A STUDY OF ADULT T-CELL LEUKEMIA/LYMPHOMA INCIDENCE IN CENTRAL BROOKLYN Paul H. LEVINE 1,2 *, Harvey DOSIK 3,15 , Edward M. JOSEPH 3 , Susanne FELTON 4 , Maude A. BERTONI 5,6 , Jose CERVANTES 7 , Vaseem MOULANA 8 , Angelica B. MIOTTI 9 , Loretta J. GOBERDHAN 3 , Stanley L. LEE 10 , Aman DAOUAD 3 , Maria DACOSTA 11 , Elaine S. JAFFE 1 , Constantine A. AXIOTIS 12 , Farley R. CLEGHORN 1 , Amy KAHN 13 and Seth L. WELLES 14 1 National Cancer Institute, National Institutes of Health, Bethesda, MD, USA 2 George Washington University School of Public Health and Health Services, Washington, DC, USA 3 Interfaith Medical Center, Brooklyn, NY, USA 4 Research Triangle Institute, Washington, DC, USA 5 Wyckoff Heights Medical Center, Brooklyn, NY, USA 6 Woodhull Medical Center, Brooklyn, NY, USA 7 St. Mary’s Hospital, Brooklyn, NY, USA 8 Brooklyn Hospital, Brooklyn, NY, USA 9 Department of Hematology/Oncology, Brooklyn Hospital, Brooklyn, NY, USA 10 Department of Hematology, Brookdale Hospital, Brooklyn, NY, USA 11 St. Joseph’s Hospital, Brooklyn, NY, USA 12 State University of New York Health Science Center at Brooklyn and King’s County Hospital, Brooklyn, NY, USA 13 New York State Cancer Registry, New York, NY, USA 14 Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, MN, USA Adult T -cell leukemia/lymphoma (AT L), a rare outcome of infection with human T-lymphotropic virus (HTLV-I), is en- demic in central Brooklyn, which has a large Caribbean migrant population. Previous studies have suggested that H T LV-I prevalence in central Brooklyn may be similar to that recorded in the Caribbean islands. W e established a pilot 1-year surveillance program to identify cases of AT L in 7 of 10 hospitals serving the residents of 18 zip codes of central Brooklyn with a combined population of 1,184,670. Of the 6,198 in-patient beds in the catchment area, approximately 83% were covered. Twelve incident cases of ATL were ascertained, all among persons of Afro-Caribbean descent, indicating an annual incidence in African-Americans in this community of approximately 3.2/100,000 person-years. U nex- plained hypercalcemia wasthe most useful screening method, identifying 3 of 5 patients not referred for possible ATL by a local hematologist. The female:male ratio was 3:1. The age pattern was different from that reported in the Caribbean Basin and closer to the pattern seen in Japan. Our study supports evidence that HTLV-I infection and ATL are en- demic in central Brooklyn and suggests that a more intensive surveillance program for this disease coupled with interven- tion efforts to reduce HTLV-I transmission are warranted. Int. J. Cancer 80:662–666, 1999. Published 1999 Wiley-Liss, Inc. ² Adult T-cell leukemia/lymphoma (ATL) is an aggressive, chemo- therapy-resistant malignancy that is the most devastating result of infection with human T-lymphotropic virus (HTLV-I) (Takatsuki et al., 1977). The lifetime risk of an HTLV-I-infected individual developing ATL has been estimated at 3% to 5% (Murphy et al., 1989), perinatal infection apparently being more important in the pathogenesis of this disease than infection acquired later in life (Cleghorn et al., 1995). Prevention of infection is a much more effective means of disease control than treating established disease; therefore, identification of endemic areas of HTLV-I infection is an appropriate target of cancer prevention and control programs. ATL is a useful marker disease for the identification of HTLV-I-endemic areas (Levine et al., 1988, 1994b), and since our case series (Dosik et al., 1988) and seroprevalence studies (Dosik et al., 1992) suggested that central Brooklyn could be an area where HTLV-I is endemic, we evaluated the incidence of ATL in central Brooklyn by developing a population-based surveillance study involving those areas where ATL cases and HTLV-I infection had been docu- mented. In addition to providing data for the evaluation of possible cancer detection and counseling programs in central Brooklyn, this project was developed as a pilot for other areas of the United States where ATL cases appear to be concentrated and where HTLV-I infection may be endemic, such as southern Florida (Harrington et al., 1991, 1995; Levine et al., 1994b). MATERIAL AND METHODS Identification of patients A surveillance system was established for 18 zip codes in central Brooklyn, which were centered around the 10 hospitals serving the area (Fig. 1).The targeted population was known to utilize the local hospitals, and affected patients were unlikely to be seen in hospitals outside of our surveillance. All 10 area hospitals were contacted, and 7, comprising 82.7% of the 6,198 in-patient beds serving the Brooklyn community, participated in a case-identification study. Potential cases were ascertained through physician referral, by review of all new in-patients and out-patients and through hospital records with diagnosed hematological malignancy, unexplained leukocytosis or unexplained hypercalcemia (no parathyroid abnor- malities, dehydration, etc.). Any patient identified by these criteria was given full information about the study. A blood sample was drawn from those who gave informed consent for a screening assay to detect HTLV-I antibody (Fujirebio, Tokyo, Japan). A positive screening test resulted in the patient’s entry into the second phase of the study, which included the collection of detailed clinical and demographic data by interview and chart review. All sera were subsequently tested by a battery of serological assays to determine the specificity of the screening result (see below). Each hospital entered into the study was monitored for 1 year. Verification of surveillance effıcacy To evaluate the completeness of our surveillance, we compared our ascertained cases with those identified by the New York State Cancer Registry. Since the early 1990s, the New York State Cancer Registry has histologically confirmed 83% of reported cases, 3.4% 15 Current affiliation: New York Methodist Hospital, Brooklyn, NY, USA. *Correspondence to: Division of Cancer Epidemiology and Genetics, Viral Epidemiology Branch, National Institutes of Health, EPN 434, Bethesda, MD 20892, USA. Fax: (301) 402–0817. E-mail: ZPL@CU.NIH.GOV Received 15 June 1998; Revised 25 September 1998 Int. J. Cancer: 80, 662–666 (1999) Published 1999 Wiley-Liss, Inc. ² This article is a US Government work and, as such, is in the public domain in the United States of America. Publication of the International Union Against Cancer Publication de l’Union Internationale Contre le Cancer