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A Strategic Approach to the Control of Cancer

A Strategic Approach to the Control of Cancer. Otis W. Brawley, M.D. Chief Medical and Scientific Officer American Cancer Society Professor of Hematology, Medical Oncology, Medicine and Epidemiology Emory University. Disclosures. Dr. Brawley has nothing to disclose.

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A Strategic Approach to the Control of Cancer

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  1. A Strategic Approach to the Control of Cancer Otis W. Brawley, M.D. Chief Medical and Scientific Officer American Cancer Society Professor of Hematology, Medical Oncology, Medicine and Epidemiology Emory University

  2. Disclosures • Dr. Brawley has nothing to disclose.

  3. Global Deaths (millions per annum) WHO (2003)

  4. CANCER – WORLDWIDE BURDEN (2005) 11 million New Cases 7 millionDeaths 25 millionLiving with Cancer

  5. CANCER – WORLDWIDE BURDEN (2030) 27 million New Cases 17 millionDeaths 75 millionLiving with Cancer

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

  7. U.S. Health Care Spending In 2009, the U.S. spent $2.53 TRILLION on Health Care

  8. 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

  9. 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

  10. Spending: US vs. Other Countries Per 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)

  11. 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)

  12. Overall Quality: Life Expectancy at 65 The US is ranked 12th for Males and 16th for Females Source: OECD, 2006 data

  13. 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

  14. Rudolph Ludwig Karl Virchow 1821- 1902

  15. 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

  16. 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.

  17. OverdiagnosisCure is Possible but not Necessary • Prostate Cancer • Breast Cancer • Lung Cancer (NSCLC) • Cervical Disease • Renal Cancer • Melanoma • Colon Cancer

  18. 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

  19. 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.

  20. 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.

  21. Cancer Incidence Rates* Among Men, US, 1975-2006 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, 1975-2006, National Cancer Institute, 2009.

  22. Cancer Death Rates* Among Men, US,1930-2006 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 1960-2006, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

  23. Cancer Incidence Rates* Among Women, US, 1975-2006 Rate Per 100,000 Breast Colon and rectum Lung & bronchus Uterine corpus Non-Hodgkin lymphoma Melanoma *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.

  24. Cancer Death Rates* Among Women, US,1930-2006 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 1960-2006, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

  25. Cancer Death Rates* by Sex, US, 1975-2006 Rate Per 100,000 Men Both Sexes Women *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.

  26. Cancer Death Rates* by Sex and Race, US, 1975-2006 Rate Per 100,000 African American men White men African American women White women *Age-adjusted to the 2000 US standard population. Source: Surveillance, Epidemiology, and End Results Program, 1975-2006, Division of Cancer Control and Population Sciences, National Cancer Institute, 2009.

  27. Cancer Incidence & Death Rates* in Children 0-14 Years, 1975-2006 Rate Per 100,000 Incidence Mortality *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.

  28. Trends in Five-year Relative Survival (%)* Rates, US, 1975-2005 1984-1986 1999-2005 Site 1975-1977 • All 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 *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 and Population Sciences, National Cancer Institute, 2009.

  29. Trends in the Number of Cancer Deaths Among Men and Women, US, 1930-2007 Men Men Women Women Number of Cancer Deaths Source: US Mortality Data, 1930-2007, National Center for Health Statistics, Centers for Disease Control and Prevention, 2010.

  30. 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).

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

  32. 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.

  33. 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)

  34. 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.

  35. 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

  36. 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

  37. 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.”

  38. The American Cancer Society 2010 Prostate Cancer Screening Guideline “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.”

  39. 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!!!

  40. Mammogram Prevalence (%), by Educational Attainment and Health Insurance Status, Women 40 and Older, US, 1991-2008 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 to 2008), National Centers for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001-2009.

  41. 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)

  42. 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%

  43. Breast Cancer • 765,870 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

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

  45. 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

  46. 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

  47. 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

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