A Strategic Approach to the Control of Cancer

Otis W. Brawley, M.D.Chief Medical and Scientific Officer American Cancer SocietyProfessor of Hematology, Medical Oncology, Medicine and Epidemiology Emory University

Disclosures

• Dr. Brawley has nothing to disclose.

WHO (2003)

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TB AIDS Malaria All 3 Cancer

Global Deaths (millions per annum)

7 million Deaths

11 million New Cases

25 million Living with Cancer

CANCER – WORLDWIDE BURDEN (2005)

17 million Deaths

27 million New Cases

75 million Living with Cancer

CANCER – WORLDWIDE BURDEN (2030)

Outline

• Observations on the US Economy• The need to redefine cancer for the 21st century• Trends in cancer epidemiology• Interventions that can save lives

U.S. Health Care Spending

In 2009, the U.S. spent

$2.53 TRILLION on Health Care

U.S. Health Care Spending

How Big is a Trillion?

1 million seconds Last week

1 billion seconds Richard Nixon’s resignation

1 trillion seconds 30,000 BCE

Spending in Context

2006

*Excludes alcoholic beverages ($150 billion) and tobacco products ($92 billion)Source: Bureau of Economic Analysis; National Bureau of Statistics of China, MGI analysis

Spending: US vs. Other CountriesPer capita health care

spending, 2006$ at PPP*

Per capita GDP ($)*Purchasing power parity.

** Estimated Spending According to Wealth. Source: Organization for Economic Co-operation and Development (OECD)

American Healthcare

• 16.2% of GDP in 2008• 17.3% of GDP in 2009• 19.3% of GDP by 2019 (projected)• 25% of GDP by 2025 (projected)

Overall Quality: Life Expectancy at 65

The US is ranked 12th for Males and 16th for Females

Source: OECD, 2006 data

Toward an Efficient Healthcare System

• Some consume too much (Unnecessary care given)

• Some consume too little(Necessary care not given)

• We could decrease the waste and improve overall health!

• Evidence Based Medicine

Rudolph Ludwig Karl Virchow

1821- 1902

Virchow’s Accomplishment

One of the first cellular pathologists

Virchow’s node

Defined conditions that cause thrombosis

One of the initial description of leukemia

Defined cancer as a disease involving uncontrolled cell growth

Defined cancer using a light microscope on specimens obtained by autopsy

Virchow’s Accomplishments

The definition of cancer used in 2010 is largely that of Virchow with minor modifications

More than 160 years later, we still use his definitions using a light microscope.

There is clear evidence that some early detected cancers do not poise a threat and do not need to be treated.

OverdiagnosisCure is Possible but not Necessary

Prostate Cancer

Breast Cancer

Lung Cancer (NSCLC)

Cervical Disease

Renal Cancer

Melanoma

Colon Cancer

OverdiagnosisCure is Possible but not Necessary

In the US, it is estimated:

More than half of all screen diagnosed prostate cancers

At least fifteen percent of screen detected frank breast cancers. A larger proportion of Ductal carcinoma in situ (DCIS)

Perhaps ten percent or more of lung cancers diagnosed through CT screening

A large proportion of cervical dysplasia

A Genomic Definition of CancerGenetics vs Genomics

Genetics is the study of heredity or inherited traits (such as eye color) and alterations in specific genes that may impact the individual potential for a given health condition.

Genomics is the study of complex sets of genes, how they are expressed in cells (what their level of activity is), and the role they play in biology.

The Growth in Cancer Incidence and Mortality is due to:

The increasing size of and the aging of the population

Industrialization and adaptation of Western habits (smoking, diet, etc.) This is especially a problem in South America, Africa and Asia

Growing biotechnology and development of diagnostic tests and screening technologies.

Cancer Incidence Rates* Among Men, US, 1975-2006

0

50

100

150

200

250

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

Prostate

Lung & bronchus

Colon and rectum

Urinary bladder

Non-Hodgkin lymphoma

Rate Per 100,000

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, 1975-2006, National Cancer Institute, 2009.

Cancer Death Rates* Among Men, US,1930-2006

*Age-adjusted to the 2000 US standard population.Source: US Mortality Data 1960-2006, US Mortality Volumes 1930-1959,National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

0

20

40

60

80

10019

30

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

Lung & bronchus

Colon & rectum

Stomach

Rate Per 100,000

Prostate

Pancreas

LiverLeukemia

Cancer Incidence Rates* Among Women, US, 1975-2006

*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, 1975-2006, National Cancer Institute, 2009.

0

50

100

150

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

Colon and rectum

Rate Per 100,000

Breast

Lung & bronchus

Uterine corpus

Melanoma

Non-Hodgkin lymphoma

Cancer Death Rates* Among Women, US,1930-2006

*Age-adjusted to the 2000 US standard population.Source: US Mortality Data 1960-2006, US Mortality Volumes 1930-1959,National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

0

20

40

60

80

10019

30

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

Lung & bronchus

Colon & rectum

Uterus

Stomach

Breast

Ovary

Pancreas

Rate Per 100,000

Cancer Death Rates* by Sex, US, 1975-2006

*Age-adjusted to the 2000 US standard population.Source: US Mortality Data 1960-2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

0

50

100

150

200

250

300

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

Men

Both Sexes

Rate Per 100,000

Women

0

50

100

150

200

250

300

350

400

450

500

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

African American men

White men

African American women

White women

Rate Per 100,000

Cancer Death Rates* by Sex and Race, US, 1975-2006

*Age-adjusted to the 2000 US standard population.Source: Surveillance, Epidemiology, and End Results Program, 1975-2006, Division of Cancer Control andPopulation Sciences, National Cancer Institute, 2009.

Cancer Incidence & Death Rates* in Children 0-14 Years, 1975-2006

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2

4

6

8

10

12

14

16

18

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

Incidence

Mortality

Rate Per 100,000

*Age-adjusted to the 2000 Standard population.Source: Surveillance, Epidemiology, and End Results Program, 1975-2006, Division of Cancer Control and Population Sciences, National Cancer Institute, 2009.

Trends in Five-year Relative Survival (%)* Rates, US, 1975-2005

*5-year relative survival rates based on follow up of patients through 2006. Source: Surveillance, Epidemiology, and End Results Program, 1975-2006, Division of Cancer Control andPopulation Sciences, National Cancer Institute, 2009.

 

 

 

Site 1975-1977 1984-1986 1999-2005All sites 50 54 68

Breast (female) 75 79 90

Colon 52 59 66

Leukemia 35 42 54

Lung and bronchus 13 13 16

Melanoma 82 87 93

Non-Hodgkin lymphoma 48 53 69

Ovary 37 40 46

Pancreas 3 3 6

Prostate 69 76 100

Rectum 49 57 69

Urinary bladder 74 78 82

Trends in the Number of Cancer Deaths Among Men and Women, US, 1930-2007

0

50,000

100,000

150,000

200,000

250,000

300,000

1930 1940 1950 1960 1970 1980 1990 2000

Women

Men

Nu

mb

er o

f C

ance

r D

eath

s

265,000

270,000

275,000

280,000

285,000

290,000

295,000

Men

Women

Source: US Mortality Data, 1930-2007, National Center for Health Statistics, Centers for Disease Control and Prevention, 2010.

Deaths averted from 1991-2020 in males and 1992-2020 in females based on current rate of decline

The blue line represents the actual number of cancer deaths recorded (solid) and projected (dashed) based on decreasing trends during 2003-2007. The red line represents the expected number of cancer deaths if cancer mortality rates had remained the same since 1990 (males)

and 1991(females).

Trends in Cigarette Smoking Prevalence* (%), by Sex, Adults 18 and Older, US, 1965-2008

*Redesign of survey in 1997 may affect trends. Estimates are age adjusted to the 2000 US standard population using five age groups: 18-24, 25-34 years, 35-44 years, 45-64 years, and 65 years and over. Source: National Health Interview Survey, 1965-2008, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

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10

20

30

40

50

60

1965

1974

1979

1983

1985

1990

1992

1994

1995

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Year

Pre

vale

nce

(%

)

Men

Women

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.

28

35

31

13

16

27

23

11

19 18 19

2725

1214

19

2523 24

8

15 15

19

3230

11

14

23

40

37

12

28

33

4040

17

32

36

28

34

39 38

22

32

18

33

2726

0

10

20

30

40

50

White, non-HispanicFemale

White, non-Hispanic Male

AfricanAmerican, non-

HispanicFemale

AfricanAmerican, non-Hispanic Male

HispanicFemale

Hispanic Male

Pre

vale

nce

(%

)1991 1995 1997 1999 2001 2003

2005 2007

Lung Cancer

Mortality down by 14.3% since 1992

Adult tobacco prevalence of 20.6% in 2008 (NHIS)

Youth Tobacco prevalence of 20.0% in 2007 (YRBS)

Prostate Cancer Screening

An issue that must be approached ethically, logically and rationally

We must realize:

What we know.

What we do not know.

What we believe.

American Urological Association

Given the uncertainty that PSA testing results in more benefit than harm, a thoughtful and broad approach to PSA is critical.

Patients need to be informed of the risks and benefits of testing before it is undertaken. The risks of overdetection and overtreatment should be included in this discussion.

PSA Best Practice Statement 2009

European Association of Urology

Recommends for informed decision making within the physician-patient relationship.

Recommends against mass screening.

“Men should obtain information on the risks and potential benefits of screening and make an individual decision”

European Urology 56(2), 2009

National Comprehensive Cancer Network

There are advantages and disadvantages to having a PSA test, and there is no ‘right’ answer about PSA testing for everyone. Each man should make an informed decision about whether the PSA test is right for him.”

“Men should have an opportunity to make an informed decision with their health care provider about whether to be screened for prostate cancer, after receiving information about the uncertainties, risks, and potential benefits associated with prostate cancer screening.”

The American Cancer Society 2010 Prostate Cancer Screening Guideline

Needs in Prostate Cancer Medicine

We need:

a better screening test

a better way to determine the cancers that need to be watched and those that need to be treated.

Then we can actually figure out how good our current treatments are!!!

Mammogram Prevalence (%), by Educational Attainment and Health Insurance Status, Women 40 and Older, US, 1991-2008

*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 to 2008), National Centers for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001-2009.

54

36

62

0

10

20

30

40

50

60

70

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2004 2006 2008

Year

Pre

va

len

ce

(%

)

Women with less than a high school education

Women with no health insurance

All women 40 and older

Breast Cancer as of 2008

Mortality down by 30.1% since 1992

Early Detection: Of women aged 40 and older who have breast screening :

53% (NHIS),

62.1% (BRFSS)

Breast CancerOdds that Mammography will save a woman’s life over a ten year period

Age 40-49 0.05%

Age 50-59 0.07%

Age 60-69 2.7%

Breast Cancer765,870 cancer deaths were averted between 1991 and 2006 in women

It is estimated that 57,000 humans did not die of breast cancer

This was due to screening, early detection, and aggressive treatment.

It is estimated screening prevalence was 45% to 50% during the period

Breast Cancer Screening in the U.S.The Ten Year Potential 64,673 deaths averted

AgeNumber inPopulation

USPSTF Estimate of

Number Needed to Screen

Avertable Deaths

Lives Lost due to Non-

Compliance

40's 22,327,592 1,900 11,751 4,113

50's 20,542,363 1,340 15,330 5,366

60's 13,909,277 370 37,592 13,157

Breast Cancer (Taskforce Estimates)One year of screening women aged 40 to

49

22,327,000 women screened

156,300 women called back for evaluation

78,700 breast biopsies

32,000 Women diagnosed with breast cancer

7800 deaths

1200 lives saved by mammography

Breast Cancer (Taskforce Estimates)One year of screening women aged 40 to

49

22,327,000 women screened

32,000 diagnosed

24,200 survive

7800 deaths

1200 lives saved by mamography

Breast Cancer (Swedish Study)One year of screening women aged 40 to 49

22,327,000 women screened

32,000 diagnosed

25,000 women survive

7000 deaths

2000 lives saved by mammography

Breast CancerTaskforce vs Swedish Study (estimates)

22,327,000 women screened per year

32,000 diagnosed

24,200 to 25,000 women survive

7000 to 7800 deaths

1200 lives saved vs 2000 lives saves

Difference of about 800 Lives per year

Colorectal Cancer as of 2008

Colorectal Cancer Mortality has decreased by 29.3% since 1992

Colorectal Cancer Screening rates:

•53.2% by NHIS and

•63.1% by BRFSS

20

16

8

21

16

9

18

12

22

16

9

19

14

9

16

12

8

1513

7

24

0

5

10

15

20

25

30

Total Less than a high schooleducation

No health insurance

Pre

va

len

ce

(%

)

1997 1999 2001 20022004 2006 2008

Trends in Recent* Fecal Occult Blood Test Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50 Years and Older, US, 1997-2008

*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: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data Tape (2000 to 2008), National Centers for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001-2009.

44

37

22

44

36

21

45

36

21

50

41

22

56

43

25

60

42

26

0

10

20

30

40

50

60

70

Total Less than a high schooleducation

No health insurance

Pre

vale

nce

(%

)1999 2001 2002 20042006 2008

Trends in Recent* Flexible Sigmoidoscopy or Colonoscopy Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50 Years and Older, US, 1997-2008

*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: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data Tape (2000 to 2008), National Centers for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001-2009.

Nutrition and Physical Activity

Obesity, high caloric intake, and lack of physical activity has the potential of being a greater cause of cancer in the U.S. than tobacco by 2030

We are currently not able to model this in an acceptable fashion

It is causing a rise in cancer incidence

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.

24.2 24.4 24.1 24.4 23.6 24.3 24.7

0

5

10

15

20

25

30

35

1994 1996 1998 2000 2003 2005 2007

Year

Pre

vale

nce

(%)

Trends in Consumption of Five or More Recommended Vegetable and Fruit Servings for Cancer Prevention, Adults 18 and Older, US, 1994-2007

Trends in Prevalence (%) of No Leisure-Time Physical Activity, by Educational Attainment, Adults 18 and Older, US, 1992-2008

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 to 2008), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997-2009.

05

1015202530354045505560

1992

1994

1996

1998

2000

2002

2003

2004

2005

2006

2007

2008

Year

Pre

vale

nce

(%)

Adults with less than a high school education

All adults

Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20 to 74, US, 1960-2008†

*Obesity is defined as a body mass index of 30 kg/m2 or greater. † Age adjusted to the 2000 US standard population. Source: 1976-2006: National Health and Nutrition Examination Survey, Hispanic Health and Nutrition Examination Survey (1982–84). Centers for Disease Control and Prevention, National Center for Health Statistics, Health, United States, 2008, With Special Feature on the Health of Young Adults. Hyattsville, Maryland: 2009. 2007-2008: National Health and Nutrition Examination Survey Public Use Data File, 2007-2008 National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

1311

1615

12

1715

13

17

2321

26

3128

3433 333535

33

36

0

5

10

15

20

25

30

35

40

45

Both sexes Men Women

Pre

vale

nce

(%)

NHES I (1960-62) NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94)

NHANES 1999-2002 NHANES 2003-06 NHANES 2007-08

Trends in Obesity* Prevalence (%), Children and Adolescents, by Age Group, US, 1971-2008

*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. 2003-06: Ogden CL, et al. High Body Mass Index for Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05. 2007-08: Ogden CL, et al. Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008. JAMA 2010; 303 (3): 242-249.

54

65

75

7

11 1110

16 16

12

1718

10

2018

0

5

10

15

20

25

2 to 5 years 6 to 11 years 12 to 19 years

Pre

va

len

ce

(%

)

NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94)

NHANES 1999-2002 NHANES 2003-06 NHANES 2007-08

Sunburn* Prevalence (%) in the Past Year, Adults 18 and Older, US, 2005

3436

32

41

44

38

19

2222 22 22

86

10

20

0

5

10

15

20

25

30

35

40

45

50

Total Male Female

Ag

e-A

dju

sted

Pre

vale

nce

(%

)

Total

White non-Hispanic

Other

Hispanic

Black non-Hispanic

*Report of at least one sunburn in the past year.

Source: National Health Interview Survey Public Use Data File 2005, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

A Strategic Approach to the Control of Cancer

Otis W. Brawley, M.D.Chief Medical and Scientific Officer American Cancer SocietyProfessor of Hematology, Medical Oncology, Medicine and Epidemiology Emory University