modifiable environmental risk factors and incidence of ...

Running head: MODIFIABLE ENVIRONMENTAL RISK FACTORS AND INCIDENCE OF COLORECTAL CANCER

Investigating the Relationship between Modifiable Environmental Risk Factors and Incidence of Colorectal Cancer: A Community Based Study

by Jeavana Sritharan

A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Health Sciences in The Faculty of Health Sciences

University of Ontario Institute of Technology June, 2012

© Jeavana Sritharan, 2012

MODIFIABLE ENVIRONMENTAL RISK FACTORS AND INCIDENCE OF COLORECTAL CANCER

Abstract Colorectal cancer is the third most diagnosed cancer and second leading cause of cancer related deaths in Canada. As Ontario has the largest population in Canada, it also has great disparities in colorectal cancer incidence. The region of Timiskaming has the highest incidence for colorectal cancer, while the region of Peel has the lowest incidence for colorectal cancer in Ontario. The purpose of this study is to identify the dominant nonnutritional modifiable environmental risk factors in the region of Timiskaming compared to the region of Peel that may be associated with diverging colorectal cancer incidence rates. The three objectives of the study included performing a systematic review on available published literature, creating an assessment questionnaire tool regarding environmental exposures, and utilizing the questionnaire assessment tool within a pilot study group while expanding it into the communities of interest. Findings indicate that there are dominant non-nutritional modifiable environmental risk factors in the regions of Timiskaming and Peel that may be associated with colorectal cancer. The dominant factors identified are tobacco/smoking, alcohol use, pesticides/organochlorines, and metal toxins. Following this study, it is imperative that recommendations are directed at a community level and relate to the assessment of potential non-nutritional modifiable environmental risk factors. Future research should accompany a larger sample size, multiple participant communities, and catering of the questionnaire tool towards the communities of interest.

Key words: colorectal cancer, environmental risk factors, community based research

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MODIFIABLE ENVIRONMENTAL RISK FACTORS AND INCIDENCE OF COLORECTAL CANCER

Acknowledgements I would first like to thank my faculty advisor, Dr. Otto Sanchez, for his immense support and guidance throughout the years. Your passion and optimism guided my research experience to become one that was both exciting and motivating. You are an incredible mentor and I feel blessed to have gained a life-long friend. I would like to thank my supervisory committee, Dr. Manon Lemonde and Dr. Clemon George, for all the encouragement, insight, and direction. You have consistently contributed to the research process and you have been great mentors. I would also like to thank Ken McFarlan, Rishikesan Kamaleswaran, and Elizabeth Suen for the time and effort put into the research process providing their expertise. The project could not have been completed without this wonderful team. I thank the program directors and staff at the Timiskaming Ontario Early Years Centre and the Mississauga Centre Ontario Early Years Centre. Your partnerships were crucial in the planning, delivering, and overall experience I had within the communities. I hope to work with you in the future. I thank my many amazing friends who have helped me with challenges, provided me with constant encouragement, and inspiration. Thank you to my four siblings – Jaline, Jeyasri, Anbhu, and Ashvinie, who have surrounded me with unlimited affection and support. I am quite blessed to have four amazing individuals as family and as my closest friends. Most importantly, I thank my wonderful parents. I would not be where I am today without you. Thank you for always believing in me, for giving me all the love and support to achieve anything and everything, and for always being there when I needed it the most.

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MODIFIABLE ENVIRONMENTAL RISK FACTORS AND INCIDENCE OF COLORECTAL CANCER

Table of Contents 1.0 Introduction ................................................................................................................. 1 1.1 Worldwide, Population, and Community Level Disparities ..................................... 1 1.2 Clinical Aspects of Colorectal Cancer ...................................................................... 4 1.3 Non-Modifiable Risk Factors .................................................................................... 5 1.4 Modifiable Risk Factors ............................................................................................ 6 1.4.1 The Effects of Active and Passive Smoking on Colorectal Cancer Risk ......... 10 1.4.2 The Interactive Effects of Alcohol Intake and the Risk of Colorectal Cancer . 14 1.4.3 Toxic Metals Environments and the Risk for Colorectal Cancer ..................... 17 1.4.4 Occupational Exposures and Colorectal Cancer Risk ...................................... 20 1.4.5 The Use of Organochlorines and Colorectal Cancer Risk ................................ 21 1.5 Objectives of the Study ........................................................................................... 23 1.6 Research Question ................................................................................................... 23 1.7 Colorectal Cancer in the District of Timiskaming .................................................. 23 1.8 Timiskaming Community Profile ........................................................................... 25 1.9 Colorectal Cancer in the District of Peel ................................................................. 27 1.10 Peel Community Profile ........................................................................................ 28 2.0 Methodology .............................................................................................................. 31 2.1 Ethical Considerations............................................................................................. 31 2.2 Systematic Review Determining Risk Factor Categories ....................................... 31 2.3 Questionnaire Tool Development ........................................................................... 32 2.4 Pilot Study ............................................................................................................... 35 2.5 Community Participation ........................................................................................ 36 2.6 Community Based – Ecological Approach ............................................................. 38 2.7 Data Collection Process .......................................................................................... 40 2.8 Incentive for Participants ........................................................................................ 42 2.9 Data Analysis .......................................................................................................... 42 3.0 Results ........................................................................................................................ 45 3.1 Sections A & I General Health & Socio-Demographic Characteristics.................. 46 3.2 Section B Tobacco Smoke & Cigarettes ................................................................ .50 3.3 Section C Alcohol Use ........................................................................................... .58 iii

MODIFIABLE ENVIRONMENTAL RISK FACTORS AND INCIDENCE OF COLORECTAL CANCER

3.4 Section D Housing Characteristics .......................................................................... 66 3.5 Section E Volatile Chemicals/Fumes/Pesticide Use ............................................... 68 3.6 Section F Metal Toxins ........................................................................................... 76 3.7 Section G Occupational Exposures ......................................................................... 79 3.8 Section H Ionizing Radiation .................................................................................. 82 3.9 Section Correlations ................................................................................................ 83 4.0 Discussion................................................................................................................... 84 4.1 Influential Socio-demographic Characteristics ....................................................... 84 4.2 Risk Associated with Patterns of Active Smoking and Second-hand Smoke ......... 89 4.3 Risk Associated with Alcohol Consumption .......................................................... 93 4.4 Risk Associated with Housing Characteristic Differences ..................................... 95 4.5 Risk Associated with Increased Pesticide & Organochlorine Use .......................... 99 4.6 Risk Associated with Community and Household Metal Exposure ..................... 102 4.7 Distribution of Occupational Exposures ............................................................... 105 4.8 Patterns of X-ray Use ............................................................................................ 107 4.9 Significant Section Correlations ........................................................................... 108 4.10 Strengths of the Study ......................................................................................... 108 4.11 Limitations of the Study ...................................................................................... 109 5.0 Conclusions & Recommendations ......................................................................... 111 6.0 References ................................................................................................................ 116 List of Tables………………………………………………………………………...…...v List of Figures…………………………………………………………………………...vi List of Appendices……………………………………………………………………...vii

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MODIFIABLE ENVIRONMENTAL RISK FACTORS AND INCIDENCE OF COLORECTAL CANCER

List of Tables Table 1 General Health and Socio-Demographic Characteristics……….………………47 Table 2 Smoking and Tobacco Exposures…….…………………………………….…...51 Table 3 Alcohol Exposure…………………………………………………………….….61 Table 4 Housing Characteristics…………….…………………………………….…......67 Table 5 Pesticides & Organochlorines…….…………………………………………......69 Table 6 Metal Toxin Exposures………….………………………………………...….…77 Table 7 Occupational Exposures……….……………………………………...….……...80 Table 8 Ionizing Radiation Exposure….…………………………………………….…...82

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MODIFIABLE ENVIRONMENTAL RISK FACTORS AND INCIDENCE OF COLORECTAL CANCER

List of Figures Figure 1 Colorectal cancer incidence rates for all ages and sexes per 100, 000 in Ontario, Canada in 2003……..…………………………...…………………………………………3 Figure 2 Non modifiable and modifiable factors that contribute to disparities in cancer incidence…………………………………………………………………………..…..….10 Figure 3 The district of Timiskaming and the district of Peel in the province of Ontario................................................................................................................................30 Figure 4 The significant differences in participant distribution regarding tobacco and smoke exposure in the communities of Timiskaming and Peel…………………….……57 Figure 5 The significant differences in participant distribution regarding alcohol intake in the communities of Timiskaming and Peel………………………………………………64

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MODIFIABLE ENVIRONMENTAL RISK FACTORS AND INCIDENCE OF COLORECTAL CANCER

List of Appendices Appendix A Ethics Approval…………………………………………………...………122 Appendix B Questionnaire for Participants………………………………………….….123 Appendix C Permission Forms………………………………………………………….147 Appendix D Invitation Letters……………...…………………………………………...153 Appendix E Participant Consent Form…………………………………………….……157 Appendix F Feedback Letter for Participants ………………………………………......160 Appendix G Google Webpage…………………………………………………………..161 Appendix H Google Webpage Information Prompt……………….………………........162 Appendix I Questionnaire Log Sheet…………………………………………………....163 Appendix J Tables of the significant section correlations (p