The second case study that I wanted to mention involved a study that we did in Ashland, Massachusetts. As I mentioned, it was site that ultimately was placed on the national priority list site, and it was referred to as the Nyanza site. So, from the early 1900s to 1978, the site was used to produce textile dyes and intermediate, quite a large volume of those dyes and intermediate, and provided those dyes all over the country. From 1965 to 1978, it was known as the Nyanza Chemical Company. As I mentioned, in 1983, the site, due to the significant contamination, was closed and placed on the US EPA's National Priority List site. So, let's talk a little bit about the background of this particular cluster investigation. In 1998, suspected cluster of rare cancers was reported to the MA Department of Public Health. I should say that it wasn't just reported to our agency. I got a call from a fellow that I came to know and like incredibly, a very vivacious young man, 27 years old. His name was Kevin Keynes. He was calling me because he had just been diagnosed with Andrea sarcoma of the lung. He was 27 years old. He had never smoked. He had been at a concert with friends and felt like he was getting a cold, began to cough up blood and knew something was wrong. So, he went to the doctors. Surely, after Kevin was diagnosed, he learned that for other young men that he had gone to high-school with and gone to school with in general were also diagnosed with rare sarcomas. All of these children, what Kevin reported to me that they all grew up in Ashland, Massachusetts and played a lot at the Nyanza site during the 1960s and 1970s. So, the reported cluster of young men with rare sarcomas were among those that had previously been identified as the potentially exposed population. The State Health Department had done several other investigations looking at hazardous waste sites in general in the state. When we looked at the Nyanza site, that population that was identified as being at greatest risk for future health effects were children that grew up in plate on the site during the '60s and '70s. Unfortunately, the Massachusetts Cancer Registry data that were available to us to look at how prevalent cancer might be among people in this age group only had data available for residents at the time of diagnosis of cancer. So, if people had moved all over the country, we had no way to know that they indeed had grown up in Ashland and played on the site during the '60s and '70s. It was now also no information available on individual exposures to the Nyanza site. These estimates of environmental exposure are very important when you're trying to tease out the role that the environment might play in cancer incidence. So, we decided at that time, we probably needed to think about doing what's called a retrospective cohort study, looking at this particular group that lived and played in Ashland during the '60s and '70s, and trying to see if we could find them and go back over time, and then see if we could understand what kinds of exposures that they may have had to the Nyanza site. I can't speak more to the importance of working closely with the community in these types of investigations, because, indeed, it was Kevin Keynes' mother, who was the high-school nurse, that sat on a Community Advisory Committee with us. We established that committee so that we could both communicate with the community about what we were doing and what the barriers were to try and to do this kind of work, but also to involve them in the work that we were doing because, frankly, no one knows more about the environment than those people who live in the environment. So, when I was explaining to the committee during one of our early meetings, I said, "I want you to know the kind of study that we have to do is going to be an incredible challenge. It's a challenge because we have to try to find the kids who lived here in the '60s and '70s and played here." Kevin Keynes' mum raises her hand and says, "Suzanne, I can help with that." I said, "What do you mean, Murray?" She said, "We keep track of every single kid that ever went to Ashland High School. No matter where they've moved, we know where they are all over this country." It was an epidemiologist dream to have somebody say they could help us identify the population that we needed to focus on. So, we worked again with the Community Advisory Committee to try to figure out how are we going to capture the exposures that might be of greatest interest to the kids who grew up and played on this site. Here's a map that we developed. I should say that there are letters in each of these map areas, but the community was not aware of what we were designating as any of those areas. What the Community Advisory Committee helped us do was come up with common terminology. This is a community, I will say, that became very familiar with living in a town where dyes were manufactured. If you look at the top of the map, you'll see what looks like to be railroad tracks. This is small brook that runs alongside the tracks. If you can see it, it's called Chemical Brook. Well, the community named that Brook, and they named it because based upon the different dye colors that were made on a given day, that was the color of the brook. So, they decided to call it Chemical Brook. You'll also see, at the lower part of the screen, a baseball field, athletic fields, and then you see what looks like little tracks. Those tracks go up to the top of what is called Malchenko Hill, which is right in the middle of this waste site where literally hundreds of drums of contaminated waste had been buried. That's where the high-school track team played. That's where they worked out. The cross-country team ran through that area daily. So, again, trying to figure out who had the greatest amount of exposure and to what parts of the site was critical, but the development of this map, with the assistance from the community, proved to be invaluable. The other thing that was tough in this investigation was trying to study soft tissue sarcomas. So, sarcomas are rare types of cancerous tumors that develop in the soft tissues of the body, but they can develop in any different part of the body. They account for less than one percent of all cancers, and they often occur more in males than females. The causes for sarcoma are largely unknown. They are related to certain inherited conditions, but there is some evidence and there was at the time of environmental associations. So, certainly, things like exposure to ionizing radiation, exposure to vinyl chloride and inorganic arsenic, and particularly, among pesticide applicator, there had been some risk demonstrated that showed an association between sarcoma and exposure to chlorinated insecticides and herbicides. So, we conducted this study in Ashland. It was a retrospective cohort study. We were able to identify the large majority of the kids who lived in Ashland and played on the site, and didn't play on the site during those years. Our results showed a consistent pattern when the analyses included all individuals with a cancer diagnosis, a confirmed cancer diagnosis, and a rare cancer diagnosis. We had to look at anybody that had cancer, and we wanted to also know whether or not they had family members that had cancer. Remember, I mentioned the risk factors for development of sarcoma, and there were certain inherited conditions that played an important role over time as we look at the literature. So, that was important. But our findings suggest, along with other things, that there could have been a possible gene-environment interaction between past Nyanza water exposures and study participants with a family history of cancer. The relative risk of developing cancer was significantly greater for study participants who reported water contact exposures in specific areas of the site, and that again goes back to those water areas marked on that map. The relative risk for developing cancer markedly increased for study participants with water contact exposure and those that also had a family history of cancer. One of the things this study did tell us though is that there really is a lack of good disease surveillance data across the United States.