Document 6wo34qX02RMyeK8jkQm4xXa36

Appendix !. MAY 1976 CONTROLLING CANCER IN NEW JERSEY Let's Protect Our People Br^nd.m T. Byrne Gove-nor mu Jo.nmo F. Finley. M.H . Cnitmmsionet ol He.ilth l* H RSV 0013403 "Prevention of cancer should now take two directions: AVOIDANCE OF EXPOSURE TO CARCINOGENS IN THE FUTURE AND IMPROVED CARE OF PEOPLE IN HIGH-RISK GROUPS TO PREVENT OTHERWISE INEVITABLE DISEASE." 1 "AN EFFORT TO CURE CANCER AT THIS TIME MIGHT BE LIKE TRYING TO LAND A MAN ON THE MOON WITHOUT KNOWING Newton's laws of motion." 2 "Until more fundamental knowledge is achieved, cancer IS BEST VIEWED AS A PROBLEM OF DISEASE CONTROL AND PREVENTION." 3 RSV 0013404 BIBLIOGRAPHY RSV 0 0 1 3 4 0 5 >> *o M Z tzo OM oM XX >0 *-3 H- 0 U3 tr c n> id v> w U> CT> II H* t-* o Ln tn C 25 >jko: 'iwxr"iJtiH w nd> o h fat ptri 0-- Qm) > H-a(aD n> fD h- O t--* H 3 D.H- 0--** U>fD3 3 0m rft+ofd>rot1O(crutt) COnuiK(/1) O 1 *cU 1 *< 1ft-3fD rVtI OMtH-h IrDt Pn '0t->* < nrIDt (rHyt- vOHQ- nHrt>(/i m > iXn>J Hit-0c3 O "0 3O h HfDt Uft HO3 o3 O0-)* W1 OHi H 3* QH(WD ft fffttt fffffffttttttt ff%tffftffttftttt ft ff%tt fffffffttffftttttttt 3(3D OMfD rt . I3HD iQ3 . *. ft EHE- 3(<D s3Qi* WrH+jMo-oQal UX fHot>< 3W QfD) tfi * fffftttt fffftttt fftt *fffttt ft ffttft fffftttt fffttt fftt fftt ft *f*t ft ft fftt ft fftt fftt fftt fftt fftt fftt ft fftt ft O> zn tJOO O oz JHOrO # * ft fftt ft fffftttt to >o zoJd oc z o fffttt fftt fftt fffffttttt fffffffttttttt ft fffftttt fffftttt fffftttt fffttt ft fffftttt M HJzO oo Co M Oz fftt fffffffftttttttt fffffttttt ft ft ft fftt ft fffftttt fffftttt fftt ft fffffttttt 44k* xU>> UJ U> co fO K) to to to *- t-- 1--* M U> K) o 00 A u> UJ to CD Ul u> to t-- to *- I- Z o 3 w tM- S ooz HMz a Table 1 Figure 1 Table 2 Figure 2-5 Tables 3-10 Table 11 Figures 6-15 Figure 16 Table 12 Figure 17 TABLES & FIGURES Pg. Nos. The Most Common Cancers............................................... 2 Rates of Cancer in New Jersey and the United States by Race & Sex per 100,000 population, 1950-1969________ Ratios of New Jersey County Mortality 3 Rates to the United States Mortality Rate: All Malignant Neoplasms 1950-1969 ...................................................................... 5 Ratios of New Jersey County Mortality Rates to the United States Mortality Rate by Race & Sex ................................................ 6-9 Ratios of New Jersey County Mortality Rates ta the United States Mortality Rates for Various Cancer Sites (Appendix II)................................................................ 47-54 Known (or Probable) Carcinogens and Their Uses . ......................................... Ratios of New Jersey County Mortality 16 Rates to United States Mortality Rates for Various Cancer Sites in Specific Races & Sexes (Appendix I). 35-45 Natural History of Untreated Disease... 18 Health Education Action, Activities & Agency Involvement in Cancer Control ............................................................................ 25 Cancer Control Cycle................................................... 31 RSV 0013406 INTRODUCTION New Jersey ~ the nation1 s most densely populated state and one of its most highly industrialized -- has taken on a new distinction in recent years; the nation's most cancer-prone state. Cancer has long been recognized as a nationwide and a worldwide problem, and statistics such as those highlighted in Table 1 -- (see page 2) have alerted us to the growing dangers and ever increasing incidences of certain types of cancers. Hew Jersey has the highest overall mortality rate for cancer in the United States. New Jersey's cancer rates for males, females, whites and non-whites alike are in excess of the national rates (see Figure 1}. For certain specific cancers, the mortality rates in New Jersey are strikingly high, particularly for cancer of the bladder, which has been shown to be related to certain chemicals such as beta-naphthylamine used in the manufacture of dyes and pesticides. At the same time, New Jersey has one of the greatest con centrations of chemical plants in the world. One chemical, vinyl chloride (a known cause of angiosarcoma of the liver), is manu factured in 58 plants in the U.S., five of which are in New Jersey. It is a plausible hypothesis -- although, as yet, an unproven one -- that a part of the very high cancer mortality in New Jersey may be related to environmental factors and, specifically, the occupational environment (see Table 1}. The New Jersey Department of Health believes that in those instances where a cause and effect relationship could be empirically demonstrated between occupational environments and cancer, preventive measures can be instituted that would have a significant effect on the health of the public. Sometimes cancer might be prevented altogether. Certainly, alarming death rates can be reduced. When a problem is of this magnitude, a scientifically grounded, people-oriented control program is imperative. This must use all the exper tise of involved and interested federal, state and local agencies with the New Jersey Department of Health as the lead agency. A discussion of such a Cancer Control Program follows. BACKGROUND OF CANCER PROBLEM New Jersey has among the highest rates of cancer mortality of any state in the nation. Mason and McKay1 showed that in the 20-year period 1950-1969, New Jersey led the nation in cancer mortality for white males, with a death rate of 205.01 per 100000 population, compared to a national rate of 174.04. For white females, the New Jersey mortality rate of 147.92 was exceeded by only one other state, and compares to a national rate of 130.10. For non-white cancer mortality, New Jersey i RSV 0013407 TABLE 1: The Most Common Cancers She Nf Csm Deaths Change In incidence I976tesi.)1976 test.) Over Fast IS Years (AU Stages! 5-Year Survival Rate* Localized** Stomach 23.000 14.000 -62% 137b 41% Mortality rate has declined 40 percent over the past smoked fish or meat, pickled vegetables, dried salted twenty-five years, for reasons unknown High-risk fish; some association with type A blood group, groups native Japanese; persons with close relatives Symptoms, chronic indigestion, who have had the disease, frequent consumers of Colon-rectum 99.000 46.000 --3% ` 44% 71% Occurs more frequently in urban and developed countries, lions as familial polyposis. For earliest possible detection. Suspected dietary influence. High risk, groups: persons digital exam and proctoscopy should be included in having ulcerative colitis for more than ten years, or with routine checkups, especially with persons over forty, close relative having such genetically influenced condi- Symptoms: change in bowel habits, rectal bleeding. Pancreas 22.000 20.000 +22% 1% 5% Seen most often in men fifty-five and older, particularly in pancreatitis. Is extremely difficult to cure because bUcks High-risk groups: cigarette smokers; diabetics, es- symptoms are not manifest until disease has already pccmIIv women; professional chemists and chemical metastasized. Symptoms: pain in abdomen and back, workers, persons with dose relatives who have hat] weight loss, some jaundice. Lung 93.000 84.000 +12971. 9% 33% Leading cause of cancer deaths among men; sharply rising of the larynx, oral cavity, bladder, and pancreas.) Early mortality rate m women Possibly 80 percent of lung detection: chest X ray, sputum exam, especially for men cancer would be prevented if cigarette smoking were over forty-five who smoke. Symptoms: persistent cough, stopped < Smokers also run a higher risk of getting cancer lingering respiratory discomfort. Breast, 88.000 33.000 4-4% 64% 84% female Leading cause or cancer deaths in women. High-risk and/or late menopause. Cancer in one breast increases groups: women over age thirty-five, especially whites; risk for other breast. Best detection: regular self-ex women who have never had a child or who bore first child amination. annual checkup. Symptoms: lump or after age thirty; women with a mother, sister, or aunt thickening in breast, who has had the disease; women with early menarche Lterus 47.000*" 11.000 -37% 64% 81% Mortality rate has declined 65 percent during the past birth-control devices is unknown. Early detection: post- forty years probably because of wider use of Pap test, menopausal women with abnormal bleeding should gel Possibly associated with early and/or frequent sexual exam: every woman should have an annual pelvic exam activity. High risk: women who had first child at an early with Pap test. Symptoms: unusual bleeding or discharge, age. seen more frequently in American blacks. Effect of Ovary 17.000 11.000 -10% 32% 76% Mortality rate is down slightly over the past twenty-five under 35. High-risk groups: women with dose relatives years Most common between ages 65-69; infrequent who Have had the disease. Symptoms: irregular menses. Prostate 56,000 19.000 +23% $6% 68% Rare in men under fifty: uncommon in Orientals. Indians, lion, checkup should include urinalysis and palpation. Mexicans, and Filipinos. Familial risk. For early detec- Symptoms: urinary difficulty, bleeding, discharge. Bladder 30.000 10.000 + 7% ' 61% 72% Over the past twenty-five years, incidence rate has in- High risk groups: industrial chemical workers; cigarette creased 21 percent for men and decreased 26 percent Tor smokers. Early diagnosis is by means of urinalysis, women. Strong association with industrial carcinogens. Symptoms: urinary difficulty, bleeding. * Adjusted ini normal life expectancy. *' Localized refers io cancers caught before metastasis occurs. **' Does not include carcinomas m situ icervical cancer), which would add 40.000 cases to the figure. Numerical data based on figures published by the American Cancer Society Leukemias (21.000 new cases) and lymphomas (30.000) omitted. RSV 0013408 FIGURE Is RATES OF CANCER IN NEW JERSEY AND U. S. BY RACE AND SEX 250 PER 100,000 POPULATION, 1950 1969 230 NEW JERSEY 200 U. S. 163 150 148 139 130 100 50 0J WHITE MALES NON-WHITE MALES WHITE FEMALES NON-WHITE FEMALES 3 RSV 0013409 ranks fifth among the states (excluding the District of Columbia) for both males and females, with rates of 230.33 and 163.41 respectively, compared to national morality rates of 164.28 and 139.18. Mason, et alA showed that almost every county in New Jersey has overall cancer mortality in the top decile for both white males and females. The relative ratio of New Jersey cancer rates by county as compared to the national rate, by sex and race, is ex hibited in Table 2 and Figures 2-5 on the following pages. As can be seen, most cancer death rates in New Jersey are greater than the national average. These data are presented graphically for race and sex, as well as for specific cancer sites in Figures 6-15 (See Appendix I) and tabulated in tables 3-10 (See Appendix II). If the bar goes farther to the right than the ratio of 1, it shows that the New Jersey rate exceeds the national average. These data by county and cancer sites are not presented for non-whites, because some of the numbers are too small to make the comparison statisti cally valid. However, where the data can be compared, they suggest that the same problems exist for non-whites in New Jersey. 1) Bladder and lower urinary tract (Figure 6 Appendix I) This is perhaps the most striking example of a high specific cancer mortality rate in New Jersey. Mason and McKay showed an adjusted white male rate of 9.68, giving New Jersey the highest mortality rate in the nation, far in excess of the national rate of 6.78. While the rate for white females is high in New Jersey, it is not nearly as striking as the male rate, with Hew Jersey ranking twelfth among the states (5.94 compared to a national rate of 5.05). Such sex-related information suggests the possibility of an occupational relationship among males. Among non-whites, New Jersey shows a death rate for bladder cancer that is fifth and sixth among the states for males and females respectively. County data are even more striking. Mason et al noted that 18 of the 21 counties in New Jersey have white male bladder cancer mortality rates in the highest decile of all United States counties. The rate for Salem County (16.1) is the top of all United States countiesvith a population of over 10,o6o, and far exceeds the national rate of 6.8. Twenty-five percent of the male labor force of Salerr. County is employed in ^the~chemical industry. While the Salem County rate is suspected ot being related to a single large chemical plant, there is obviously a higher risk of bladder cancer in many parts of Mew Jersey deserving of investigation. RSV 0013410 4 Table 2 Ratios of New Jersey County Mortality Rates to the United States Mortality Rate: All Malignant Neoplasms - 1950-1969 New Jersev Atlantic Countv 3eraen Countv 'urlincton Countv C-mcen Countv '=ce Mav Countv Curtoerlanc Countv Cssex County loucester Countv Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean Countv Passaic County Salem County Somerset County Sussex Countv Mr..:, or. C tun tv Harrer. Count'/ White Males 1.18 1.12 1.16 1.08 1.18 1.12 1.04 1.24 1.10 1.33 1.01 1.18 1.27 1.14 1.03 1.07 1.20 1.07 1.05 1.04 1.17 1.09 Nonwhite Males 1.25 1.19 1.53 1.17 1.24 1.00 0.85 1.19 0.99 1.57 1.61 1.10 1.51 1.22 1. 35 1.44 1.47 1.26 1.23 4.96 T "T 1.49 White Females 1.14 1.12 1.14 1.08 1.14 1.10 1.08 1.19 1.09 1. IB 1.10 1.12 1.15 1.13 1.04 1.05 1.14 1.13 1.04 1.08 1.17 1.14 Nonwhite Females 1.17 1.08 1.38 1.01 1.27 1.27 1.04 1.11 1.05 1.42 2.18 1.08 1.50 0.97 1.22 1.66 1. 31 1.16 1.64 3. 34 1.19 1.35 RSV 0013411 FIGURE 2: RATIOS OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE: ALL MALIGNANT NEOPLASMS 1950 1969 WHITE MALES 0 1 1 U.S. RATE 1 J S .4 . . .7 .1 .* .1 .2 .3 .4 .5 - .7 .9 .9 1 '-----1----1----- 1---- 1-----1-----1----- ---- 1-----1-----1----1--7 T----- 1-----1 1 New Jersey Atlantic County Bergen County Burlington County Camden County 1 1 1 ' -------- 1 "1 ------- 1 ------- 1 Cape May County ___ J Cumberland County p Essex County 1 .1 .2 .3 .*__ t--r 1--r Gloucester County Hudson County 1 _T Hunterdon County Mercer County 1 Middlesex County Monmouth County .1 -------1 Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County Warren County Stare Institutions Military Posts Key: Relative rate of 1 no difference between N.J. rates & U.S. average rates. Prepared by the Public Health Statistics Program New Jersey State Department of Health 6 RSV 0013412 FIGURE 3: RATIOS OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE: ALL MALIGNANT NEOPLASMS 1950 -1969 NON WHITE MALES US. New Jersey Atlantic County Bergen County Burlington County Camden County Caoe May County Cumberland County Essex County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County Warren County State stitut'ons Military Posts Prepared by the Public Health Statistics Program New Jersey State Department of Health 7 RSV 0013413 FIGURE 4: RATIOS OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE: ALL MALIGNANT NEOPLASMS 1950 -1969 WHITE FEMALES US, RATE New Jersey Atlantic County Bergen County Burlington County Camden County Caoe May County Cumberland County Essex County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County '.Varren County State Institutions Military Posts Preoared by the Public Health Statistics Program New Jersey State Department of Health K RSV 0013414 FIGURE 5: RATIOS OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE: ALL MALIGNANT NEOPLASMS 1950 -1969 NON WHITE FEMALES U.S. New Jersey Atlemic County Bergen County Burlington County Camden County Caoe May County Cumberland County Esse* County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County Warren County State institutions Military Posts Prepared by the Public Health Statistics Program New Jersey State Department of Health 9 RSV 0013415 2) Gastrointestinal tract and associated organs (Figures J-13 Appendix I) The cancer mortality for almost all of the gastrointestinal tract and associated organs is exceedingly high in New Jersey. For cancer of the esophagus, New Jersey ranks fourth and fifth among the states for white male and female rates respectively; for stomach cancer, New Jersey is third and fourth among the states for white males and females; for large intestine, except rectum. New Jersey is second and first for white males and females. The rates for non-whites are not as striking, but are still high, particularly for cancer of the rectum, where the non-white female rate for New Jersey is highest in the country. New Jersey also shows particularly high death rates among some groups for cancers of the liver, biliary tract and pancreas. The State is fourth in the nation in white male liver and biliary passage cancer mortality; fourth in the nation in white male pancreas cancer mortality; and third in the nation in white female cancer mortality. 3) Respiratory tract (Figure 14 & 15 Appendix I) In both the upper and lower respiratory tract. New Jersey has high cancer mortality. In cancers of the tongue, mouth and oral pharynx, New Jersey ranks sixth for both white and non-white males. Similarly, high rates are seen for laryngeal cancer in males, where New Jersey ranks fifth and third for white and non-white males respectively. For nasopharynx, New Jersey is seventh for white males and fourth in rank for white females. Mortality in New Jersey for cancer of the trachea, bronchus and lung, is high "across the board." New Jersey ranks third for white males, fifth for non-white males, fourth for white females and sixth for non-white females. In county pro files, while almost all New Jersey counties have high white male mortality ratesT it is particularly striking in the more industrial northern portion of New Jersey, in counties"such as Passaic, Bergen, Essex and Hudson. 4) Breast (Table 7 Appendix II) New Jersey has particularly high rates for breast cancer, both male and female. In all RSV 0013416 JO race-sex categories. New Jersey ranks third among the states for breast cancer mortality, except for non-white females, where New Jersey is fourth. The high rate of breast cancer in females is especially marked in counties near the cities of New Yor)c"~and Philadelphia*! ~~ 5) Other Cancer Relatively high mortality is present in New Jersey for uterine cancer, excluding the cervix uteri, where New Jersey ranks third among white females, and for the ovary, fallopian tube and broad ligament cancer, where the State is first for white females and fifth for non-white females. New Jersey also has high cancer mortality for some categories of endocrine cancers. In thyroid cancers among whites, the State is sixth and third for males and females respectively. For other endocrine glands, the State is fourth for white females. New Jersey also has a high relative mor tality for neoplasms of bone in non-whites, ranking third and second for males and females respectively. RSV 0013417 11 CANCER CONTROL From the long range point of view, the most effective method of cancer control is prevention. This is best accom plished by identifying the causes of cancer and curtailing their presence in the environment. In today's state of knowledge, several factors have been thought to be causative of cancer, some of which may be interrelated. These include genetic factors, viruses and environmental factors. It is now believed that environmental factors play a much larger role in causing cancer than was previously thought. Preventive aspects of cancer control can be divided into two areas; namely, 1) collecting evidence of what causes cancer; and 2) controlling known or suspected cancer causes. The collection of evidence, supported by scientific findings, will necessarily require a multi-faceted approach. On the one hand, compounds with known cancer causing effects must be located in our personal environments (high-risk areas must be identified). On the other hand, rates of cancers must be defined. We must know in whom, where and when cancers of various sites of the body occur (development of a cancer reg istry). From the basic data, it is possible to scientifically ''zero-in" on why cancer rates are high in certain groups and not in others. The working hypotheses can be tested (epidemio logical investigation). Armed with this new knowledge of the causes of cancer, programs of prevention, control and protection can be designed. 1. Cancer Registry One of the highest priority needs in New Jersey at the moment is a simple cancer registry. This is basic to all the information gathering systems that will be needed. There is no method now in use to determine the occurrence of cancer in New Jersey. The only method we have of any knowledge of cancer in New Jersey is mortality data. This is insufficient for the development of adequate data. A registry of the occurrence of cancer in specific pop ulations is need. As an example, the State Health Department at present is involved in the study of bladder cancer through a grant from the National Cancer Institute. Cases for the study are based on the only registry we now have available -- the death certificate registry. Since the causal exposure may have occurred two decades prior to the diacmosis of the cancer, it is obvious that interviewing live patients available through an incidence cancer registry would be much more valuable and productive than the minimal data available on a death certificate. RSV 0013418 12 The data generated by a cancer registry will be most valuable in at least two instances. First, major varia tions in rates of cancer may be pinpointed. This informa tion will generate hypotheses that can be tested. Secondly, an increased rate of disease in a particular location such as near an industry, in a particular work setting, or in the delivery pattern of a water supply, should trigger a search for carcinogens in the environment by the Department of Environmental Protection. If particular .industries display a pattern of cancer higher than that in populations nearby, a whole armanentarium of occupational health expertise should be set in motion. The Public Health Council has the power to make cancer a reportable disease. They are prepared to do so. But simply to make cancer a reportable disease without the resources to effectively use the data that would be generated by this reporting system would be of little value. What is obviously necessary is the establishment of a system of data utiliza tion. It is anticipated that reporting of cancer from diagnostic laboratories will be a wholly adequate method for New Jersey. Almost every cancer is diagnosed, at some point, in a laboratory. In the climate of laboratory reporting that has already been generated in New Jersey, it is estimated that 95 percent of the cancers could reach the registry by this route alone. The addition of other methods of reporting would get the last 5 percent, but would so greatly add to the cost of registry that it would not be cost effective. The data from the registry would be available to State and other qualified investigators. Methodology will have to be established to insure confidentiality for individuals, and at the same time provide necessary data for proper investiga tion. The cancer registry is necessary to provide the correla tions between the occurrence of cancer cases and possible environmental factors. It is also necessary for proper evalua tion of cancer treatment and prevention measures that are currently in progress, or will be initiated in the future. The question to be answered is: has the incidence of a particular cancer decreased with the institution of early detection, adequate treatment and follow-up programs for that particular cancer? 2. Epidemiologic Investigations The New Jersey State Department of Health is in a position to lead other interested state and federal agencies in investigating possible environmental relationships to high cancer mortality in our state, and to institute appro priate preventive measures and controls. This Department RSV 0013419 13 has demonstrated over the years an expertise in epidemiology -- the "detective work" of public health -- that has become nationally known and respected* The current example of this ability is the identification by the New Jersey Department of Health of the "Swine" influenza outbreak at Fort Dix; but other examples in the infectious disease field -- in hepatitis and in virus disease spread by mosquitoes -- are abundant. In the noninfectious disease area, investigations into relationships of phenothiazines to encephal opathies and possible adverse effects on human health of pesti cides have been conducted. Since the expertise required for cancer epidemiology is essentially the same as that which we have already demonstrated in studying infectious and noninfectious diseases, this Depart ment is confident that it can expand into this new area if adequate resources are provided. The State Department of Health has custody of, or direct access to, vital records and hospital and laboratory reports that are critical to good epidemiologic research. In addition, we have developed a close relationship with hospitals allowing review of necessary records, and reporting, that has allowed epidemiologic investigations throughout the State. The Depart ment also has regulatory authority over hospitals and labora tories to assure access to data. Thus, we are uniquely qualified, competent and able to investigate the problem of Cancer in New Jersey. Epidemiology is the study of the occurrence, distribution and cause(s) of disease. With the information gained through the registry, epidemiological investigation may begin. Two areas of investigation are indicated: 1) the study of distribution of the cancer and 2) the search for the causes of the observed distribution. The first activity would describe the type and site of cancer in terms of age, sex, race, residence, occupation, family history, personal habits such as smoking, diet, cultural factors, and would point out variations in the distribution. The second area would attempt to explain why the distri bution is different in one population group than in another. Hypotheses will be developed as to potential cause and statis tical methods utilized to test the significance of these hypo theses . These types of investigations and information provide the scientific basis for measures to control cancer. RSV 0013420 14 In other words these studies allow us to pinpoint the at-risk population and environment, and to institute indicated controls. 3 . Identification of High Risk Areas Fourteen chemical agents have already been recognized as probable or proven human carcinogens by HEW's National Institute of Occupational Safety and Health (NIOSH). The chemicals and their uses are tabulated in Table 11 on the following page. We do not now know what quantities of these known carcinogens are manufactured, used, or imported into the state. We do not know what plants use them, manufacture them, or produce them as by-products of some process. We know nothing of the identity, or numbers of workers who come in contact with them, nor of the levels to which they are exposed. We do not have the necessary knowledge of the industrial screening and medical services available to the workers exposed to these substance, or the protections offered them. We have little idea whether humans acquire cancer from exposure to these substances by repeated occupa tional contact, or by their release through sewage, air, or other means, including even transport by workers' clothing into their households. These known significant carcinogens must be traced through New Jersey. We must know how much is imported and how much is produced, who is exposed and what are the con sequences of such exposures. Specific knowledge that carcinogens are utilized in a particular industry will suggest searching the cancer registry for excess cases working in that industry. Failure to identify excess cases will justify re-directing attention to the next highest priority carcinogen. However, documenta tion of increased risk will mandate further analysis such as length of exposure, adequacy of customary protective devices, interactions with other cancer risks such as smoking, etc. Suspicious findings from the registry in the environs of an industry using a carcinogen will mandate a search for environ mental contamination. We view this cataloging as an ongoing process. As suspicious agents are suggested, industries utilizing the agent must be catalogued by the Department of Labor and Industry. Carcinoqen-use cataloging by the Department of Labor and Industry will be a new endeavor. The law on which this effort will be based will have to be reviewed and the mechanism for its implementation will have to be developed. RSV 0013421 15 TABLE 11: KNOWN (OR PROBABLE) CARCINOGENS AND THEIR USES . AGENT 4-Nitrobipheny1 Alpha Naphthylamine 4,4-Methylene bis {2 - chioroaniline) Methyl chloromethyl ether 2,2-Dichlorobenzidine 3is-chloromethy1 ether Beta Naphythy1amine Benzidine 4-Aminodipheny1 Ethyleneimine ."3eta Propiolactone 2-Acetylaminofluorene --Dime thy iaminoszooenzene M- Mitrcsodime tnyi amine j USES Analytical standard In manufacture of herbicides, dyestuffs, food colors and color film, paint, plastics, rubber and petroleum products. Curing agent for epoxy and other polyurethane resins. In manufacture of ion exchange resins, textiles, and drugs. In manufacture of printing inks, dyes, plastics and crayons. In manufacture of ion exchange resins. In manufacture of dyes and pesticides, in Photography, and as a chemical reagent. In production of dyes, rubber and plastics, printing ink, fire proofing and in medical laboratories. As an antioxidant in rubber manufacture and as an intermediate chemical in dye production. In paper and textile industries in herbicides, resins, drugs, and jet fuel. In plastic manufacture. Potentially as a herbicide As a dye. As an industrial solvent and in svnthesis of rocket fuel. RSV 0013422 The registry, therefore# will be used to evaluate the extent of the potential problem created by industrial use of carcinogens. Most carcinogens will be adequately contained, but when rates generated by the registry suggest, and epidemic logical studies confirm that the carcinogen is actually respon sible for cases in a specific locale, controls will have to be instituted to limit the exposure. The laws necessary for such control activities will have to be reviewed, and supplemented where necessary. Thus, by homing-in on agents demonstrated to be actually carcinogenic, in regions where the registry has identified high cancer rates rather than sampling hither and yon, from the long list of potential carcinogens, we will both most effectively expend our resources and protect the public*s health. In summary then, based upon the epidemiological investi gations of the State Department of Health alluded to above, certain environmental and biological specimens will be obtained from "high-risk" areas and "at-risk" persons by the Department of Environmental Protection and the State Depart ment of Health respectively. The laboratory testing of these specimens will indicate what particular chemicals are polluting the environment, particularly in the work place, and indicate that engineering techniques must be changed to control and prevent the release of these materials, or that known protective measures must be vigorously employed. The laboratory testing is an integral part of a meaning ful occupational health and safety program to insure the well-being of our work force. Currently, due to Federal malaise and historically due to weak state leadership no statewide program of occupational health and safety exists. Such a program should be re-established in the State Depart ment of Health, initially as part of our Cancer Control Program. The epidemiological investigations that pinpoint the areas to be studied by laboratory methods will lead to true primary prevention, i.e. finding a population with a high frequency of a particular cancer, identifying the deter minants of that cancer and instituting the necessary regula tions and controls to prevent the people from being exposed to or coming in contact with the causal agent. RSV 0013423 17 4. Early Detection--'Screening Certain cancers in the early stages are amenable to mass or selected screening programs which are now sometimes provided by various agencies at various times with out coordination. There should be a coordinated effort led by the New Jersey Department of Health utilizing the expertise of the Medical and Osteopathic Societies, American Cancer Society, local health departments, hospital clinics, neighborhood and family health centers and industrial medical programs to provide for early identification of rectal cancer by rectal exam, cervical cancer by pap smear, oral cancer by oral exam and breast cancer through self examination,regular palpation and possible thermography or mammography. The Department will utilize and encourage those screening techniques that have been found to be costeffective and technically sound in identifying potential cancers and will continually evaluate newly proposed methods by limited clinical trials before embarking on a mass screening technique. The Department, in essence, will be involved in the evaluation of the effectiveness of screening techniques, and then the encouragement to the local agencies to utilize the effective methods, rather than "jumping-on-the-bandwagon" for any newly described procedure. The purpose of any screening program is to intervene as early as possible in the course of disease. If we look at the model^ below of the natural history of un treated disease in an individual and deal with cancerthe disease in question--then we can see that during the periods C-D (early physiologic changes) and D-E (early symptoms), are the times when screening techniques for cancer would be most effective i.e. before the cancer has progressed too far. FIGURE 16: The Natural History of Untreated Disease Birth Exposure to Risk D Precursory Physiologic Changes Early Symptoms TIME 18 Frank, but not dis- abling ill ness Disabling Illness 4 Death RSV 0013424 Several screening techniques that are accepted and/or in the developmental stages will be discussed briefly. Cytological Screening For a number of years the use of cytology (the microscopic examination of body cells) has been advocated and studied as a selective screening procedure to identify early cancer in various sites. Cervical Cytology The most widely accepted and one of the most easily accessible sites for this technique has been the uterine cervical smear (Pap test). Cervical cancer discovered early in its course (in-situ) by this technique has an almost 100% cure rate. The rate drops when the cancer becomes invasive. All women, over the age of 30 years, should have a Pap test at least annually in order to detect the disease as early as possible. A recent study in Massachusetts however, indicates that the most important age groups to test, are not being reached. Routinely, women in the childbearing ages are given Pap tests prenatally, early in pregnancy, in family planning clinics or during their annual check-up. The study showed that only 44% of the total number of Paps were performed on women over 35 years of age. Women in this age group accounted for 97.5% of the deaths due to cervical cancer and more importantly the death rate increased steadily with age while the proportion of women who had Pap tests decreased with aoe. The means for early detection and virtual elimina tion of cervical cancer through proper treatment is readily available, yet thousands of women nationally, and hundreds in New Jersey, annually die needlessly of this disease. In fact, a study in British Columbia screened 80% of the women over 20 years of age and the mortality for this group fell from 11.4 deaths per 100,000 population in 1958 to 6.9 deaths per 100,000 in 1970. The incidence of clinical cancer of the cervix in the screened group was only 14% of the un screened population.* The State Department of Health has recently submitted an application to the Department of Health, Education and Welfare's National Cancer Institute to support a statewide program of cervical cancer screening follow-up in the high-risk populations. This is one of the few programs of cancer control which NCI budget presently supports. With the proper word from Congress, which "watch-dogs" NCI's budget, some programs of environmentally related cancer control might also be supported in States such as New Jersey. and 19 RSV 0013425 Bladder Cytology Certain industrial processes are associated with a high incidence of bladder cancer. Selective urinary cytologicai screening of this population is of value to identify bladder tunors in their early stages. Such a selective screening program is indispensable in any work setting where the hazard of occupational exposure to potential bladder carcinogens exists. Urinary cytology is also indicated for patients presenting with any symptoms suggestive of urinary tract cancer.^ I.ung Cytology Several researchers have advocated that heavy smokers with a productive cough be screened cytologically.-i^ If the sputum shows abnormal cells, then the fiberoptic bronchoscope-, would allow visualization of all major areas of the lung and possibly locate an operable cancer. Colon and Rectal Cancer Screening Over 2,000 New Jerseyans die annually from cancer of this site yet the American Cancer Society contends that approximately 75% of these patients might be saved through early diagnosis and treatment. One method being advocated annually for all patients over 40 years of age and those with a history of cancer, ulcerative colitis, polyps or familial polyposis is a take-home specially prepared slidepacket to test for occult blood in stool specimens. On three successive days--because gastrointestinal bleeding may be intermittent--the individual patient smears thin fecal samples on a paper slide and then mails the slides to the physician or lab. The addition of a specially prepared mixture to the sample by the physican or technician pro duces a bluish-ring on the slide paper if any blood cells are present. Persons must be on a meat-free, high-residue diet. They must not take medications containing iron or aspirin during the testing period, nor be bleeding from hemorrhoids or menses prior to taking the specimens. This test has been well received by patients. It can be used as a mass screening device by labor groups and community organizations, with cooperating physicians and laboratories. It does not provide conclusive evidence of the presence or absence of pathology, but it raise's the index-of-suspicion and helps the physician to decide whether and which diagnostic procedures are indicated. A recent report on a 25-year follow-up study of 18,000 persons older than 50 years emphasizes the value of periodic proctoscopic exams for colon and rectal cancer. Those individuals who had received the periodic exams had a cancer rate of onl'^ 15? of that expected if exams had not been done regularly .ir. RSV 0013426 Experimental Techniques Active research has led to techniques for identifying potentially carcinogenic agents much earlier than is pre sently possible. Animal studies have proved meaningful. It has also proven useful in identifying persons in the population that may be more prone to develop cancer due to inherited traits. Mutagenesis If a chemical is carcinogenic (capable of producing cancer) then it might also be mutagenic (capable of pro ducing a genetic change in a cell). It has been found that when such an agent is "fed" to microbiologic (bacteria cells etc.) systems, genetic changes may occur in the cells. Individual cell duplication can be visualized and changes identified more rapidly than from present methods of research on the interaction of agents with animal tissues. This gives researchers a new method to identify potential carcinogens. Controls can then be applied more rapidly, to protect indivi duals from contact and exposure to the particular agent. This is an important screening technique to which the State's laboratory could be adapted. Differing Susceptibility to Cancer Susceptibility to cancer appears to be inherited, or at least a predisposition to develop cancer under the right conditions seems to be inherited. Some persons have a higher susceptibility to develop cancer than others.id. Studies indicated, in the past, that particular types of cancer tended to occur in families. Newer studies,, however, show that relatives of cancer victims even appear to be at increased risk for completely different cancers.il Growing evidence indicates that the metabolite(s) of a chemical rather than the parent chemical may be carcino genic and that the human body reaction to a specific metabo lite depend upon certain enzyme levels in the body. One such enzyme which increases markedly with certain chemical exposures is aryl hydrocarbon hydroxylase (AHE). The levels of this enzyme activity appears to be genetically determined. Subsceptibility to lung cancer, for example, is associated with higher levels of AHH activity. If this work can be further substantiated, then future screening programs might include tests for "AHH inducibility." Those persons found to have highly inducible enzyme activity would require closer and more frequent screening and possibly even ex clusion from the hazardous environment.!! Work placement physical examinations are used in enlightened industries. Certain workers can do certain things, and should not be introduced to other activities. Placement by standards of physiologic protection does not exclude people from the work place, but rather ensures the use of their talents for a greater number of productive years. RSV 0013427 This potential screening technique could identify sus ceptible individuals before they become exposed to potential carcinogens and prevent the occurrence of disease. These techniques are in the developmental stages, but emphasize the fact that through scientifically grounded programs we may be able to effectively and efficiently identify potentially hazardous chemicals and potentially susceptible individuals. Then, through these techniques effect a change in environmental contamination and indivi dual exposure in order to prevent cancer. Follow-up and Treatment All screening programs must provide the mechanism whereby a positive screenee and his physician is notified and proper action instituted. It is, incumbent upon the State in conjuntion with the organizations and individuals mentioned above, to make maximum use cf present means for detecting cancer in its early stages and insure prompt definitive follow-up and treatment. It is not the role of the State to carry out treatment tut it is the State's role to assure the quality and effect iveness of the therapy in each institution after appropriate referral is made. This assurance is accomplished through the State's responsibility to set standards for the operations and staffing of health facilities. Also, the certificate-ofneed process ensures that there is a documented need for the specific cancer treatment modality in a specific area of the State and that the expertise to operate such a facility does indeed exist. Furthermore, through the development of the cancer registry, institutions would be encouraged to develop active evaluation committees to study the effectiveness of their diagnostic methods and treatments of specific cancers. Once the registry is established and statis tics are available, we will be able to define that cer tain cancers in certain hospitals are diagnosed much later in their course than in other areas of the State because the five-year survival rate for a specific cancer is markedly different from one area of the State to another. This will tend to push hospitals to be more effective in increasing their survival rate be cause they will not want to look "bad" compared to other New Jersey hospitals. The New Jersey Cancer Institute once fully estab lished will have an integral role in assuring that upto-date, effective means of diagnosis and treatment are instituted throughout the State, and will depend on the registry tc conduct their own scientific investigations of the effectiveness in diagnosis and treatment in various institutions. RSV 0013428 6. Laboratory Support Cancer investigators will be searching for carcinogens in human and environmental samples. Control programs, in part, will be based on eliminating exposure to carcinogens. Laboratory facilities capable of analyzing for carcinogens at levels of parts per billion are a necessary part of this effort* Essential to this laboratory effort is a gas chrom atograph and support personnel. The Chemistry Laboratory of the State Department of Health has had experience in the field of gas chromatography, primarily in a pesticide re search project, using equipment loaned by the Federal Gov ernment. This experience should be expanded. As mutagenesis testing becomes an accepted screening technique for identifying potential carcinogens, then the State Department of Health Laboratory should be equipped to augment studies performed at the Federal level for chemicals peculiar or common in New Jersey. The State Department of Health Laboratory role in other laboratory services, (cytological examinations and AHH enzyme activity) is to insure the quality of the in dependent and hospital laboratory services through the States* Clinical Laboratory Improvement Program. 7. Health Education If there is to be control of existing disease as well as prevention of occurrence and progression of cancer, then Health Education must be an integral part of each aspect of the program. The incidence and mortality from various types of cancer, but especially lung cancer, are broadly the re sult of the use of tobacco, especially cigarette smoking. If we are really to effectuate a change in cancer incidence and mortality then this one factor must be attacked vigorously. Tobacco-related cancer can best be avoided, of course, by avoiding the cigarette habit. Education programs must be developed and directed to sensitive and susceptible age groups especially the young schoolage child. This is very important because the younger the individual is when he begins smoking, the greater the chance of developing lung cancer and other related diseases. For the established smoker other possibilities exist. First, is enticing the individual into parti cipating in "smoke-ending" clinics and programs by RSV 0013429 23 interesting him more intimately in his personal health and assuring him that the effects of cigarette smoking, are not irreversible except after very long, excessive use. Second, is through the release of information on the tar and nicotine content of cigarettes to give smokers the alternative of smoking cigarettes with lower concentrations of these substances. The tobacco industry appears to have been motivated through this technique to decrease the levels of nicotine and tar, because of the potential competetion for sales. Ulti mately, State and Federal legislation or regulations with maximum allowable concentrations for tar and nic otine may be enacted and promulgated. Uppermost, in cancer control and in any control program is the prevention and early detection of disease. In order for this to occur, there must be a high-index-of-suspicion in the professional and lay community. The Cancer Control Program must by necessity address the health education activities outlined in Table 12 on the following page: 8. Role of State Agencies Several state agencies are necessary for the implementation of an effective Cancer Control Program. The tasks of each of these agencies as they relate to the entire program follows : Department of Health 1) Registry - A cancer incidence registry of diagnosed cases in New Jersey patients. 2) The epidemiologic process - Define in whom, where, and when, cancer rates in New Jersey are high. From these data, establish through further in vestigation why the cancer rates are high in certain groups and not in others. From this knowledge, programs of prevention, control and protection can be designed. 3) Prevention primary - curtail the known carcinogens in relation to populations at risk; secondary - develop methods, or apply known methods for early detection; develop and apply workable health education methods to change human behavior to reduce exposure to carcinogens. RSV 0013430 24 TABLE 12: HEALTH EDUCATION ACTION, ACTIVITIES, AND AGENCY INVOLVEMENT IN CANCER CONTROL ACTION TYPES OF ACTIVITIES TYPES OF AGENCIES INVOLVED Individual action and behavior change Medical and Health Professionals Education Community Action -early attitudinal and value formation as regards one's health (school curricula) -adult education program relating to: seven danger signals for cancer smoking withdrawal avoidance of undue exposure to sun breast self-exam change of dietary practices -occupational programs relating to: wearing protective clothing and equipment and observing pro tective measures avoidance of known hazards Schools, Voluntary Organizations, Labor Unions, Management, Community Groups, Professional Groups, Local Health Departments -training and continuing education to improve expertise in counselling early detection, treatment, control of cancer preventive techniques for high-risk population educating patients Academy of Medicine, Medical Schools Nursing Schools Other Health Training Schools, Voluntary Organizations, New Jersey Cancer Institute -control the physical and biologic environ ment by developing the climate for environmental pollution control, environ mental design and safety engineering, and human factors engineering. -control the social environment through: dissemination of information smoking control codes provision of smoking withdrawal resources Community and Civic Organizations, Elected Representatives, Local Health Departments , Special Interest groups (consumer groups. RSV 0 0 1 3 4 3 1 4) Human Surveillance Extend the present health protection of workers and others at risk, through surveillance, screen ing, laboratory back-up and follow-up. 5) Referrals to treatment and rehabilitation Assist in the development of the appropriate network and ensure referral of patients detected to have cancer to it. 6) Program and facility standards - Through the planning andregulatory process, provide New Jersey with se lected high quality cancer treatment sites. 7) Food and products safety enforcement - Continue cooperation with FDA to ensure elimination of carcinogens from food and drug products stored and distributed in New Jersey. 8) Health education - Community based programs, and assistance to Department of Education in teacher training and curriculum development. Department of Labor and Industry 1) Industrial mapping - Relate potentially hazardous industrial processes and emissions to geographic areas. 2) Historical data - Define relevant industries active in New Jersey during the last five decades. 3) Process surveys - Locate and inventory suspected carcinogenic substances in the occupational environ ment. (carcinogen-use cataloging) Department of Environmental Protection 1) Carcinogenicity testing - Provide aggregate samples of air, water, etc. to the appropriate research laboratory to be tested for their carcinogenic and mutagenic properties. 2) Monitor - Determine the presence and concentrations of carcinogenic substances in the environments, par ticularly those to which Department of Health studies point as suspect. 3) Inventory - Determine the use, production, transport and waste products known or suspect of being carcino genic . RSV 0013432 26 4) Emission Standards - Establish standards to limit the emission of carcinogenic substances into the air and water, or through improper disposal of wastes. 5) Cluster monitoring - Monitor extensively and compre hensively at sites where Department of Health studies show cancer cases to be clustered. 6) Permit review - Review of existing and new permit applications to ensure that carcinogenic substances are not emitted to the environment. Department of Higher Education 1) Training of industrial hygiene, occupational health and safety specialists, and continuing education for those currently employed. 2) Training of medical and allied professional manpower for cancer control, treatment and rehabilitation, and continuing education. 3) Industrial Research and Development performs a feas ibility study on the academic basing in New Jersey of an industrial R & D Institute to be involved in training, and also in the testing of processes prior to their introduction into the work environment to determine their safety to humans, or alterations which will make them safe. Also test current pro cesses suspected of hazard, for alteration. Department of Agriculture 1) Investigation of food production - to determine presence or absence of use of carcinogens as in animal and poultry feeding. 2) Enforcement - enforce the elimination of carcinogens from food production. Department of Education 1) Develop curricula for a total health education program to teach children to develop positive attitudes toward health, self-responsibility, and appropriate decision making skills relative to cancer prevention, detection and periodic exams. 2) Mandate teaching of the developed curricula in all schools by qualified, capable teachers. RSV 0013433 27 9. FEDERAL AGENCIES OSHA Congress* goal in enacting the 1970 Occupational Safety and Health Act was *'to assure as far as possible every working roan and woman in the nation safe and health ful working conditions..." This act created the Occupa tional Safety and Health Administration in the U.5. Department of Labor to set mandatory safety and health standards and to enforce these. OSHA, unfortunately, is woefully understaffed. There is only one inspector for each several thousand workplaces. OSHA has primarily directed its attention to the more visible and sudden safety hazards and has not, by and large, addressed itself to the more chronic concerns of health hazards such as occupational carcinogenesis. OSHA is neither staffed with medical competence, nor can it examine workers. It is constrained to look only at the industrial environment. The New Jersey experience with OSHA supports these con tentions . New Jersey may be able to augment OSHA's activity by calling for its increased funding. New Jersey must also make clear that the message is for more and vigor ous activity in New Jersey, rather than a shying from delicate situations. As the New Jersey cancer control program delineates carcinogenic exposures that must be eliminated, OSHA must be called on for enforcement. Failing an augmentation in OSHA's activity, a state program may have to be reinstituted. NIOSH National Institute of Occupational Safety and Health is a division of the Center for Disease Control, DHEW, Its primary responsibility is to establish, through research, occupational hazards that are to be controlled by OSHA. NIOSH has only research capability, and no regulatory power. NIOSH also responds to requests by labor or management to investigate potential health hazards in the work place. NIOSH is staffed with five physicians to respond to Health Hazard Evaluation for the entire United States. New Jersey's relationship to NIOSH is again two-fold. On the one hand, we must encourage proper funding so that NIOSH can adequately respond without unreasonable delay to Health Hazard Evaluation. On the other hand, NIOSH is a potential partner in demonstration programs of RSV 0013434 28 occupational health services that can be launched by the New Jersey Health Department's Cancer Control Program. They are not only a potential funding source, if their budget is adequate to respond to our requests, but also a source of consultation and expertise. NCI The National Cancer Institute has several missions. It not only conducts clinical treatment research and development, but also more basically, seeks to expose the etiology of cancer. For twenty years, the National Cancer Institute has explored infectious agents relation ships to causes of cancer. It has explored "biology gone wrong" at the molecular level. Their efforts have not been bent toward actually controlling cancer. If the NCI is to be a further partner with New Jersey, their budget and program priorities must be re-examined. RSV 0013435 29 SUMMARY The appalling statistics presented certainly give New Jersey the distinction as "Cancer-State-U.S.A." Why is New Jersey's cancer death rate so high for so many different types of cancer? These statistics are merely the "tip-of-the-iceberg." How many of our citizens have, as yet, undiscovered cancers, and how many are being exposed on a daily basis to high levels of carcinogenic substances in the occupa tional setting, and other environments? These are the questions that must be answered if we are to truly control and prevent cancer. Accurate information is essential, if we are to answer these questions. This information must be obtained through a registry of cancer patients as soon as they are diagnosed, not after they succumb to the disease. Also, we must pinpoint areas of the state where known carcino genic substances are produced, used, stored or given off as by-products in order to know what population groups are most at-risk. Then, based upon this information, we can undertake vigorous on-going epidemiologic investigations to answer essential questions. The information gathering, epidemio logic studies, and education are the cornerstone of a Cancer Prevention Program. When linked with screening,early diagnosis, treatment and follow-up, these activi ties constitute a total Cancer Control Program. Such a Control Program for New Jersey has been outlined in the previous pages. Finally, a "Cancer Control Cycle, " which in essence is a flow chart summarizing a New Jersey Cancer Control Program follows: RSV 0013436 JO FIGURE 17: CANCER CONTROL CYCLE 3! RSV 0013437 BIBLIOGRAPHY 1. Selikoff, Irving J., Prof, of Medicine and Community Medicine. Director of Environmental Sciences Laboratory, Mt. Sinai School of Medicine, N.Y.C. 2. Spiegelman, Sol, Columbia University 1971 testimony before the Senate Subcommittee on Health. 3. Aron, Michael, "The Anti-Social Cell" Harper's Magazine, June 1974, 4. -------Harpers Magazine, June 1976 5. Mascn, Thomas J., McKay Frank W. U.5. Cancer Mortality by County: 1950-1969. Epidemiology Branch, National Cancer Institute, DHEK Publication No. (NIH) 74-615. 6. Mason, Thomas J. McKay, Frank W. - Hoover, Robert. Blot t william J.? Fraumeni, Joseph F., Jr. Atlas of Cancer Mortality for U.S. Counties: 1950-1969"! Epidemiology Branch, National Cancer Institute DHEW Publication No. (NIH) 75-780. 7. Thorner, Robert M. "Strategy Problems in Disease Preven tion and Tneir Relationship to Cost" Early Disease Detection, Future Publishing Co., Inc., Mt. Kisco, N. Y., 19 71. 8. ----"Papanicolaou Testing--Are We Screening the Wrong Women." New England Journal of Medicine 294:223, 1976. 9. Boyes, D.A. et al Bull. Cancer 11:4, 1973 10. Randall, K.J. The Lancet 11:1303, (Nov 30), 1974 11. ------"Medical News" Journal of American Medical Association 234:137, 1975 12. Rauscher, F.J. Jr. Journal of American Medical Association 232:647, 1975 13. Anderson, C. L., in Community Health Pg. 93 CV Mosby Co., St. Louis, 1973. 14. Li. F. p. et al Journal of American Medical Association 234:138, 1975 15. Brooks, S. M. JOM 17:21, Jan, 1974 RSV 0013438 3: NEW JERSEY STATE HEALTH DEPARTMENT CANCER CONTROL BUDGET Personnel including, but not limited to a Director of Cancer Control# Epidemiologists (M.D. and non-M.D.), Research Assistants# Statistician# Cancer Regis trar# Public Health Nurse(s)# Nurse Consultants or Project Nurse(s)# Field Personnel# Health Educator(s), Media Specialist (s), Curriculum (Specialist (s), industrial Hygenists(s)# Occu pational Health and Safety Experts and Clerical Staff.................................................................................................................$ 350,000 20% Fringe.................................................................................................. 70,000 Other Costs Travel Equipment Furniture Telephones Supplies Conferences# Printing ~ Seminars $10,000 5#000 5,000 2#000 2,000 10,000 10,000 $44,000 44.000 Grants-in-Aid to local agencies on matching basis and subject to meeting standards of per formance.............................................................................................. Initial Laboratory Support Registry Costs............................... 500.000 350.000 200.000 TOTAL $1 ,514,000 RSV 0013439 33 RSV 0013440 FIGURE 6: RATIOS OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE: CANCER OF THE BLADDER 1950- 1969 WHITE MALES UJ. RATE - Prepared by the Public Health Statistics Program . New Jersey State Department of Health RSV 0013441 FIGURE 7: RATIOS OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE: CANCER OF THE ESOPHAGUS 1950 1969 New Jersey At lentic County Bergen County Burlington County Camden County Cepe May County Cumberland County Essex County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County .. e Warren County State Institutions Military Posts Prepared by the Public Health Statistics Program New Jersey State Department of Health 36 0013442 FIGURE 8: RATIOS OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE: CANCER OF THE STOMACH 1950 1969 WHITE MALES US. RATE 01 2 New Jersey Atlantic County Bergen County Burlington County Camden County Cape May County Cumberland County Essex County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County Warren County State Institutions Military Potts Prepared by the Public Health Statistics Program New Jersey Stete Department of Health 37 RSV 0013443 FIGURE 9: RATIOS OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE: CANCER OF THE STOMACH 1950-1969 WHITE FEMALES U.S. RATE New Jersey Atlantic County Bergen County Burlington County Camden County Cape May County Cumberland County Essex County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Satem County Somerset County Sussex County Union County Warren County State Institutions Military Posts Prepared by the Public Health Statistics Program ___New Jersey State Department of Health 31 R$y 0013444 FIGURE 10: RATIO OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE: CANCER OF THE LARGE INTESTINE, EXCEPT RECTUM 1950-1969 WHITE MALES 0 .1 .a . < .< .i ii U.S. RATE 1 .* .r . .* i r" i \ .1 i .7 .3 . .S . .7 .a .t i--s--i--i--i--i" 1-----T .1 .3 T 1----- T"T New Jersey Atlantic County --- -------------- i -------------------------- , Bergen County Burlington County -- i .................... Camden County Cape May County Cumberland County -- ... "i l' Essex County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County .i Union County Warren County State Institutions Military Posts Key: Relative rate of 1 no difference between NJ. rates ft U.S. average rates. Prepared by the Public Health Statistics Program New Jersey State Department of Health 39 RSV 0013445 FIGURE 11: RATIO OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE: CANCER OF THE LARGE INTESTINE. EXCEPT RECTUM 1950 * 1969 WHITE FEMALES U.S. RATE A .1 .3 .4 .9 A .7 .9 .9 ----- 1----- 1 ------1-----} 1----- 1 1 1 .1 .2 .3 .4 .9 .* .9 .1 .* 11|11 1111 .1 .* .3 .4 .9 i i--i--i--r New Jersey Atlantic County Bergen County Burlington County 1 j j - -.................... 1 1 1 i Camden County "1 : Cape May County Cumberland County .1 __ 1 Essex County Gloucester County "1 Hudson County Hunterdon County Mercer County Middlesex County Monmouth County -- . ... ...... 1 i ' '1 ................ ... i * 1- Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County i - - - 1 1 1 ..... .. .-- ...................... -- - - -- i ................------------------- 1 --------------------------------------------- * 0 Warren County State institutions Military Posts 1 Key: Relative rj te of 1 no difference between NJ. rates & U.. Prepared by the Public Health Statistics Program New Jersey State Department of Health 40 RSV 0013446 FIGURE 12: RATIO OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE: CANCER OF THE RECTUM 1950 1969 WHITE MALES 0 a 1 .* a 11 . a IT U.S. RATE 1 .* .7 . a a .3 .a .a . .? .a .t T--1--"1--1------ --1--i--|--l "l "--l--1--i-- New Jersey Atlantic County Bergen County ....... -- 1 1 1.1--.3r .* . TT Burlington County Camden County Cape May County " "1 ......... - - -....... . -- i " 1 Cumberland County Essex County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County ' V.,- * ... Warren County Stare Institutions Military Posts J Key: Relative rate of 1 no difference between NJ. retes & U.S. average rates. Prepared by the Public Health Statistics Program New Jersey State Department of Health 41 * RSV 0013447 FIGURE 13: RATIO OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE: CANCER OF THE RECTUM 1950 -1969 WHITE FEMALES 0 .1 .2 .3 .4 . 1T i ~7' 1 .6 .7 11 U.S. RATE 1 .e . ii r --r.1 .2 .3 .4 'I .* .r 1-----1-----T New Jersey .3 Atlantic County .i .4 . 1-----T 1--r Bergen County Burlington County .i Camden County Cepe May County Cumberland County Essex County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County ___i Warren County State Institutions Military Pons Key: Relative rate of 1 * no difference between NJ. rates & U.S. average rates. Prepared by the Public Health Statistics Program New Jersey State Department of Health 42 RSV 0013<*48 FIGURE 14: RATIOS OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE: CANCER OF THE RESPIRATORY SYSTEM (TRACHEA, BRONCHUS & LUNG) 1950-1969 WHITE MALES U.S. RATE 01 .1 i .2 i J 1 . i s i .7 .a .* r--i--i--i-- ---.11----.21----.31----.41---.1i----.1*----.71----.11----.1---- New Jersey ' "l .1 .8 .1 .4 .& t--i--i--i--T Atlantic County Bergen County Burlington County Camden County Caoe May County _ ,, | __ --- 1 -- ----------1 1 1 i Cumberland County i Essex County Gloucester County _____1 | |i Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County Warren County State institutions Military Posts Key: Relative rate of 1 " no difference between NJ. rates & U.S. average rates. Preoared by the Public Health Statistics Program New Jersey State Department of Health *3 RSV 0013449 FIGURE 15: RATIOS OF NEW JERSEY COUNTY MORTALITY RATES TO THE US. MORTALITY RATE: CANCER OF THE MOUTH & ORAL PHARYNX 1950 1969 WHITE MALES 0 .1 i .2 . i1 U.S. RATE 12 .a .$ .9 .7 .a .* .] .2 .2 .4 .9 . .7 J .9 .1 .a .3 .4 .9 i t--i--i--;-- -----1----- 1----- 1----- 1----- 1------1----- 1----- 1----- 1----- "i--i--i--I--T New Jersey AiUntie County * 1 | ------- Bergen County Burlington County Camden County Cepe May County I 1 I j 1I -- ' i| Cumberland County Essex County Gloucester County Hudson County ---------------------------------------, Hunterdon County 1 Mercer County Middlesex County Monmouth County 1 i , ( 1 Morris County Oeean County Passaic County Salem County Somerset County Sussex County Union County Warren County State Institutions Military Posts Key: Relative rate of l no difference between NJ. rates & U.S. average rates. Prepared by the Public Health Statistics Program New Jersey State Department of Health RSV 00X3450 FIGURE 16: RATIOS OF NEW JERSEY COUNTY MORTALITY RATES TO THE U.S. MORTALITY RATE; CANCER OF THE BREAST 1950 1969 WHITE FEMALES U.S. RATE .1 .2 .a 1--I----- r i.--.r "i--r . .* t--r .1 .2 .1 .4 .ft .4 1--I--T T-----T .4 .4 .1 T----------T T.2--.1r i4--.frt Nnv Jersey Atlantic County Bergen County Burlington County Camden County Cape May County i Cumberland County Essex County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County Warren County State Institutions Military Posts Key: Relative rate of 1 * no difference between N.J. rates it U.S. average rates. Prepared by the Public Health Statistics Program New Jersey State Department of Health 45 RSV 0013451  \. RSV 0013452 TABLE 3: Ratios of Hew Jersey County .Mortality Rates to the United States Mortality Rate: Cancer of the Large Intestine, Except the Rectum - 1950*^969 Hew Jersey Atlantic County Beraren County Burlington County _ Camden County Caoe Mav County Cumberland County Essex Countv Gloucester Countv Hudson County Hunterdon County Mercer County Middlesex County Monmouth Countv Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County White Male 1-3U 1.31 1.32 1.35 1-U* 1.32 1.09 1.50 1-15 1 .LL 0.89 1.38 1 .Li 1.38 1.11 1.15 1.27 0.97 1.08 0.98 1.3*4 1.L3 White FpidsIp 1.10 1.32 1.27 1.38 1.L3 1.13 1.10 1.3U 1.28 1-31 1.18 1.35 1.26 1.37 1.22 1.27 1.25 1.25 _ . 1-13 1.07 1.29 1.11 RSV 0013453 47 TABLE 4: Ratios of New Jersey County Mortality Kates to the United States Mortality Rates: Cancer of the Rectum - 1950-1969 New Jersev Atlantic County Bercen County Burlington County Camden County Cane Mav County Cumberland County Essex Countv Gloucester County Hudson Countv Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County Warren County White Male 1.52 l.liO 1.53 1.27 1 .Li 1.29 0.9L 1.71* 1.23 1.8L 1.50 1.61 1 .L6 1.28 1.29 1.15 1.69 1.07 1.18 JLS1 i.gL 1.69 White Female 1 .Li 1 *51* 1.39 1.12 1.L3 1.10 1.22 1.51 1 .Li 1.66 1.ti9 1.37 1.33 ______________l-2_9 1.29 1.22 1.51 ______________1--2-2 1.10 i.M .1*31 JL31 48 RSV 0013454 TABLE 5: Ratios of New Jersey County Mortality Rates to the United States Mortality Rate: Cancer of the Stomach - 1950-1969 New Jersey Atlantic County Bergen County Burlington County Camden County Cane May County Cumberland County Essex County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County Warren County White Female 1.28 1.08 1-3U T .Oli 1.06 1-05 I.O/i 1.31 0.90 1.57 1 .Oh 1.18 1.57 1.1/4 0.96 1.03 1.51 0.86 1.12 1.18 1.38 0.97 White Male 1 *2h 1.16 1.22 1.05 1 .lii 1.18 1 .lli 1.22 1.05 1.52 1.15 1.33 1.50 1.12 1.02 0.99 I.Ui 0.99 1.19 1.00 1.25 0.95 RSV 0013^55 49 TABLE 6: Ratios of Rev Jersey County Mortality Rates to the United States Mortality Rate: Cancer of the Respiratozy Systen (Trachea, Bronchus and Lung) - 1950-1969 New Jersey Atlantic County Bersren County Burlington County Camden County Cane Mav County Cumberland County Essex County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County Warren Countv White Males 1.23 1.12 1.22 1.10 1.33 1.20 1-13 1.18 1.12 1.51 1.02 1.18 1.L3 1.28 1.08 1.28 1.22 1.0*5 1.16 1.07 1.11 1.10 R$V 0013456 so TABLE 7: Ratios of New Jersey County Mortality Rates to the United Stakes Mortality Rate: Cancer of the Breast White Females 1950-1969 New Jersev 1.20 Atlantic County 1.07 Bergen County 1.28 Burlington County 1.09 Camden County 1.16 Cape May County 1.03 Cumberland County 0.94 Essex County 1.29 Gloucester County 1.13 Hudson County 1.20 Hunterdon County 1.11 Mercer County 1.04 Middlesex County 1.19 Monmouth County 1.18 Morris County 1.20 Ocean County 1.10 Passaic County 1.14 Salem County 1.20 Somerset County 1.11 Sussex County 0.95 Union County 1.35 Warren County 1.04 RSV 0013457 5 TABLE 8: Ratios of New Jersey County Mortality Rates to the United States Mortality Rate: Cancer of the Bladder White Males 1950-1969 New Jersey Atlantic Countv 1.43 1.28 Bergen Countv 1.31 Burlington County 1.36 Canden County 1.37 Cape May County 1.70 Cumberland County 1.33 Essex County 1.61 Gloucester County 1.36 Hudson County 1.52 Hunterdon County 1.62 Mercer County 1.36 Middlesex County 1.24 Monmouth County 1.53 Morris County 1.19 Ocean County 1.65 Passaic County 1.33 Salem County 2.37 Somerset County 1.17 Sussex County 1.61 Union Countv 1.46 Warren Countv 1.17 52 RSV 0013458 TABLE 9: Ratios of New Jersey County Mortality Rates to the United States Mortality Rates: Cancer of the Mouth and Oral Pharynx 1950*1969 __________________________________White Males New Jersey 1.31 Atlantic County 1.14 Bergen County - 1.26 Burlington County 1.31 Camden County 1.35 Cape May County 0.78 Cumberland County 1.02 Essex County 1.45 Gloucester County Hudson County Hunterdon County 0.95 1.85 1.21 Mercer County 1.57 Middlesex County 1.31 Monmouth County 1.07 Morris County 0.86 Ocean County 0.71 Passaic County 1.47 Salem County 0.57 Somerset County 0.90 Sussex County 0.69 Union County 1.26 Warren County 1.07 53 RSV 0013^59 t TABLE 10: Ratios of New Jersey County Mortality Rates to the United States Mortality Rate: Cancer of the Esophagus 1950-1969 White Males New Jersey 1.40 Atlantic County 1.29 Bergen County Burlington County - 1.34 1.07 Caisden County 1.10 Cape Mav County 1.22 Cumberland County 1.05 Essex County 1.44 Gloucester County 1.07 Hudson County 2.00 Hunterdon County 0.83 Mercer County . 1.61 Middlesex County 1.93 Monmouth County 1.00 Morris County 1.02 Ocean County 1.10 Passaic County 1.51 Salem County 1.10 Somerset County 1.27 Sussex County 1.27 Union County 1.27 Warren County 1.32 RSV 0013460 54 *67