The 2002 Healthcare Conference Surviving or Thriving ? 29 September-1 October 2002 Scarman House,...

The 2002 Healthcare ConferenceSurviving or Thriving ?

29 September-1 October 2002

Scarman House, The University of Warwick, Coventry

Session A1 : Trends in CI - Cancer

Trends in incidence and mortality rates

Working Party / Research Sub-party Progress Report

Neil Robjohns & Richard Morris

Critical Illness Trends Research Group

Our Aims : To examine underlying trends in the factors influencing UK

Insured Critical Illness claim rates, and from these, to assess : The historic trend in incidence and death rates for the major CI’s Any pointers for future trends in Standalone CI, Mortality and hence

Accelerated CI.

Formed in March 2001

Cancer Sub-Group Members

ActuariesAzim Dinani

Richard Morris

Neil Robjohns

Medical ExpertsProfessor Rubens - Consultant Oncologist

Cancer Trends

England & Wales population trends - recap Variation by deprivation category International comparisons Incidence versus mortality Lung cancer / modelling impact of smoking Future trends

Cancer Incidence and Mortality Rates, 1971 - 97All Ages

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

Male Incidence Female Incidence

Male Mortality Female Mortality

Cancer Incidence and Mortality Rates, 1971 - 97"Key Insurance Ages"

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

Male Incidence Female Incidence

Male Mortality Female Mortality

Possible Reasons Behind Observed Trends

Issues with Data Recording Cancer Screening Initiatives Behavioural changes Treatment

of Cancer of other illnesses

Awareness Other ?

Breast CancerChanges in Incidence Rates, by age band, over 1971 - 97

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

45-49 50-54 55-59 60-64 65-69

Prostate CancerChanges in Incidence Rates, by age band, over 1971 - 97

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Lung CancerChanges in Incidence Rates, by age band, over 1971 - 97

1971 1975 1979 1983 1987 1991 1995

35-39 45-49 55-59

65-69 75-79 85+

Females

1971 1975 1979 1983 1987 1991 1995

35-39 45-49 55-59

65-69 75-79 85+

Malignant MelanomaChanges in Incidence Rates for Males, by age band, over 1971 - 97

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

35-39 45-49 55-59 65-69 75-79 85+

Breast CancerChanges in Mortality Rates, by age band, over 1971 - 97

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

35-39 40-44 45-49 50-54 55-59 60-64

Stomach CancerChanges in Incidence Rates for Males, by age band, over 1971 - 97

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

45-49 50-54 55-59 60-64 65-69

Testicular CancerChanges in Incidence Rates, by age band, over 1971 - 97

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

20-24 25-29 30-34 35-39 40-44

Cancer Incidence Rates by Site of CancerFemales, 1997

Key Insured Ages

Breast47%

Colorectal6%

Lung6%

Uterus4%

Cervix5%

Ovary6%

Stomach1%

Bladder & Pancreas

Malignant melanoma

4%Other16%

All Ages

Breast29%

Colorectal12%

Lung11%

Uterus4%

Cervix2%

Ovary5%

Stomach3%

Bladder & Pancreas

Malignant Melanoma

Other22%

Cancer Incidence Rates by Site of CancerMales, 1997

All Ages

Lung19%

Prostate17%

Colorectal14%

Bladder & Pancreas

Stomach5%

Mouth & Oesophagus

Kidney3%

Testis1%

Leukaemia3%

Malignant Melanoma

2% Other19%

Key Insured Ages

Lung15%

Prostate6%

Colorectal13%

Bladder & Pancreas8%

Stomach4%

Mouth & Oesophagus

Kidney4%

Testis5%

Leukaemia3%

Malignant melanoma5%

Other23%

Summary of Trends in Cancer Incidence and MortalityAverage Change % pa, for Females, aged 40 - 59, over 1971 - 97

Size of Balls Indicates Relative Importance of Cancer Site, measured by Incidence Rates in 1997.

-6.0% -4.0% -2.0% 0.0% 2.0% 4.0%

Change in Mortality, %pa

Breast

Uterus & Ovary

Colorectal

Cervix

Malignant melanoma

Pancreas & Bladder

Mouth & Oesophagus

Kidney

Stomach

Summary of Trends in Cancer Incidence and MortalityAverage Change % pa, for Males, aged 40 - 59, over 1971 - 97

Size of Balls Indicates Relative Importance of Cancer Site, measured by Incidence Rates in 1997.

-6.0% -4.0% -2.0% 0.0% 2.0% 4.0%

Change in Mortality, %pa

Colorectal

Pancreas & Bladder

Mouth & Oesophagus

Prostate

Stomach

Kidney

Malignant melanoma

Testis

Some Thoughts Looking Forwards

Tentative Initial Views :

Cancer Mortality : “Good News” ? “Continuing Reductions, at least for ages below 65” ?

Cancer Incidence : “Bad News” ? “Underlying, steady increase, plus jumps up” ? !

Cancer Trends

Variation by deprivation category

Scottish data Carstairs & Morris deprivation categories:

Postcode based

Categories 1-7 (1=“affluent”; 7=“deprived”) Classes 1-3 = Insured class? Key Sites (data limited)

Split of Scottish Population by Deprivation Category

Unassigned

1991 Data

Link with deprivation category

Inception Rates

Mortality Rates

Positive Negative InconclusiveLung Breast Colo-rectal

Cervix Prostate KidneyBladder Brain LeukaemiaLarynx Malignant melanoma

Oesphagus TestisPancreas Ovary

Positive Negative InconclusiveLung Prostate Colo-rectal

Cervix Brain KidneyBladder Malignant melanoma LeukaemiaLarynx Ovary Breast

Oesphagus TestisPancreas

Link with deprivation code: Lung Cancer

Mortality & Incidence: Positive correlation Lagged link to smoker prevalence

Causes? Smoking Air pollution?

Cohort effect (e.g. cigarette smoking) Temporal effect (e.g. air pollution, cigarette

composition (tar content), new treatment) Sharp fall in mortality over next 5-10 years?

Smoker Prevalence 1974-1998: Females

1974 1978 1982 1986 1990 1994 1998

IIINM IIIM

1974 1978 1982 1986 1990 1994 1998In

IIINM IIIM

England & Wales: General Household Survey 2000

Smoker Prevalence 1974-1998: Males

1974 1978 1982 1986 1990 1994 1998

IIINM IIIM

1974 1978 1982 1986 1990 1994 1998In

IIINM IIIM

England & Wales: General Household Survey 2000

Annualised change in inception rate: 1982-2000:Lung Cancer - Males Ages:40-59

1 2 3 4 5 6 7

Deprivation Code

alised

Annualised change in inception rate: 1982-2000:Lung Cancer - Females Ages:40-59

1 2 3 4 5 6 7

Deprivation Code

alised

Scottish Population Data : Trends by Deprivation Category, 1982-2000Rates per 10,000

Incidence, I See LegendLung Cancer 40-59 standardisedMenCritical Illness Sex Event Deprivation Category Age Band

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

Scottish Population Data : Trends by Deprivation Category, 1982-2000Index (1982 = 100)

40-59 standardisedLung Cancer Men Incidence, I See LegendCritical Illness Sex Event Deprivation Category Age Band

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

Incidence, I See LegendLung Cancer 40-59 standardisedWomenCritical Illness Sex Event Deprivation Category Age Band

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

40-59 standardisedLung Cancer Women Incidence, I See LegendCritical Illness Sex Event Deprivation Category Age Band

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

Link with deprivation code: Breast Cancer

Incidence: negative correlation Screening related difference? Social / environmental differences Reproductive history

Mortality: link inconclusive Differences in treatment? Differences in stage of presentation?

Incidence, I See LegendBreast Cancer All - StandardisedWomenCritical Illness Sex Event Deprivation Category Age Band

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

Incidence, I See LegendBreast Cancer 40-59 standardisedWomenCritical Illness Sex Event Deprivation Category Age Band

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

40-59 standardisedBreast Cancer Women Incidence, I See LegendCritical Illness Sex Event Deprivation Category Age Band

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

Mortality, Q See LegendBreast Cancer 40-59 standardisedWomenCritical Illness Sex Event Deprivation Category Age Band

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

40-59 standardisedBreast Cancer Women Mortality, Q See LegendCritical Illness Sex Event Deprivation Category Age Band

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

Link with deprivation code: Prostate Cancer

Incidence & mortality: negative correlation Screening related? Hormonal factors? Diet?

Annualised change in inception rate: 1982-2000:Prostate Cancer - Males Ages:40-59

1 2 3 4 5 6 7

Deprivation Code

Incidence, I See LegendProstate Cancer All - StandardisedMenCritical Illness Sex Event Deprivation Category Age Band

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

All - StandardisedProstate Cancer Men Incidence, I See LegendCritical Illness Sex Event Deprivation Category Age Band

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

Link with deprivation code: Cervical Cancer

Incidence & mortality: Positive correlation Causes?

Sexual activity Smoking Parity

Incidence, I See LegendCervical Cancer 40-59 standardisedWomenCritical Illness Sex Event Deprivation Category Age Band

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

40-59 standardisedCervical Cancer Women Incidence, I See LegendCritical Illness Sex Event Deprivation Category Age Band

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

Link with deprivation code: Colo-rectal Cancer

Incidence & mortality: No clear link Causes?

High-fat diet Low physical activity Reproductive history

Cancer by Deprivation Code: Trends

Lung cancer Smoker-related trend to emerge?

Breast cancer No identifiable difference in trend

Prostate cancer Reflection of trend in screening?

Cervical cancer No identifiable difference in trend

Colo-rectal cancer Inconclusive link to deprivation code

Cancer Trends

International ComparisonsAll Cancers ; All Ages

See Legend All CISee Legend

Rates per 10,000

All - StandardisedSee Legend

Cancer Trends 1971 - 1998

Country Sex Event Cancer Site Age Band

Can_F_Q_Can_M_Q_EandW_M_Q_ EandW_F_Q_ Scot_M_Q_ Scot_F_Q_ USA_M_Q_ USA_F_Q_

USA_M_I_ USA_F_I_ Can_M_I_ Can_F_I_EandW_M_I_ EandW_F_I_ Scot_M_I_ Scot_F_I_

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

International ComparisonsAll Cancers ; Ages 40 - 59

See Legend All CISee Legend

Rates per 10,000

40-59 standardisedSee Legend

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

International ComparisonsLung Cancer ; Ages 40 - 59

See Legend LungSee Legend

Rates per 10,000

40-59 standardisedSee Legend

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

International ComparisonsProstate Cancer ; All Ages

See Legend ProstateSee Legend

Rates per 10,000

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

Prostate Cancer “Screening”

See Legend ProstateUSA

Rates per 10,000

See LegendMen

Not in UseQ_75-79Q_50-54 Q_55-59 Q_60-64 Q_65-69 Not in Use Q_70-74

Not in Use I_70-74 I_75-79 Not in UseI_50-54 I_55-59 I_60-64 I_65-69

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

International ComparisonsBreast Cancer ; All Ages

See Legend BreastSee Legend

Rates per 10,000

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

International ComparisonsMalignant Melanoma ; All Ages

See Legend MelanomaSee Legend

Rates per 10,000

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

Cancer Trends

Ratio of Mortality Rate to Incidence RateMales ; England & Wales ; 1998

Ages 40 - 59 All Ages

All CI Cancers 51% 62%

Stomach 58% 71%Colorectal 41% 49%Lung 86% 92%Malignant Melanoma 26% 31%Prostate 17% 42%Testis 6% 5%Bladder 20% 37%

Ratio of Mortality Rate to Incidence RateFemales ; England & Wales ; 1998

Ages 40 - 59 All Ages

All CI Cancers 34% 55%

Stomach 57% 79%Colorectal 38% 50%Lung 80% 89%Malignant Melanoma 16% 25%Breast 22% 34%Cervix 42% 42%Ovary 52% 76%

Ratio of Mortality Rate to Incidence RateMales ; Ages 40 - 59 ; 1998

E&W Scotland USA

All CI Cancers 51% 49% 35%

Stomach 58% 59% 52%Colorectal 41% 43% 31%Lung 86% 79% 86%Malignant Melanoma 26% 26% 15%Prostate 17% 17% 3%Testis 6% 5% 6%Bladder 20% 21% 10%

Ratio of Mortality Rate to Incidence RateFemales ; Ages 40 - 59 ; 1998

E&W Scotland USA

All CI Cancers 34% 34% 26%

Stomach 57% 64% 58%Colorectal 38% 37% 30%Lung 80% 70% 70%Malignant Melanoma 16% 19% 9%Breast 22% 24% 16%Cervix 42% 26% 32%Ovary 52% 41% 35%

Cancer Trends

Observed Lung Cancer Incidence and Mortality RatesEngland & Wales

I_40-44 I_50-54 I_60-64 I_65-69 I_70-74 I_75-79 I_80-84 I_85+

Q_85+Q_80-84Q_40-44 Q_50-54 Q_60-64 Q_65-69 Q_70-74 Q_75-79

Country Sex Event Cancer Site Age BandSee Legend LungEngland & Wales

Rates per 10,000

See LegendMen

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

Trend in Smoker Proportions in England And WalesAll Adult Ages

1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998

Men Women

Trend in Smoker Proportions in England And WalesBy Age Group

1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998

Men, 16-19 Men, 20-24 Men, 25-34 Men, 35-49 Men, 50-59 Men, 60+

Women, 16-19 Women, 20-24 Women, 25-34 Women, 35-49 Women, 50-59 Women, 60+

Modelling the Impact of Smoking

Build model to simulate population distribution by smoking habit, over time

Use Doll & Peto style formula

Adjust parameters to seek a good fit against observed lung cancer rates over time For Males, England & Wales, 1974 - 1998

Then project forward by making assumptions on trend in smoking habits

Modelling the Impact of Smoking

Doll & Peto Studied mortality / morbidity effects of cigarette

smoking by following a cohort of British Doctors Modelled relationship between lung cancer incidence

and level and duration of smoking habit 1951 – 1971

Rate = 0.273 * 10 –12 (dose + 6)2 * (age – 22.5)4.5

Fit of Model against Actual

1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998

50-54, P 55-59, P 60-64, P 65-69, P 70-74, P 75-79, P 80-84, P 85+, P

50-54, A 55-59, A 60-64, A 65-69, A 70-74, A 75-79, A 80-84, A 85+, A

Fit of Actual Rates against Model

1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998

Fit of Actual Rates against Model

35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85plus

1974-1978 1979-1983 1984-1988 1989-1993 1994-1998 1974-1998

Model Projection to 2010Assuming current rates of change in smoker status remain constant

1974 1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010

Male 40-44 Male 45-49 Male 50-54 Male 55-59 Male 60-64

Male 65-69 Male 70-74 Male 75-79 Male 80-84 Male 85-89

The next challenge !!

I_40-44 I_50-54 I_60-64 I_65-69 I_70-74 I_75-79 I_80-84 I_85+

Q_85+Q_80-84Q_40-44 Q_50-54 Q_60-64 Q_65-69 Q_70-74 Q_75-79

Country Sex Event Cancer Site Age BandSee Legend LungEngland & Wales

Rates per 10,000

See LegendWomen

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

Cancer Trends

Future Cancer TrendsImpact of Medical Advances :

Prevention Reduce Smoking ; Dietary Advice ; Protect from UV light Overall, effect positive but likely to be relatively small

Detection Rapid advance in screening / tests Questionable value for widespread screening But tests likely to be commercially available Potential for significant step-increases in “incidence”

Treatment Expect reductions in morbidity, plus slow gains on mortality

Session A1 : Trends in CI - Cancer

Trends in incidence and mortality rates

Working Party / Research Sub-party Progress Report

Neil Robjohns & Richard Morris

The 2002 Healthcare Conference Surviving or Thriving ? 29 September-1 October 2002 Scarman House,...

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