Summary of the Process to Assess Excess Cancer Occurrence

(Suspected Cancer Clusters) in a SC Community

Prepared by the SC Central Cancer Registry

The SC Central Cancer Registry (SCCCR) follows the established guidelines from the CDC
Guidelines for Investigating Suspected Cancer Clusters and Responding to Community Concerns.
(https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6208a1.htm ). According to CDCs
definition, a Cancer Cluster is a greater-than-expected number of cancer cases (or deaths) that
occurs within a group of people in a geographic area over a period of time. Until all of the
parameters are met, a group of cancers is often referred to as a suspected cluster. When all
criteria are met, a true cluster may be detected. A true cluster is one that can happen
randomly by chance. A meaningful cluster is one that meets all the criteria of a true cluster
and has a probable known environmental agent associated with the occurrence of cancer cases.

There is a four-step process for assessment of cancer excess to determine if a true or

meaningful cluster exists. The steps are listed below:

Step 1 Initial Contact and Response with the requestor to fully understand the
concern.
Step 2 Assessment (statistical testing)
Step 3 Determining Feasibility to Conduct Study (if excess found)
Step 4 Conducting an Epidemiologic Investigation

To determine if there are any unusual cancer patterns in an area the first step is to look at the
number of new cancer cases (incidence) and deaths (mortality) occurring in the ZIP code and
compare this to the number of cancer cases and deaths expected to occur by chance alone;
that is, if the area of concern had similar cancer rates as the rest of the state. The number of
expected cases and deaths are determined by using South Carolina state cancer incidence and
mortality rates and applying them to the population of the geographic area of interest at the
ZIP code level. These observed and expected values allow for comparison of the ratio of
observed-to-expected numbers or SMR (standardized morbidity or mortality ratio), and the
confidence intervals are evaluated to determine statistically significant differences. When
significant results are encountered, additional steps are taken to look at the data more closely
to look for any abnormal patterns seen in the case counts, types of cancer, age, stage-at-
diagnosis.

In determining whether or not further public health action is warranted (Steps 3 and 4),
consideration is given to several things:

The frequency and magnitude of the number of cases/deaths compared to the number
expected to occur (at least a 3-5 fold increase of a particular cancer type)
The types of cancer involved (clusters involve rare cancer types)
Whether any difference that is noted is statistically significant

1
All newly diagnosed cancer cases (incidence) must be reported to the SC Central Cancer
Registry (SCCCR) by state statute. The SCCCR contains all newly diagnosed cancer cases
occurring in South Carolina since 1996. All deaths are provided by DHEC Vital Records. A subset
of deaths due to cancer are utilized by the SCCCR for these assessments.

The time interval from reporting to public release for national and state-specific cancer
statistics is generally 24 months. This is true for cancer data nationwide, not just in South
Carolina. This time lag is due to extensive quality control and de-duplication of the cases that
must take place during this interval to ensure cancer data are reported and counted correctly.
Currently, the data available from the SC Central Cancer Registry include cases and deaths from
1996 to 2014. Trends over time can help identify unusual cancer patterns. Cancer usually takes
years to develop, so unusual cancer patterns are usually detected across many years of data.
The most recent five years of data available (2010-2014) are currently used for these analyses.

A Community Cancer Assessment (CCA) Report is provided to the community for every concern
received by the SCCCR. This report contains a summary of the statistical analysis performed as
well as the results of the assessment of new cases and deaths due to cancer occurring in the ZIP
code area.

June 27, 2017