of the Village of Clyde who were diagnosed with any type of blood cancer in the 15 years of the study were diagnosed with the more frequently occurring ALL. Blood cancers by type (all ages) Different blood cancers are known to affect people of different ages. Although AML is relatively uncommon in children, it is one of the most common types of leukemia in adults. In the present study, the majority of people with AML were age 65 or older at the time of their diagnosis. A significant fraction, however, were under age 45, including the children considered above. Addresses at the time of diagnosis were plotted for 36 of the 37 people of all ages diagnosed with AML. (The address of one person could not be plotted due to insufficient information.) The addresses that were plotted tended to follow the population, with the largest number of addresses in the area in and around the Villages of Waterloo and Seneca Falls. Several adults lived in the immediate vicinity of some of the children with AML identified for this study, but these were mostly elderly people diagnosed in the years prior to or following the years when the children were diagnosed. For the other specific types of leukemia, the 31 diagnoses of chronic lymphocytic leukemia occurred in people age 45 and older, with the majority age 65 and older. Chronic myeloid leukemia occurred in 17 people, ranging in age from young adults through the middleaged and elderly. On the other hand, of the 10 people identified with acute lymphocytic leukemia, the majority were children, with a small number of middle-aged and elderly people. Twenty one additional people were listed with other specified or unspecified types of leukemia, with the majority of unspecified leukemias occurring in the earlier years of the time period and among middle-aged or elderly people. Lymphomas include Hodgkin s disease, and various other types known collectively as the non-hodgkin s lymphomas. Lymphomas were the most frequently identified class of blood cancer in people of all ages in the seven-zip Code area. Of these, there were 28 cases of Hodgkin s disease. People with Hodgkin s disease ranged in age from children to the elderly, although, as is typically seen, the majority were young adults. Many specific types of non- Hodgkin s lymphomas were found, including unspecified lymphomas. These occurred among people of ages ranging from young adults to the elderly, with the greatest numbers in the oldest age groups. Cancers classified as multiple myelomas, which includes multiple myeloma and other plasma cell cancers, were seen in 41 people at ages 35 and up; the majority of people affected were age 65 and older. Additional search of the Cancer Registry for years since 1990 in the area of the Village of Clyde thus identified one or more additional children with AML diagnosed around the same 5

7 time and living in the same area as the children originally reported. There were no unusual patterns in any of the other blood cancers in children or in adults. Further analyses of individual and environmental characteristics will therefore include all children with AML with characteristics similar to the children originally reported, including those reported by the resident and those identified from Cancer Registry files. Individual characteristics Methods Individual-level information on the children diagnosed with AML was obtained from hospital records. For the children reported by the resident, these were the records used to further confirm the precise diagnosis. Hospital records for the children first identified from Cancer Registry files were obtained and reviewed following the identification of the children. Findings Prior to the diagnosis of leukemia, none of the children had any significant previous medical conditions recorded on their medical records. In particular, no genetic diseases or syndromes were noted and there were no unusual pre-natal or early childhood exposures recorded. All of the birth weights that were recorded were in the normal range, although some, but not all, of the children were noted to be above normal weight at the time of their diagnosis. Some of the children also had a prior surgical history of tonsil and adenoid removal. All of the children had a history of some type of cancer in one or more family members. The majority of the children had a family history of leukemia or some other type of blood cancer or nonmalignant blood condition. Other than the blood cancers, the cancers seen in family members of the children were of all different types. Little information was available on the residence histories of the children. Available records indicate that some of the children had lived in the area at the time of their birth, while others had moved to the area at some time prior to their diagnosis. The children for whom information on school attendance was recorded attended different schools (in different school districts) at the time of their diagnosis, although this information was not recorded for all the children. Studies of childhood cancers often consider parental occupations. Occupations were not recorded for the parents of any of the children, however from the information that was provided it was possible to determine the occupation of one of the parents. This occupation may have involved exposures to paints and/or solvents. 6

8 Environmental review Methods Staff from the New York State Department of Health, Bureau of Environmental Exposure Investigation, examined available environmental databases to identify any potential unusual environmental exposures to people in the seven ZIP Codes in the area of the Village of Clyde. These included databases on inactive hazardous waste sites and Toxics Release Inventory facilities. Areas served by public water supplies and the school districts in the area were identified and plotted on a map. Staff also evaluated the results of laboratory testing of water samples from the area that were analyzed by the Department of Health s Wadsworth Center laboratories, and examined data from the Department of Health s statewide database of radon measurements in indoor air. Findings Six inactive hazardous waste sites were identified within the seven ZIP Codes, with two more located just beyond the ZIP Code boundaries. These include the Parker Hannifin Old Erie Canal site in the Village of Clyde, the Gould Pumps site in the Village of Seneca Falls, the Evans Chemetics and Sessler Scavenger Waste Disposal sites west of the Village of Waterloo, and the Seneca Meadows and Tantalo landfills north of the Village of Waterloo. The Barker Chemical site is located just outside of ZIP Code in the Town of Sodus, and the Geneva Manufactured Gas Plant is located just outside of ZIP Code in the Town of Fayette. In addition, two sites included in the Brownfields Cleanup Program, the Cahoon Parcel site in the Town of Wolcott and the Northwest Storage Area in the Village of Seneca Falls, and a voluntary clean-up site, the 43 Main Street (Alaskan Oil) site in the Village of Waterloo, are located in the seven-zip Code area. Of these, the Parker Hannifin site is associated with groundwater contamination with volatile organic chemicals (VOCs), primarily trichloroethylene (TCE). This contaminated groundwater, however, is not migrating to off-site locations. Soil vapor on- and off-site has been contaminated with VOCs, and investigation of nearby residences has shown the need to install a vapor mitigation system at one residence. None of the other sites is considered to be a source of off-site exposures in the general vicinity of the residences of any of the children with AML. Nine facilities were identified that were required to report chemical releases to the Toxics Release Inventory. These include four facilities in Lyons (Agway Lyons Fertilizer, Finger Lakes Packaging and two facilities belonging to the Parker Hannifin Corporation), three facilities in or near the Village of Seneca Falls (two facilities belonging to Gould Pumps, Inc., and the Matthews Int. Corporation), one facility in the Village of Waterloo (Evans Chemetics), and the Parker Hannifin site in the Village of Clyde. This site reported releases of Freon 113 into the air from 1988 through 1994, and TCE into the air in

9 There are three areas served by different public water supplies within the seven ZIP Codes. Some of the children with AML were found to live in an area served by a public water supply at the time of their diagnosis, while the others did not. Review of the results of testing did not show any detections of any bacteriologic, organic, or metal contaminants at levels above health guidelines for any of the public water supplies in the area. Review of testing results for water samples collected from private wells in the towns where children with AML (who did not live in an area served by a public water supply) lived at the time of their diagnosis found no samples that exceeded drinking water standards for any substance. Comparison of the locations of the residences of the children with AML with school district boundaries in the area showed that the children did not all live in the same school district. This information cannot tell us whether the children actually attended public schools in the district in which they lived. Information on the school attended at the time of diagnosis was available from the medical record for some, but not all, of the children. Radon is a naturally occurring gas that comes from the radioactive decay of uranium in soil, rock and water. Radon can become a health concern when it builds up to high levels in the air inside homes. Estimates based on measurement data show that 8% of the homes in Wayne County and 3% of the homes in Seneca County have radon concentrations in the air in living areas above the US EPA action level of 4 pci/l (picocuries per liter). The estimated percentage of homes in the towns of the study area with indoor radon concentrations above this level ranges from 5% to 14% for the towns in Wayne County, and 2% to 6% for the towns in Seneca County. Of the Wayne County towns, only the Town of Lyons, west of the Village of Clyde, had over 10% of homes estimated to have radon levels above the action level. Discussion Leukemia Leukemias are cancers of the cells in the bone marrow that give rise to the various types of blood cells. The leukemias can be classified according to the course of the disease (acute or chronic), and the type of blood cell affected (lymphocytic or non-lymphocytic). Acute lymphocytic leukemia (ALL) is the most common type of leukemia in children, but also affects adults, particularly the elderly. Acute non-lymphocytic leukemia, also called acute myeloid leukemia (AML), occurs in both adults and children. Chronic lymphocytic leukemia most commonly affects adults over age 55 and rarely occurs in children. Chronic myeloid leukemia occurs mainly in adults, but has been known to affect children. Although it is often thought of as a disease of children, most cases of leukemia occur in older adults. At this time, scientists do not know what causes most cases of leukemia. Different types of leukemia have been found to have different, but overlapping, sets of risk factors. Since it has not always been possible to look at different types of leukemias separately, much of what is known about leukemia risk factors comes from studies where all the leukemias are looked at as 8

10 a group. In addition, not all risk factors identified for adults are applicable to children, and certain risk factors identified for children do not hold for adults. Most types of leukemia have been associated with exposure to high doses of ionizing radiation, such as atomic bombs or radiation treatments for other forms of cancer. People with Down syndrome and certain other genetic abnormalities are known to develop leukemia more frequently. Certain unusual forms of leukemia are caused by a rare virus. Long-term exposures to certain chemicals found in the workplace, such as benzene, have also been linked to leukemia, and people treated with certain anti-cancer drugs are known to be at higher risk. Recent research suggests that leukemia, especially the myeloid types, is associated with cigarette smoking (4, 5). As stated above, ALL is the most frequently diagnosed type of leukemia in children, accounting for about three quarters of all cases of childhood leukemia. AML is the second most frequently occurring type of leukemia in children, accounting for 15-20% of all cases. Of the risk factors associated with AML in children specifically, the most firmly established are exposure to ionizing radiation, and certain genetic syndromes including Down s syndrome (4, 5). Children may also develop AML following treatment with certain anti-cancer drugs, but the use of these drugs is rare in children. A number of possible reproductive risk factors have been identified, including high birth weight, prior fetal loss in the mother, and maternal alcohol consumption (4, 5). Several studies have noted associations of childhood AML with various types of pesticides, but a consistent picture has yet to emerge. Studies have also looked at parental occupations and exposures, and have suggested possible associations with parental occupations with exposures to paints and pigments, metals, textiles, and benzene and other solvents (5, 6). Study findings The follow-up study identified a small number of children not known to the resident who reported the first children who had disease and personal characteristics similar to the children originally reported. No other unusual patterns of any other cancer in children or adults were found, and the total numbers of each major type of blood cancer were similar to the numbers that would be expected for this area. Looking at additional information on the children with AML, all of the children had a family history of some type of cancer, and most had a family history of leukemia or some other blood cancer or disorder. Cancer, considered as a group of diseases, is a common disease, at least in adults, and some type of cancer has been estimated to affect three-quarters of all families. Given the relatively small number of children in the study, it may not be surprising to find all of them had a family history of cancer. Leukemia is one of the less common cancers, and there have been some reports in the scientific literature of AML (and other leukemias) running in families (4). Family members share a common genetic heritage but may also share a common environment at some time in their lives. Much research is currently under way on the way in which inherited differences may influence cancer risk. 9

11 One of the parents of the children was found to have an occupation that might have involved exposures to paints or solvents, which have been linked in some studies with leukemia in the children of people who have been exposed. As these types of occupations are not uncommon in the general population, and no information was available on the occupations of the other parents, it is not possible to determine whether parental occupations may have played a role in the development of the childhood leukemias. Environmental considerations For any substance to have an effect on human health, people have to come into contact with it. This is what is known as exposure. People may be exposed to a chemical substance by breathing it in (inhalation), consuming it in food or water (ingestion), or getting it on their skin (dermal exposure). Even with exposure, not all hazardous substances cause cancer. The risk of developing cancer upon exposure to a cancer-causing substance depends on the amount of the substance people are exposed to, the length of time they are exposed to it, and how often they are exposed to it. To assess the potential for exposure to known chemical contaminants, we compared available information on the residences of the children identified in this study with available environmental information. Only one of the inactive hazardous waste disposal sites identified in the general vicinity of the residences of any of the children is considered a source of off-site exposures, and at the time of their diagnosis none of the children lived in homes actually impacted by these exposures. Other releases of contaminants at various times were identified, but given what is known about where the children were living at the time of their diagnosis and at birth, it is not likely that all the children could have been affected by the same unusual chemical exposure. The children did not all share the same public or private water supply, and testing of public and private water supplies showed no contaminants above health guidelines. The potential for radon exposures in the area of the Village of Clyde appears unremarkable. Limitations Medical records were the most important source of information on the children in this study, however they did not contain all of the information that would be needed for a complete assessment of risk factors and possible exposures. In particular, the information available on residence histories, school attendance and parental occupations was limited. There could therefore be some other individual risk factors or commonalities among the children of which we are not aware. Some of the characteristics found among the children have been identified as possible risk factors for childhood AML. Risk factors are characteristics that identify someone as being at increased risk of a disease, but are not necessarily themselves causes of the disease. Some of the possible risk factors identified in the present study, such as having a family history of a blood cancer or disorder, also occur in children without blood cancers, and finding them among the affected children does not necessarily mean the possible risk factors were related to their disease. In addition, since the actual number of children with AML was relatively small (for 10

12 statistical purposes) and small numbers are very sensitive to the effects of random fluctuation, it is not possible to say with any confidence whether any of the possible risk factors identified may be more common among the children with AML than among children in the general population. Statistical issues This study was conducted to follow up on the finding of an unusual occurrence of AML in children in the area of the Village of Clyde. It is important to realize that it is possible for an unusual occurrence to happen purely by chance. Given the thousands of communities in New York State and the over 100 different types of cancer, it is even likely that there will be some communities experiencing unusual occurrences of some type of cancer in some age group at some point in time; the Clyde area could be one of them. It is therefore still possible that the occurrence of an unusual number of cases of childhood AML in the Clyde area was the result of chance. Interpretation The present study has confirmed an unusual pattern of childhood AML in the area of the Village of Clyde during the mid-1990s. This unusual pattern was not apparent for any of the other blood cancers or in adults, and appears to have been limited to a relatively short span of time. The finding that most of the children had a family history of some type of blood cancer or other blood condition may indicate that some of the children might have had an inherited susceptibility to the disease. Given the limited information available, it is not possible to determine whether any other individual characteristics may have played a role. The area does not stand out as unusual in its known chemical exposures, and no widespread exposures to hazardous materials that might have linked the children were identified. The information available thus does not allow us to attribute the leukemias to any single cause or combination of causes. Although this unusual occurrence could be related to factors we have not been able to uncover, given the (statistically) small number of children involved, it is also possible that it occurred by chance. 11

13 Table 1. Blood cancer 1 diagnoses by year, ZIP Codes (Clyde), (Waterloo), (Seneca Falls), (Lyons), (North Rose), (Wolcott) and (Savannah), Wayne and Seneca Counties, New York, Year Number of diagnoses Total Includes leukemias, lymphomas, and multiple myeloma 2 Source of data: New York State Cancer Registry 13

14 Table 2. Blood cancer 1 diagnoses by ZIP Code, ZIP Codes (Clyde), (Waterloo), (Seneca Falls), (Lyons), (North Rose), (Wolcott) and (Savannah), Wayne and Seneca Counties, New York, ZIP Code Average population 3 Number of diagnoses Number expected , , , , , , , Total all ZIPs 44, Includes leukemias, lymphomas, and multiple myeloma 2 Source of data: New York State Cancer Registry 3 Source of data: Claritas, Inc. 4 Expected numbers of diagnoses are based on standard cancer incidence rates by age and sex for New York State, exclusive of New York City. Standard rates were applied to the total population of each ZIP Code and the total study area to obtain expected numbers of diagnoses. 14

15 Table 3. Blood cancer 1 diagnoses by type and sub-type, ZIP Codes (Clyde), (Waterloo), (Seneca Falls), (Lyons), (North Rose), (Wolcott) and (Savannah), Wayne and Seneca Counties, New York, Number of diagnoses Number expected 3 Leukemias Acute myeloid leukemia (AML) 37 Chronic lymphocytic leukemia (CLL) 31 Chronic myeloid leukemia (CML) 17 Acute lymphocytic leukemia (ALL) 10 Other and unspecified leukemias 21 Lymphomas Hodgkin s disease 28 Non-Hodgkin s lymphomas 144 Multiple myeloma Includes leukemias, lymphomas, and multiple myeloma 2 Source of data: New York State Cancer Registry 3 Expected numbers of diagnoses are based on standard cancer incidence rates by age and sex for New York State, exclusive of New York City. Standard rates were applied to the total study population to obtain expected numbers of diagnoses. 15

16 References 1. Wu XC, McLaughlin CC, Lake A et al., (eds). Cancer in North America, , Springfield, IL: North American Association of Central Cancer Registries, Inc. May 2007 (Appendix D). 2. Fritz A, Percy C, Jack A, et al., (eds.) International Classification of Diseases for Oncology Third Edition U.S. Interim Version Geneva: World Health Organization, Molina EC, Poisson's Exponential Binomial Limit, Huntington, NY: Robert E. Krieger Co., Linet MS, Devesa S, Morgan GJ, The leukemias, in Schottenfeld D, and Fraumeni JF Jr. (eds.), Cancer Epidemiology and Prevention, 3rd Ed., New York: Oxford University Press, Sandler DP and Ross JA, Epidemiology of acute leukemia in children and adults, Seminars in Oncology 24(1):3-16, Belson M, Kingsley B, Holmes A, Risk factors of acute leukemia in children: a review, Environmental Health Perspectives 115(1): ,

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