Final Hudson School Cluster Sent 12.20.22

2600 University Capitol Centre, The University of Iowa, Iowa City, IA 52242-5500,
PH 319/335-8609, FAX 319/335-8610
December 20, 2022
Diane Anderson
4028 Sterling Lane
Cedar Falls, Iowa 50613
RE: Suspected Excess of Cancer in Hudson Schools
Dear Ms. Anderson,
Thank you for your inquiry regarding a suspected excess of cancer in individuals teaching in the elementary
and junior high school buildings in Hudson, Iowa. Enclosed is our analysis. Our initial conversations focused
on a concern of breast cancer because you knew of more than 10 teachers that had been diagnosed since
2010. Many of these women have had genetic testing done stating no known genetic mutations associated
with breast cancer. You mentioned that the water in one specific classroom had a strange smell and there
was also a smell (possibly mold) in the classroom.
We conducted several analyses, as described in detail below. Briefly, we compared the cancer experience of
employees of Hudson School with the remainder of Hudson, as well as both the Dike and Cedar Falls ZIP
codes. All of these analyses showed similar results, suggesting that the cancer experience of the Hudson
Schools staff was similar to the cancer experience in each of the three comparison groups.
We also compared the cancer experiences of residents in the Hudson ZIP code with residents in the Dike
and Cedar Falls ZIP codes. Overall, the results of these analyses suggest that the cancer experience of the
Hudson Zip Code target area has been similar to the cancer experience in the comparison groups of Dike
and Cedar Falls, except that males in Hudson city were more likely to be diagnosed with prostate cancer
when compared to Cedar Falls.
Cancer cluster investigation methods

Following discussion on the appropriate analytical methods and a consideration of your specific requests for
the analysis, we opted to compare the cancer experience in the employees of the Hudson schools
(hereafter: target area) with the remainder of Hudson as the initial comparison group. We had hoped to use
employees of another school as a second comparison group but were unable to obtain the data needed for
this analysis. Instead, we utilized demographic and socioeconomic data to find a comparison area similar in
median household income, percentage with college education, and percent non-White population. The ZIP
code areas of Dike and Cedar Falls were most like Hudson, and so were used in this analysis. We examined
Registry data from 2010-2020, the most recent complete year of data in our database.
The Hudson school district provided us an employee census of 1,352 people to compare against our
incidence data. We were provided first and last name, a ZIP code that could not be verified as current, job
type, and hire and termination dates. Ideally, more information is needed to verify a match against the
incidence database, such as middle name, date of birth, and social security number. However, using a
combination of diagnosis and current address ZIP codes, along with matching the same or very similar
first and last name, helped to improve the likelihood of correct matches. To verify matches we compared
data against the Driver’s License, Voter Registration, and other databases that provide information on
1
address history over time. After this process, we found 68 patients and 77 cancers. From those that were
matched, the hire date was then taken into consideration. There were 14 matched patients with 17
cancers where the diagnosis dates for the matching patient were earlier than the hire date for the
Hudson school district. These cases were removed from our analysis, though we did include 20 matched
patients with 22 cancers with no hire date whose cancers may have been diagnosed before they started
working at Hudson school. The final total of matches was 55 patients who had a total of 61 cancers (6
people were diagnosed with more than one cancer).
The focus of our investigation was the years 2010-2020. Of the 61 cancers that matched, 38 were
diagnosed during this time period, including seven invasive breast cancers. We identified two in situ (pre-
invasive) breast cancers which were not included in our analysis, as cluster investigations are typically
limited to invasive cancers.
For this type of data, a method of examining the impact of a disease upon the target group is to calculate
the proportional incidence ratio (PIR). In the PIR, the proportion of cancer from a specified cancer site
relative to all cancer sites in the target group is compared with the corresponding proportion in the
comparison group. For a cancer site to be included, there must be two cases of that cancer type in both
the target area and the comparison area. Therefore, if a cancer site is not presented in our analysis below,
it means that there were not more than two cases of that cancer diagnosed. A 95% confidence interval can
be computed for the PIR which shows where we think the true magnitude of effect lies with 95% assurance.
The important things to note about the PIR are:
 If the PIR is 1.00 (or the confidence interval contains the value 1.00), the proportions among the
target group and comparison group are considered the same.
 If it is greater than 1.00 (and the confidence interval does not contain 1.00), the proportion among
the target group is greater than the corresponding proportion among the comparison group.
 If it is less than 1.00 (and the confidence interval does not contain 1.00), the proportion among the
target group is smaller than the corresponding proportion among the comparison group.
The Centers for Disease Control and Prevention recommend the usage of the standardized incidence ratio
for cancer cluster investigations. However, we do not have the population data available for areas smaller
than the county level and thus utilize the PIR analysis.
Results comparing Hudson School to Remainder of Hudson, IA Comparison Group

Here are the main findings comparing males and females in Hudson schools to the remainder of Hudson:
 We were able to evaluate lung and bronchus, skin melanoma, and prostate among males and skin
melanoma, breast, total leukemia, and benign brain cancers among females. The proportions
among the target group and the comparison group were considered the same, as the confidence
intervals for all sites evaluated contained the value 1.00.
Results comparing Hudson School to Dike Zip Code Comparison Group

Here are the main findings comparing males and females in Hudson schools to the Dike Zip Code:
melanoma, breast, thyroid, and benign brain cancers among females. Similar to the remainder of
Hudson comparison group, the proportions among the target group and the comparison group
were considered the same, as the confidence intervals for all sites evaluated contained the value
1.00.
Results comparing Hudson School to Cedar Falls Zip Code Comparison Group
Here are the main findings comparing males and females in Hudson schools to the Cedar Falls Zip Code:
melanoma, breast, thyroid, total leukemia, and benign brain cancers among females. The results of
2
this comparison group were similar; the proportions among the target group and the comparison
group were considered the same, as the confidence intervals for all sites evaluated contained the
value 1.00.
Breast cancer incidence in Hudson School employees

Breast cancer was the initial concern as you were aware of 13 women diagnosed in the last 12 years. Breast
cancer was not found to be elevated in the analyses completed comparing Hudson Schools to the three
different comparison groups. This cluster investigation was difficult for many reasons. The first being that it
was a workplace target population rather than the typical geographic-based target areas of the
investigations we have done in the past. A worksite evaluation relies on sufficient personal identifying
information which allows for an accurate linkage to the Iowa Cancer Registry cancer incidence database.
These necessary variables were not included in the “directory information” data released to us from the
Hudson School District. As mentioned earlier, we only had first and last name and ZIP code for us to use.
While we tried our best using the resources we have at the Registry, we may have been able to match more
individuals had we had the necessary information including middle name or initial, date of birth or even
age, and social security number. We also know of two breast cancers diagnosed in 2021 in employees of
Hudson Schools. We could not include 2021 data as they are not considered 100% complete for the state of
Iowa until November 2023.
Because of the possibility of missing cases in those employed in Hudson Schools, we utilized all of Hudson
for a second set of analyses. All individuals with a Hudson Zip Code were included in this new target area.
Results of those analyses follow.
Results comparing City of Hudson as Target Area to Dike Zip Code Comparison Group
We also evaluated the entire community of Hudson (Hudson Zip Code) as the target area, comparing to
the community of Dike (Dike Zip Code), to evaluate what the cancer experience has been in the
community of Hudson as a whole. The following graphic of the PIRs (the circles) and confidence intervals
(the grey lines) shows the cancer sites which were observed at higher or lower proportions in the Hudson
Zip Code target area compared to the Dike Zip Code as the comparison group. Some of our main findings
comparing males and females in the two areas are:
 While the proportion of colon and rectum, lung, and cancers of “other sites” were higher among
females in the City of Hudson, similar results were not seen in males. The PIR for lung cancer was
lower among males in the City of Hudson compared to Dike.
 Breast cancer was lower among females in the City of Hudson compared to Dike.
PIRs for Hudson Zip Code Target Area versus Dike Zip Code Comparison Group, 2010-2020
Results of City of Hudson as Target Area and Cedar Falls Zip Code Comparison Group
3
The final grouping included an analysis of the Hudson Zip Code as the target area and the Cedar Falls Zip
Code as the comparison group. The following graphic of the PIRs (the circles) and confidence intervals (the
grey lines) shows the cancer sites which were observed at higher or lower proportions in the Hudson Zip
Code target area when compared to the Cedar Falls Zip Code comparison group. Some of our main findings
comparing males and females in the two areas are:
 While the proportion of rectum, eye and orbit, and total leukemia were higher among females in
the City of Hudson, similar results were not seen in males. There were zero cases of eye and orbit
cancer in males. The confidence intervals were wide for cancers of the eye and orbit due to the
small number of cases in both the city of Hudson and Cedar Falls.
 Prostate cancer was higher among males in the City of Hudson.
 “Other sites” were lower in females in the City of Hudson.
PIRs for Hudson Zip Code Target Area versus Cedar Falls Zip Code Comparison Group, 2010-2020
Summary of results, and limitations

The detailed results of the analysis for cancer patients identified from the Hudson Schools target area,
Hudson, Iowa versus the remainder of Hudson comparison group for diagnosis years 2010-2020 are
provided in Table 1 for males and Table 2 for females. Tables 3 and 4 show the results of the Hudson
Schools target area versus the Dike Zip Code area as the comparison group for diagnosis years 2010-2020.
The final comparison group for the Hudson Schools target area was the Cedar Falls Zip code and results of
this analysis are shown in Tables 5 and 6. All three of these analyses have similar results, suggesting that the
cancer experience of the Hudson Schools target area has been similar to the cancer experience in each of
the three comparison groups.
Results of the second set of analyses looked at cancer patients identified from the entire Hudson Zip Code
area versus two different comparison groups. The first included the Dike Zip Code as the comparison group
with diagnosis years 2010-2020 and results are provided in Table 7 for males and Table 8 for females. The
second analysis used the Cedar Falls Zip Code comparison area and results are provided in Table 9 for males
and Table 10 for females. Overall, the results of our analyses suggest that the cancer experience of the
Hudson Zip Code target area has been similar to the cancer experience in the comparison groups of Dike
and Cedar Falls, except for prostate cancer in males when compared to Cedar Falls.
There are several limitations to this analysis. A major problem in the interpretation of the PIR is that the
relative frequency of other cancer sites can affect the proportional incidence for the site of interest. Thus,
PIRs can only suggest that a risk might exist. In addition, while the PIR may indicate that there is an
4
increased risk of certain cancers, random variations in cancer cases can exist that might increase the PIR
above one. This is especially true when comparing small populations/areas such as towns and counties.
In summary, we did not find statistical evidence of a breast cancer cluster among the Hudson Schools staff,
but our analysis does not definitively rule one out. We can continue to monitor the cancer experience of
the staff in future years if an updated directory is provided to us. It is possible that the teachers who were
diagnosed with breast cancer share risk factors for breast cancer that are unrelated to the school or
geographic area for Hudson. For example, a study of teachers in California concluded that they had an
excess of cancer – breast cancer, in particular - but have been unable to determine the cause of the excess
[https://pubmed.ncbi.nlm.nih.gov/12296510/]. We did unexpectedly find a higher than expected
proportion of prostate cancer among male residents of the Hudson ZIP code and have provided some
information on risk factors for prostate cancer below.
Risk factors for Prostate Cancer

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not
mean that you will get cancer; not having risk factors does not mean that you will not get cancer.
Results of the second group of analyses showed that prostate cancer was elevated in males in the target
area of the city of Hudson, as compared to Cedar Falls. Many of the known risk factors for prostate cancer
are non-modifiable including age. Prostate cancer is most common in men over the age of 40 and incidence
increases with each decade after. Prostate cancer risk is highest among the non-Hispanic Black population
and in Caribbean men of African ancestry than in men of other races. Family history is also a major risk
factor for prostate cancer. A family history of a brother or father with prostate cancer increases the risk for
prostate cancer, with the risk higher for those with a younger relative affected. Additional information on
risk factors for prostate cancer can be found at https://www.cancer.org/cancer/prostate-cancer/causes-
risks-prevention/risk-factors.html.
Please let us know if you have further questions after reviewing this report.
Sincerely,
Mary Charlton., Ph.D. Michele M. West, Ph.D.

Director and Principal Investigator Coordinator, Special Studies
5
Table 1
Proportional Incidence Ratios (PIRs) and 95% Confidence Intervals for Hudson School (target area) versus
Remainder of Hudson community (comparison area), Males, All Ages, 2010-2020
95%
Observed Number of Confidence
Cancer Site Cancer Cases PIR Interval
Hudson School Remainder of Hudson
Lung and bronchus 3 7 2.75 0.98-7.67
Skin melanoma 2 7 1.83 0.50-6.73
Prostate 5 36 0.89 0.43-1.86
Other sites 7 59 0.76 0.43-1.34
All sites 17 109 reference
* P < 0.05; interval does not include 1.00.
Table 2
Remainder of Hudson community (comparison area), Females, All Ages, 2010-2020
95%
Hudson School Remainder of Hudson
Skin melanoma 2 6 1.94 0.52-7.24
Breast 7 28 1.45 0.79-2.66
Total leukemia 2 5 2.32 0.62-8.68
Benign brain 2 9 1.29 0.35-4.82
Other sites 8 74 0.63 0.36-1.08
All sites 21 122 reference
6
Table 3
Dike Zip Code (comparison area), Males, All Ages, 2010-2020
95%
Hudson School Dike Zip Code
Skin melanoma 2 7 1.14 0.31-4.20
Prostate 5 21 0.95 0.46-1.99
Other sites 7 31 0.90 0.51-1.59
All sites 17 68 Reference
Table 4
Dike Zip Code (comparison area), Females, All Ages, 2010-2020
95%
Hudson School Dike Zip Code
Skin melanoma 2 4 1.33 0.36-4.98
Breast 7 18 1.04 0.57-1.90
Thyroid 2 2 2.67 0.71-9.97
Benign brain 2 3 1.78 0.48-6.64
Other sites 8 29 0.74 0.43-1.27
7
Table 5
Cedar Falls Zip Code (comparison area), Males, All Ages, 2010-2020
95%
Hudson School Cedar Falls Zip Code
Skin melanoma 2 91 1.60 0.44-5.90
Prostate 5 315 1.16 0.55-2.42
Other sites 7 692 0.74 0.42-1.30
Table 6
Cedar Falls Zip Code (comparison area), Females, All Ages, 2010-2020
95%
Hudson School Cedar Falls Zip Code
Skin melanoma 2 71 1.55 0.41-5.79
Breast 7 329 1.17 0.64-2.14
Thyroid 2 37 2.98 0.80-11.12
Total leukemia 2 30 3.67 0.98-13.71
Benign brain 2 64 1.72 0.46-6.43
Other sites 6 625 0.53 0.27-1.04
8
Table 7
Proportional Incidence Ratios (PIRs) and 95% Confidence Intervals for Hudson Zip Code (target area) versus
Dike Zip Code (comparison area), Males, All Ages, 2010-2020
95%
Hudson Zip Code Dike Zip Code
Colon and rectum 7 3 1.40 0.69-2.88
Pancreas 4 2 1.20 0.46-3.15
Lung and bronchus 7 9 0.47 0.23-0.96*
Skin melanoma 7 7 0.60 0.29-1.23
Prostate 40 21 1.15 0.89-1.47
Kidney and renal pelvis 7 3 1.40 0.69-2.88
Non-Hodgkin lymphoma 3 2 0.90 0.30-2.76
Total leukemia 5 3 1.00 0.43-2.36
Benign brain 2 3 0.40 0.10-1.58
Other sites 31 15 1.24 0.92-1.68
9
Table 8
Dike Zip Code (comparison area), Females, All Ages, 2010-2020
95%
Hudson Zip Code Dike Zip Code
Colon and rectum 16 2 3.53 2.23-5.59*
Pancreas 3 2 0.66 0.22-2.03
Lung and bronchus 15 4 1.66 1.03-2.67*
Skin melanoma 6 4 0.66 0.30-1.45
Breast 30 19 0.70 0.51-0.95*
Uterus 9 7 0.57 0.30-1.07
Brain 3 2 0.66 0.22-2.03
Benign brain 10 3 1.47 0.81-2.67
Other sites 32 10 1.41 1.05-1.91*
10
Table 9
Cedar Falls Zip Code (comparison area), Males, All Ages, 2010-2020
95%
Hudson Zip Code Cedar Falls Zip Code
Colon 3 55 0.60 0.20-1.84
Rectum 4 27 1.63 0.62-4.27
Pancreas 4 40 1.10 0.42-2.88
Soft tissue 2 8 2.75 0.70-10.88
Skin melanoma 7 91 0.85 0.41-1.74
Skin, non-epithelial 2 8 2.75 0.70-10.88
Prostate 40 315 1.40 1.09-1.79*
Testis 3 23 1.44 0.47-4.39
Bladder (invasive and noninvasive) 4 103 0.43 0.16-1.12
Thyroid 2 11 2.00 0.51-7.91
Total leukemia 5 40 1.38 0.58-3.24
Benign brain 2 51 0.43 0.11-1.71
Other sites 18 224 0.89 0.58-1.35
11
Table 10
Cedar Falls Zip Code (comparison area), Females, All Ages, 2010-2020
95%
Hudson Zip Code Cedar Falls Zip Code
Colon 11 77 1.29 0.73-2.27
Rectum 5 11 4.10 1.74-9.69*
Pancreas 3 27 1.00 0.33-3.07
Skin melanoma 6 71 0.76 0.35-1.67
Breast 30 331 0.82 0.60-1.12
Cervix 2 11 1.64 0.42-6.49
Uterus 9 65 1.25 0.67-2.35
Bladder (invasive and noninvasive) 3 20 1.35 0.44-4.14
Eye and orbit 2 2 9.02 2.28-35.69*
Brain 3 9 3.01 0.98-9.20
Myeloma 3 15 1.80 0.59-5.52
Total leukemia 7 30 2.11 1.02-4.33*
Benign brain 10 65 1.39 0.77-2.52
Other sites 15 247 0.55 0.34-0.88*
12

Final Hudson School Cluster Sent 12.20.22

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2600 University Capitol Centre, The University of Iowa, Iowa City, IA 52242-5500,

PH 319/335-8609, FAX 319/335-8610

December 20, 2022

RE: Suspected Excess of Cancer in Hudson Schools

Dear Ms. Anderson,

Cancer cluster investigation methods

Results comparing Hudson School to Remainder of Hudson, IA Comparison Group

Results comparing Hudson School to Dike Zip Code Comparison Group

Breast cancer incidence in Hudson School employees

Summary of results, and limitations

Risk factors for Prostate Cancer

Mary Charlton., Ph.D. Michele M. West, Ph.D.

* P < 0.05; interval does not include 1.00.

* P < 0.05; interval does not include 1.00.

* P < 0.05; interval does not include 1.00.

* P < 0.05; interval does not include 1.00.

* P < 0.05; interval does not include 1.00.

* P < 0.05; interval does not include 1.00.

* P < 0.05; interval does not include 1.00.

* P < 0.05; interval does not include 1.00.

* P < 0.05; interval does not include 1.00.

* P < 0.05; interval does not include 1.00.

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