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THE WAR ON CANCER – 2010

THE WAR ON CANCER – 2010. THE CURRENT STATE PREVENTION STRATEGIES HEALTH DISPARITIES. D.E. KENADY M.D. Otis W. Brawley, M.D. Chief Medical Officer Executive Vice President American Cancer Society. Professor of Hematology, Oncology, Medicine and Epidemiology Emory University.

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THE WAR ON CANCER – 2010

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  1. THE WAR ON CANCER – 2010 • THE CURRENT STATE • PREVENTION STRATEGIES • HEALTH DISPARITIES D.E. KENADY M.D.

  2. Otis W. Brawley, M.D.Chief Medical OfficerExecutive Vice PresidentAmerican Cancer Society Professor of Hematology, Oncology, Medicine and Epidemiology Emory University

  3. 2009 Estimated US Cancer Deaths* Men292,540 Women269,800 Lung & bronchus 30% Prostate 9% Colon & rectum 9% Pancreas 6% Leukemia 4% Liver & intrahepatic 4%bile duct Esophagus 4% Urinary bladder 3% Non-Hodgkin 3% lymphoma Kidney & renal pelvis 3% All other sites 25% 26% Lung & bronchus 15% Breast 9% Colon & rectum 6% Pancreas 5% Ovary 4% Non-Hodgkin lymphoma 3% Leukemia 3% Uterine corpus 2% Liver & intrahepatic bile duct 2% Brain/ONS 25% All other sites ONS=Other nervous system. Source: American Cancer Society, 2009.

  4. US Mortality, 2006 No. of deaths % of all deaths Rank • 1. Heart Diseases 631,636 26.0 • 2. Cancer559,888 23.1 • 3. Cerebrovascular diseases 137,119 5.7 • 4. Chronic lower respiratory diseases 124,583 5.1 • 5. Accidents (unintentional injuries) 121,599 5.0 • 6. Diabetes mellitus 72,449 3.0 • 7. Alzheimer disease 72,432 3.0 • 8. Influenza & pneumonia 56,326 2.3 • Nephritis* 45,344 1.9 • 10. Septicemia 34,234 1.4 Cause of Death *Includes nephrotic syndrome and nephrosis. Source: US Mortality Data 2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

  5. Change in US Death Rates* from 1991 to 2006 Rate Per 100,000 1991 2006 * Age-adjusted to 2000 US standard population. Sources: 1950 Mortality Data - CDC/NCHS, NVSS, Mortality Revised. 2006 Mortality Data: US Mortality Data 2006, NCHS, Centers for Disease Control and Prevention, 2009.

  6. Cancer Death Rates* by Sex, US, 1975-2005 Rate Per 100,000 Men Both Sexes Women *Age-adjusted to the 2000 US standard population. Source: US Mortality Data 1960-2005, National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.

  7. Cancer Death Rates* Among Men, US,1930-2005 Rate Per 100,000 Lung & bronchus Stomach Prostate Colon & rectum Pancreas Leukemia Liver *Age-adjusted to the 2000 US standard population. Source: US Mortality Data 1960-2005, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.

  8. Cancer Death Rates* Among Women, US,1930-2005 Rate Per 100,000 Lung & bronchus Uterus Breast Colon & rectum Stomach Ovary Pancreas *Age-adjusted to the 2000 US standard population. Source: US Mortality Data 1960-2005, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.

  9. 2009 Estimated US Cancer Cases* Men766,130 Women713,220 27% Breast 14% Lung & bronchus 10% Colon & rectum 6% Uterine corpus 4% Non-Hodgkin lymphoma 4% Melanoma of skin 4% Thyroid 3% Kidney & renal pelvis 3% Ovary 3% Pancreas 22% All Other Sites Prostate 25% Lung & bronchus 15% Colon & rectum 10% Urinary bladder 7% Melanoma of skin 5% Non-Hodgkin 5% lymphoma Kidney & renal pelvis 5% Leukemia 3% Oral cavity 3% Pancreas 3% All Other Sites 19% *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2009.

  10. Cancer Incidence Rates* by Sex, US, 1975-2005 Rate Per 100,000 Men Both Sexes Women *Age-adjusted to the 2000 US standard population and adjusted for delays in reporting. Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database: SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008.

  11. Cancer Incidence Rates* Among Men, US, 1975-2005 Rate Per 100,000 Prostate Lung & bronchus Colon and rectum Urinary bladder Non-Hodgkin lymphoma Melanoma of the skin *Age-adjusted to the 2000 US standard population and adjusted for delays in reporting. Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database: SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008.

  12. Cancer Incidence Rates* Among Women, US, 1975-2005 Rate Per 100,000 Breast Colon and rectum Lung & bronchus Uterine Corpus Ovary Non-Hodgkin lymphoma *Age-adjusted to the 2000 US standard population and adjusted for delays in reporting. Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database: SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008.

  13. Cancer Incidence & Death Rates* in Children 0-14 Years, 1975-2005 Rate Per 100,000 Incidence Mortality *Age-adjusted to the 2000 Standard population. Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

  14. Cancer Incidence Rates* in Children 0-14 Years by Sex, 2001-2005 Site Male Female Total All sites 16.1 14.1 15.1 Leukemia 5.4 4.5 5.0 Acute Lymphocytic 4.3 3.6 3.9 Brain/ONS 3.4 3.1 3.2 Soft tissue 1.1 1.0 1.1 Non-Hodgkin lymphoma 1.2 0.6 0.9 Kidney and renal pelvis 0.8 0.8 0.8 Bone and Joint 0.7 0.7 0.7 Hodgkin lymphoma 0.7 0.4 0.5 *Per 100,000, age-adjusted to the 2000 US standard population. ONS = Other nervous system Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

  15. Cancer Death Rates* in Children 0-14 Years by Sex, US, 2001-2005 Site Male Female Total All sites 2.7 2.3 2.5 Leukemia 0.8 0.7 0.8 Acute Lymphocytic 0.4 0.3 0.4 Brain/ONS 0.8 0.7 0.7 Non-Hodgkin lymphoma 0.1 0.1 0.1 Soft tissue 0.1 0.1 0.1 Bone and Joint 0.1 0.1 0.1 Kidney and Renal pelvis 0.1 0.1 0.1 *Per 100,000, age-adjusted to the 2000 US standard population. ONS = Other nervous system Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

  16. Tobacco Use in the US, 1900-2005 Per capita cigarette consumption Male lung cancer death rate Female lung cancer death rate *Age-adjusted to 2000 US standard population. Source: Death rates: US Mortality Data, 1960-2005, US Mortality Volumes, 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006. Cigarette consumption: US Department of Agriculture, 1900-2007.

  17. Trends in Cigarette Smoking Prevalence* (%), by Sex, Adults 18 and Older, US, 1965-2007 Men Women *Redesign of survey in 1997 may affect trends. Source: National Health Interview Survey, 1965-2007, National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.

  18. Current* Cigarette Smoking Prevalence (%) Among High School Students by Sex and Race/Ethnicity, US, 1991-2007 *Smoked cigarettes on one or more of the 30 days preceding the survey.Source: Youth Risk Behavior Surveillance System, 1991, 1995, 1997, 1999, 2001, 2003, 2005, 2007 National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2008.

  19. Trends in Consumption of Five or More Recommended Vegetable and Fruit Servings for Cancer Prevention, Adults 18 and Older, US, 1994-2007 Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000, 2003, 2005, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2004, 2006, 2008.

  20. Trends in Prevalence (%) of No Leisure-Time Physical Activity, by Educational Attainment, Adults 18 and Older, US, 1992-2007 Adults with less than a high school education All adults Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Educational attainment is for adults 25 and older. Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000, 2002, 2004, 2005, 2006, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2003, 2005, 2006, 2007, 2008.

  21. Trends in Obesity* Prevalence (%), Children and Adolescents, by Age Group, US, 1971-2006 *Body mass index (BMI) at or above the sex-and age-specific 95th percentile BMI cutoff points from the 2000 sex-specific BMI-for-age CDC Growth Charts. Note: Previous editions of Cancer Statistics used the term “overweight” to describe youth in this BMI category. Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2006: Ogden CL, et al. High Body Mass Index for Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05.

  22. Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20 to 74, US, 1960-2006† *Obesity is defined as a body mass index of 30 kg/m2 or greater. † Age adjusted to the 2000 US standard population.Source: National Health Examination Survey 1960-1962, National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2004, 2005-2006: National Health and Nutrition Examination Survey Public Use Data Files, 2003-2004, 2005-2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006, 2007.

  23. Mammogram Prevalence (%), by Educational Attainment and Health Insurance Status, Women 40 and Older, US, 1991-2006 All women 40 and older Women with less than a high school education Women with no health insurance *A mammogram within the past year. Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data Tape (2000, 2002, 2004, 2006), National Centers for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2000, 2001, 2003, 2005, 2007.

  24. Female Breast Cancer Death Ratesby Race and Ethnicity, US, 1975-2004

  25. Adjusted Breast Cancer Survival by Stages and Insurance Status, among Patients Diagnosed in 1999-2000 and Reported to the NCDB

  26. Breast Cancer • It is estimated that 57,000 breast cancer deaths were averted between 1990 and 2005 due to screening, early detection, and aggressive treatment. • Breast cancer screening rates have actually gone down during the period 2000 to 2005

  27. Breast Cancer • Imagine a world in which • Mammography rates were greater than 80% • All women with an abnormal screen got it evaluated • All women with breast cancer got optimal therapy

  28. Trends in Recent* Pap Test Prevalence (%), by Educational Attainment and Health Insurance Status, Women 18 and Older, US, 1992-2006 All women 18 and older Women with no health insurance Women with less than a high school education * A Pap test within the past three years. Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Educational attainment is for women 25 and older. Source: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data Tape (2000, 2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Center for Disease Control and Prevention, 1997, 1999, 2000, 2000, 2001, 2003, 2005, 2007.

  29. Screening Guidelines for the Early Detection of Colorectal Cancer and Adenomas, American Cancer Society 2008 • Beginning at age 50, men and women should follow one of the following examination schedules: • A flexible sigmoidoscopy (FSIG) every five years • A colonoscopy every ten years • A double-contrast barium enema every five years • A Computerized Tomographic (CT) colonography every five years • A guaiac-based fecal occult blood test (FOBT) or a fecal immunochemical test (FIT) every year • A stool DNA test (interval uncertain) • Tests that detect adenomatous polyps and cancer • Tests that primarily detect cancer People who are at moderate or high risk for colorectal cancer should talk with a doctor about a different testing schedule

  30. Trends in Recent* Fecal Occult Blood Test Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50 Years and Older, US, 1997-2006 *A fecal occult blood test within the past year. Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001, 2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007.

  31. Trends in Recent* Flexible Sigmoidoscopy or Colonoscopy Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50 Years and Older, US, 1997-2006 *A flexible sigmoidoscopy or colonoscopy within the past ten years. Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001, 2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007.

  32. Adjusted Colorectal Cancer Survival by Stages and Insurance Status, among Patients Diagnosed in 1999-2000 and Reported to the NCDB

  33. Colorectal Cancer • It is estimated that 77,000 colorectal cancer deaths were averted between 1990 and 2005 due to screening, early detection, and aggressive treatment. • Colorectal cancer screening rates have actually gone down during the period 2000 to 2005

  34. Colorectal Cancer • Imagine a world in which • Colorectal cancer screening rates were greater than 80% • All men and women with an abnormal screen got it evaluated • All with colorectal cancer got optimal therapy

  35. Sunburn* Prevalence (%) in the Past Year, Adults 18 and Older, US, 2004 *Reddening of any part of the skin for more than 12 hours. Note: The overall prevalence of sunburn among adult males is 46.4% and among females is 36.3%. Source: Behavioral Risk Factor Surveillance System Public Use Data Tape, 2004. National Center for Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2005.

  36. Ultraviolet Radiation Exposure Behaviors* Prevalence (%), Adults 18 and Older, US, 2005 *Proportion of respondents reporting always or often practicing the particular sun protection behavior on any warm sunny day. †Used an indoor tanning device, including a sunbed, sunlamp, or tanning booth at least once, in the past 12 months. Source: National Health Interview Survey Public Use Data File 2005, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

  37. Cancer Survival and Deprivation in Scotland

  38. Survival Rates RMS TitanicConcept of Dr. Lisa Newman

  39. How can we provide adequate high quality care (to include preventive care) to a population that has so often not received it?

  40. Quality of Care • There are more than two dozen patterns of care studies to show racial disparities in care received by Blacks and/or the poor have: • Delayed treatment • No adjuvant chemotherapy • Dose reductions of chemotherapy • No hormonal therapy • No surgery • No radiation when it was appropriate

  41. Quality of Care Matters • CMF post mastectomy adjuvant chemotherapy • CMF useful when > 85% of planned dose given for 12 cycles • 5 year Relapse Free Survival • > 85% of planned dose 77% • No Chemotherapy 45% p=0.0001 • Subgroup getting < 65% of planned dose 48% • Bonadonna et al NEJM 1981 • Bonadonna et al NEJM 1995

  42. Quality of Care • Receipt of “minimum expect care” in SEER-Medicare data 1992-1999 • Blacks less likely OR 0.67 95% CI (.59-.76) • Hispanics less likely OR 0.77 95% CI (.66-.90) • Haggstrom, Cancer 2005

  43. Quality of Care • In a prospective study of 764 women getting chemotherapy for breast cancer, the following were associated with intentional reduction of chemotherapy dose in univariate analysis • Education Attainment • Zip Code Correlated SES Measures • BMI • Geographic region • Griggs et al JCO 2007

  44. Quality of Care • In a multivariate analysis, factors independently associated with a decrease in chemotherapy dose OR 95% CI • Obesity 2.47 (1.36 to 4.51) • Severe obesity 3.04 (1.46 to 11.19) • <HS Education 3.07 (1.57 to 5.99) • Griggs et al, JCO 2007

  45. Quality of Care • In a study of women breast cancer patients aged 20 to 54, a higher proportion of Blacks had a greater than three month delay in treatment from initial consultation. • 22.4% of Blacks • 14.3% of Whites • Gwyn et al, Cancer 2004

  46. Quality of Care • In a SEER Study of more than 870 Blacks and 2430 Whites treated in 2000 to 2001 • Blacks were 4 to 5 fold more likely to get definitive treatment more than 60 days after initial consultation • Of patients treated with lumpectomy 61% of Blacks and 72% of whites completed radiation • In one SEER registry 7.5% of Blacks with clinically localized disease got no surgical therapy vs 2% of whites • Lund et al Breast Ca Res Treat, 2007

  47. Quality of Care • In a SEER Study of more than 870 Blacks and 2430 Whites treated in 2000 to 2001 7.5% of Black women with clinically localized disease got no surgical therapy vs 2% of whites Note: These women had enough access to get diagnosed • Lund et al, Breast Ca Res Treat, 2007

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