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1. What did the CDC’s Agency for Toxic Substances and Disease Registry (ATSDR) find in their 2009 Public Health Assessment?

Per the requirements of the Comprehensive Emergency Response, Compensation, and Liability Act (CERCLA or Superfund), ATSDR completed a public health assessment (PHA) on the area of Fort Detrick proposed to be placed on the US EPA’s National Priority List for long-term cleanup. ATSDR’s report on the Fort Detrick Area B Groundwater evaluated estimated exposures to the maximum measured TCE and PCE concentrations found in private drinking water wells around the Area B site. ATSDR concluded that these exposures were unlikely to produce any harmful health effects, including cancer. ATSDR’s Public Health Assessment estimated the TCE and PCE exposure doses to residents of those houses by using the maximum measured concentrations of the chemicals in 1992 (when potable use of the wells ceased). Evaluation of these contaminants and estimated ingestion doses of TCE and PCE for children and adults lead to the following conclusions: a) "Harmful effects are unlikely for users of the contaminated private wells based on maximum measured concentrations of PCE and TCE (cancer and non-cancer health effects). b) Residences with contaminated wells are currently being provided with alternate water. Current exposure to VOCs at these locations is limited to incidental use of the wells for irrigation or other outside uses. These exposures are unlikely to result in any harmful health effects. The full ATSDR report can be found here: http://www.atsdr.cdc.gov/HAC/pha/FtDetrickAreaBGroundwater/FortDetrickPHAFinal12-09-2009.pdf

2. Who is responsible for collecting information about cancer?

The Maryland Cancer Registry receives information from health care providers, hospitals, and other entities about cancer cases in Maryland. Hospitals, laboratories, radiation facilities, and physicians report cancer and benign central nervous system tumor data quarterly to the Registry. They have 6 months from the date of diagnosis to report a case. Once received, the reports that come in from various sources are “consolidated” into one tumor report. Cancer registration in the US is finalized in each state two years after the end of the diagnosis year. This helps to assure the quality and completeness of the data. Once the data are finalized, the Registry prepares summary statistics for the state. Information on tumor reporting requirements in Maryland can be found at http://www.fha.state.md.us/cancer/mcr_home.cfm. Reports on Cancer in Maryland can be found at http://www.fha.state.md.us/cancer/surv_data-reports.cfm.

3. What is a cancer “cluster?”

The US Centers for Disease Control and Prevention (CDC) defines a cancer cluster as a greater than expected number of cancer cases within a group of people who are linked by some factors. They may be linked by geography, by type or place of work, or by some other factor such as time. The idea of a cluster is often that some common factor or exposure may be responsible for the cancer. However, this is often difficult to prove, for a number of reasons: (1) Cancer is a common disease; (2) All cancers are not the same, and their causes are often different as well; (3) There may be too few cases to achieve a reasonable level of statistical certainty; and (4) Many cancers have multiple causes.

When trying to determine whether a group of cancers is due to chance alone, or is a true “cluster,” some of the questions that should be asked include: (a) Is this the same type of cancer, or is it many different types?; (b) Are the cancers occurring in people who typically get this kind of cancer, or are these cancers happening in people who don’t typically get this type of cancer?; (c) Are the cancers occurring in people who are known to have a specific exposure?; (d) If an exposure is suspected of being related to a cancer, is there a reasonable period of time between when the exposure happened and when the cancer happened (because chemicals that are known to cause cancer typically take several years to several decades between when the exposure happens and when the cancer is finally apparent)?; and (e) Are the cancers common cancers, or are they very rare types of cancers?

4. How are cancer cluster concerns investigated in Maryland?

The Maryland Department of Health and Mental Hygiene (DHMH) works with local health departments, like the Frederick County Health Department, to investigate concerns about cancer. There is a protocol in which the Maryland Cancer Registry, DHMH Center for Environmental Health Coordination, and the local health department work together to address the concerns. The investigation may involve several stages, depending on the nature of the concern. Some questions can be answered very simply, using publicly available data. In other cases, more investigation with the Maryland Cancer Registry data is required. If the questions still cannot be answered, a more complex investigation may be initiated. Often, the U.S. Environmental Protection Agency, the federal Agency for Toxic Substances and Disease Registry (ATSDR), or the Maryland Department of the Environment may be needed to help with the evaluation of potential environmental exposures.

The Maryland Cancer Registry is an ongoing registry since 1992, and the data are used for many different purposes. For example, data are used to look at the numbers and rates of cancer by type of cancer, race, ethnicity, age, gender, and geographic residence. In addition to all of its other responsibilities, the Registry provides data to the counties, which use the data to target cancer surveillance, screening, and prevention activities in conjunction with local health care providers and organizations. The review of state cancer data, to determine whether any particular area has more cancer than would be expected under normal circumstances, is a complicated task that requires additional resources beyond the other activities of the Registry and the health department. However, both the state and county health departments are committed to providing resources to this review of Registry data, because of community concerns.

5. What is the relationship between cancer and environmental exposures?

Very few cancers are known to be caused solely by environmental chemicals. The best known example of this is a type of cancer called mesothelioma, which is almost always associated with asbestos exposure. However, most cancer is caused by some combination of genetic factors, personal behaviors, and environmental factors. This makes it hard in most cases to determine whether a particular cancer in one person is due to environmental factors. This question is also complicated because in many cases the exposure that might have caused the cancer took place years or decades before the individual developed cancer symptoms. Since the Maryland Cancer Registry reports contain the individual’s home address at the time of diagnosis, an investigation “looking back” at home residence locations in the Maryland Cancer Registry would be limited to cases residing in the area of interest at the time of diagnosis and would miss persons who may have lived elsewhere at the time of diagnosis. This makes it harder to figure out how to interpret current exposure information because the exposure that might have caused the disease took place years, even decades, in the past.

6. What are the cancer rates in Frederick?

Cancer is generally measured in two ways, by incidence (the number of new cases relative to the whole population) and mortality (the number of deaths relative to the whole population). In Frederick County as a whole, the incidence rate for all cancers is 541.4 cases of cancer per 100,000 persons, which is higher than the state average of 463.2 cases per 100,000 persons (based on 2002-2006 data from the state cancer profiles database of CDC). However, the mortality rate for cancer in Frederick County for the same period was 187.6 per 100,000 persons, which is similar to the Maryland state average of 193.3 deaths per 100,000 persons.
The CDC’s data site can be found at http://statecancerprofiles.cancer.gov/map/map.withimage.php?24&001&090&00&0&1&0 &1&5&0#map.

The Frederick County Health Department conducted a Community Health Assessment in 2007 by surveying Frederick County residents. Participants were asked about a past diagnosis of non-skin cancer and modifiable risk factors associated with the development of cancer. The responses were then reported out separately for respondents from Central Frederick County, Northern Frederick County, and Southern Frederick County. The full Community Health Assessment can be found at http://www.frederickcountymd.gov/index.aspx?NID=2371 .
For more information: Question and Answers about Cancer Clusters (Maryland Department of Health and Mental Hygiene) http://fha.maryland.gov/pdf/cancer/mcr_combined_cancer_cluster.pdf

7. What was the scope of the preliminary cancer cluster investigation by the Maryland Department of Health and Mental Hygiene (DHMH)?

People who were living within what is approximately a 1-mile radius from the perimeter of Ft. Detrick Areas A and B whose cancers were diagnosed between 2000 and 2007 were included in the initial preliminary investigation using the Maryland Cancer Registry data, even if they have moved out of the area after diagnosis (one exception could be if they were active duty military and not seen in the civilian health care system). People who moved and whose residence at the time of diagnosis is out of the three Census Tracts were not included in the preliminary investigation.

The Maryland Department of Health and Mental Hygiene began its preliminary investigation using data that was already collected by the Maryland Cancer Registry. The initial cancer investigation is being conducted to answer questions and concerns that have been raised by Frederick County residents about cancer in the area, and proceeded independently of any ongoing issues related to environmental remediation at Fort Detrick. As additional concerns are raised as a result of this preliminary investigation and any future investigations, they will be addressed by the Frederick County Health Department, working together with the appropriate state and federal agencies.

8. Why was 2000 the earliest year of analysis in the preliminary report of the initial cancer cluster investigation?

The initial cancer cluster investigation by the Maryland Department of Health and Mental Hygiene started with the three census tracts that immediately surround Fort Detrick, Areas A and B. Data in the Maryland Cancer Registry contains census tract identification only for cases beginning in 2000. The reason to use census tracts is because census tracts are smaller areas than ZIP code areas and we know the population of the census tracts (the population is counted in each decennial census). Knowing the population at a given time allows us to compare the actual number of cases of cancer in the census tracts with the number expected, based on Frederick County and Maryland cancer rates. In future analyses, additional cases could be added from 1992-1999, but these do not have census tract data, and the analysis will require considerably more data processing or a much bigger geographic area (zip codes). Cases that occurred before 1992 are not in the Maryland Cancer Registry. An investigation of cases before 1992 would require an entirely different (and more difficult) approach from that of the preliminary analysis utilizing the Maryland Cancer Registry.

9. What were the preliminary findings of the DHMH cancer data analysis?

Preliminary results were presented during the October 4, 2010 Community Cancer Concerns meeting by the Maryland Department of Health and mental Hygiene. The number of cases of cancer observed in the 3 census tracts examined (for the time period 2000-2007, using the Maryland Cancer Registry source of data, and for the cancers selected) were not statistically higher than what was expected based on Frederick County rates of cancer, but the number of all cases of cancer observed in the 3 census tracts examined was statistically greater than the number expected based upon the Maryland rate for all cancers in the same time period using the same source of data.

10. Is the risk of non-cancer health conditions being assessed?

Cancer is the condition that has been most often mentioned in connection with community concerns surrounding Fort Detrick. It is also a condition that must be reported to the state, so there is a Cancer Registry that can be used to provide valid, reliable data for the investigation. At this juncture, cancer data was deemed the most appropriate way of conducting the investigation as it was the only readily available source of verified health conditions.

11. If significant excess cancers are found in a specific geographic area within the county, then what?

If cancer in the area is found to be above what would be expected based on Frederick County and Maryland cancer rates, the next question would be to look at the types of cancer that are increased, and at what kinds of factors are known or suspected of being associated with increased risk of these cancer types. This could provide clues as to what might be involved in contributing to an increase in cancer cases. Ultimately, if there are environmental conditions that are thought to be contributing to an increased risk of cancer, the health department will communicate that fact to the community and appropriate agencies and work to correct the problem. If other factors are thought to be involved, the Frederick County Health Department will work with the community to reduce cancer rates through its cancer prevention program and the work of the Frederick County Cancer Coalition.

12. Who can I talk to for more information?

For questions about the cancer investigation, you can contact the Frederick County Health Department, at 301-600-7400. Questions about Fort Detrick work conditions or the environmental investigation and remediation should be directed to Fort Detrick. Employees who are concerned that their health may have been adversely affected by their work environment are encouraged to speak to their employer, personal health care provider, or the Maryland Occupational Safety and Health program.