Cancer and Effect on Companies

June 18-19, 2009 | Hyatt Regency Chicago

Sponsored by

Otis W. Brawley, M.D. Otis W. Brawley, M.D. Chief Medical Officer

Executive Vice PresidentAmerican Cancer SocietyAmerican Cancer Society

Professor of Hematology, Oncology, Medicine and Epidemiology

Emory University

2009 Estimated US Cancer Deaths*

ONS=Other nervous system.Source: American Cancer Society, 2009.

Men292,540

Women269,800

26% Lung & bronchus

15% Breast

9% Colon & rectum

6% Pancreas

5% Ovary

4% Non-Hodgkin lymphoma

3% Leukemia

3% Uterine corpus

2% Liver & intrahepaticbile duct

2% Brain/ONS

25% All other sites

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%

US Mortality, 2006

*Includes nephrotic syndrome and nephrosis.Source: US Mortality Data 2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

1. Heart Diseases 631,636 26.0 2. Cancer 559,888 23.13. 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 9. Nephritis* 45,344 1.910. Septicemia 34,234 1.4

Rank Cause of DeathNo. of deaths

% of all deaths

Change in US Death Rates* from 1991 to 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.

17.8

63.3

34.8

313.0

215.1

43.6

180.7200.2

0

100

200

300

400

Heart diseases Cerebrovasculardiseases

Influenza &pneumonia

Cancer

1991

2006

Rate Per 100,000

Cancer Death Rates* by SexUS 1975-2005

*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.

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

Cancer Death Rates* Among Men, US 1930-2005

*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.

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 Death Rates* Among Women, US 1930-2005

*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.

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

2009 Estimated US Cancer Cases*

*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2009.

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-Hodgkin5% lymphoma

Kidney & renal pelvis 5%

Leukemia 3%

Oral cavity 3%

Pancreas 3%

All Other Sites 19%

Cancer Incidence Rates* by Sex US 1975-2005

*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.

0

100

200

300

400

500

600

700

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

Both Sexes

Men

Women

Rate Per 100,000

Cancer Incidence Rates* Among Men, US 1975-2005

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


Cancer Incidence Rates* Among Women, US 1975-2005


0

50

100

150

200

250

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

Colon and rectum

Rate Per 100,000

Breast

Lung & bronchus

Uterine CorpusOvary

Non-Hodgkin lymphoma

Cancer Incidence & Death Rates* in Children 0-14 Years, 1975-2005

0

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, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

Cancer Incidence Rates* in Children 0-14 Years by Sex, 2001-2005

*Per 100,000, age-adjusted to the 2000 US standard population.ONS = Other nervous systemSource: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

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

Cancer Death Rates* in Children 0-14 Years by Sex, US 2001-2005

*Per 100,000, age-adjusted to the 2000 US standard population.ONS = Other nervous systemSource: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

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

Tobacco Use in the US, 1900-2005

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

1900

1905

1910

1915

1920

1925

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

Year

Per

Cap

ita

Cig

aret

te C

on

sum

pti

on

0

10

20

30

40

50

60

70

80

90

100

Ag

e-A

dju

sted

Lu

ng

Can

cer

Dea

th R

ates

*

*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.

Per capita cigarette consumption

Male lung cancer death rate

Female lung cancer death rate

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

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 1992-2007

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.

05

1015202530354045505560

1992

1994

1996

1998

2000

2002

2003

2004

2005

2006

2007

Year

Pre

vale

nce

(%)

Adults with less than a high school education

All adults

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.

54

65

7

5

7

11 1110

16 16

12

1718

0

5

10

15

20

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

Pre

vale

nce (%

)

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

NHANES 1999-2002 NHANES 2003-2006

Trends in Obesity* Prevalence (%), By GenderAdults 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.

1311

1615

12

1715

13

17

2321

26

3128

3433 323535

3436

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 2003-2004 NHANES 2005-2006

Mammogram Prevalence (%), by Educational Attainment and Health Insurance StatusWomen 40 and Older, US, 1991-2006

*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.

0

10

20

30

40

50

60

70

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

Year

Pre

vale

nce (%

)

Women with less than a high school education

Women with no health insurance

All women 40 and older

Disparities in Health

• The concept that some populations (however defined) do worse than others

• Populations can be defined or categorized by race, culture, area of geographic origin, socioeconomic status


• The concept that some populations (however defined) do worse than others

• The measure can be incidence, mortality, survival, quality of life

All Sites – Cancer Mortality Rates1973-2004 By Race, Males and Females

100

150

200

250

300

'75 '78 '81 '84 '87 '90 '93 '96 '99 '02

Year

Rat

e

Incidence and mortality rates per 100,000 and age-adjusted to 2000 US standard populationSEER Cancer Statistics Review 1975-2004.

African American

Caucasian

AI/ANHispanic

API


• We need to approach this issue logically and rationally

• We must focus on what we can change and not on what we cannot change

• We must define social and logistical issues versus scientific issues.

My Concern

• “Equal treatment yields equal outcome among equal patients”

• There is not equal treatment• There is not enough concern about nor

emphasis on the fact that there is not equal treatment

How can we provide adequate, high-quality care (to include

preventive care) to a population that has so often

not received it?

0

5

10

15

20

25

30

35

40

45

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002

Year

Rat

e p

er 1

00,0

00

African Americans

Whites

Hispanic/Latina

American Indian/Alaska Native

Asian American/Pacific Islander

American Cancer Society, Surveillance Research, 2007

2004

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

Adjusted Breast Cancer Survival by Stages and Insurance Status, among Patients Diagnosedin 1999-2000 and Reported to the NCDB

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

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

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

20

16

8

21

16

9

18

12

22

16

9

19

14

9

16

12

8

24

0

5

10

15

20

25

30

Total Less than a high schooleducation

No health insurance

Pre

vale

nce (%

)

1997 1999 2001 20022004 2006

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.

44

37

22

44

36

21

45

36

21

50

41

22

56

43

25

0

10

20

30

40

50

60

Total Less than a high schooleducation

No health insurance

Pre

vale

nce

(%

)

1999 2001 2002 2004 2006

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.

U.S. Colorectal Cancer Mortality 1975-2005

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.019

75

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

Rat

e pe

r 10

0,00

0 Blalck Male

WhiteMale

Black Female

White Female

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

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

Colorectal Cancer

Imagine a world in which…• Colorectal screening rates were greater than 80%• All men and women with an abnormal screen got it

evaluated• All with colorectal cancer got optimal therapy

Sunburn* Prevalence (%) in the Past Year, Adults 18 and Older, US, 2004

46.4

36.3

22.524.0

18.4

5.7 5.8

26.3

0

5

10

15

20

25

30

35

40

45

50

Male Female

Ag

e-A

dju

sted

Pre

vale

nce

(%

)

White non-Hispanic

Other

Hispanic

Black non-Hispanic

*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.

Sunburn* Prevalence (%) in the Past Year, Adults 18 and Older, US 2004

Ultraviolet Radiation Exposure Behaviors* Prevalence (%), Adults 18 and Older, US, 2005

30

33

1210

30

14

19

26

1311

37

11

40

1210

24

17

40

0

5

10

15

20

25

30

35

40

45

Applysunscreen

Seek the shade Wear a hat Wear long-sleeved shirt

Wear longpants

Used indoortanningdevice†

Pre

vale

nce (

%)

Total Male Female

*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.

Cancer Survival and Deprivation in Scotland

5yr survival Affluent Deprived

Breast 58% 48%

Colon 40% 34%

Lymphoma 58% 42%

Prostate 45% 36%

Bladder 70% 58%

Melanoma 84% 69%

Survival Rates RMS TitanicConcept of Dr. Lisa Newman

First Class 60%

Second Class 43%

Third Class 20%

How can we provide adequate, high-quality care (to include preventive care) to a population that has so

often not received it?

Higher Per Capita Spending in the U.S. Does NotTranslate into Longer Life Expectancy

The Cost of a Long Life

Life Expectancy – Per Capita Spending

2006 CIA FACTBOOK

Ave

rag

e L

ife

Ex

pec

tan

cy

(y

ears

)

Pe

r C

apit

a S

pe

nd

ing

in U

SD

74

75

76

77

78

79

80

81

82

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

United States

The Economics of Healthcare

• Healthcare is 17% of the nation’s Gross Domestic Product and growing

• The country with the second greatest is Israel with 9.5% of its GDP devoted to healthcare

• The U.S. spends more on healthcare than it spends on food and clothing

The Economics of Healthcare

• The average Medicare costs per beneficiary nationwide in 2006 was $8,304

• New York City $9,564• Honolulu $5,311• Miami $16,351• San Francisco $8,331

NY Times June 11, 2009


• Some consume too much (unnecessary care given)• Some consume too little (necessary care not given)• We could decrease the waste and improve overall

health!!


There are dramatic geographical differences in use of a number of expensive screening technologies and therapies without evidence of difference in outcomes.

•Prostate cancer screening and overtreatment•Lung cancer screening•Third and fourth-time chemotherapy of metastatic disease•Intensity Modulated Radiation Therapy in some cancers•Overuse of radiologic imaging

Faith-based versus Evidence-based Medicine

• We in medicine have a tendency to adopt things before fully accessing their benefit or harm.

• We also criticize those who question the benefit and some even praise/worship advocates with a monetary interest.

• Bone marrow transplant for breast cancer• Lung cancer screening with chest X-ray• Neuroblastoma screening with urine VMA• The Halsted Mastectomy• Postmenopausal hormone replacement• Prostate cancer screening


• A call for the use of “Evidence-Based Care” That is:

The rational use of medicinenot the rationing of medicine

We know WHAT to do,

We just need to DO it!!

Cancer and Effect on Companies

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