Cancer PowerPoint #2 November 3, 2009

1. Cancer PowerPoint #2November 3, 2009

2. 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.

3. US Mortality, 2006 No. of deaths % of all deaths Rank Cause of Death • 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 *Includes nephrotic syndrome and nephrosis. Source: US Mortality Data 2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

4. Change in US Death Rates* from 1991 to 2006 Rate Per 100,000 1991 2006 * Age-adjusted to 2000 US standard population. Sources: US Mortality Data, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

5. Trends in the Number of Cancer Deaths Among Men and Women, US, 1930-2006 Men Men Women Women Number of Cancer Deaths Source: US Mortality Data, 1930-2006, National Center for Health Statistics, 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. Cancer Death Rates* by Race and Ethnicity, US, 2001-2005 *Per 100,000, age-adjusted to the 2000 US standard population. † Persons of Hispanic origin may be of any race. Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

10. Cancer Sites in Men for Which African American Death Rates* Exceed White Death Rates*, US, 2001-2005 Ratio of African American/White Site African American White • All sites 313.0 230.7 1.4 • Prostate 59.4 24.6 2.4 • Larynx 4.8 2.1 2.3 • Stomach 11.5 5.0 2.3 • Myeloma 8.3 4.3 1.9 • Oral cavity and pharynx 6.7 3.8 1.8 • Small intestine 0.7 0.4 1.8 • Liver and intrahepatic bile duct 10.3 6.7 1.5 • Colon and rectum 31.8 22.1 1.4 • Esophagus 9.8 7.8 1.3 • Lung and bronchus 93.1 71.3 1.3 • Pancreas 15.4 12.1 1.3 *Per 100,000, age-adjusted to the 2000 US standard population. Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

11. Cancer Sites in Women for Which African American Death Rates* Exceed White Death Rates*, US, 2001-2005 Ratio of African American/White Site African American White • All sites 186.7 159.2 1.2 • Stomach 5.5 2.5 2.2 • Myeloma 6.0 2.8 2.1 • Uterine cervix 4.7 2.3 2.0 • Esophagus 2.8 1.6 1.8 • Uterine corpus 7.1 3.9 1.8 • Small intestine 0.5 0.3 1.7 • Larynx 0.8 0.5 1.6 • Colon and rectum 22.4 15.3 1.5 • Pancreas 12.4 9.0 1.4 • Breast 33.5 24.4 1.4 • Gallbladder 1.0 0.8 1.3 • Urinary bladder 2.8 2.2 1.3 • Liver and intrahepatic bile duct 3.9 2.9 1.3 *Per 100,000, age-adjusted to the 2000 US standard population. Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

12. Cancer Death Rates* by Sex and Race, US, 1975-2005 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, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

13. 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.

14. 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.

15. 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.

16. 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.

17. Cancer Incidence Rates* by Race and Ethnicity, 2001-2005 Rate Per 100,000 *Age-adjusted to the 2000 US standard population. †Person of Hispanic origin may be of any race. Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

18. Cancer Incidence Rates* by Sex and Race, US,1975-2005 Rate Per 100,000 African American men White men White women African American women *Age-adjusted to the 2000 US standard population. Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database: SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008.

19. Lifetime Probability of Developing Cancer, Men, 2003-2005* Site Risk All sites† 1 in 2 Prostate 1 in 6 Lung and bronchus 1 in 13 Colon and rectum 1 in 18 Urinary bladder‡ 1 in 27 Melanoma§ 1 in 39 Non-Hodgkin lymphoma 1 in 45 Kidney 1 in 57 Leukemia 1 in 67 Oral Cavity 1 in 72 Stomach 1 in 90 * For those free of cancer at beginning of age interval. Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.3.0 Statistical Research and Applications Branch, NCI, 2008. http://srab.cancer.gov/devcan

20. Lifetime Probability of Developing Cancer, Women, US, 2003-2005* Site Risk All sites† 1 in 3 Breast 1 in 8 Lung & bronchus 1 in 16 Colon & rectum 1 in 20 Uterine corpus 1 in 40 Non-Hodgkin lymphoma 1 in 53 Urinary bladder‡ 1 in 84 Melanoma§ 1 in 58 Ovary 1 in 72 Pancreas 1 in 75 Uterine cervix 1 in 145 * For those free of cancer at beginning of age interval. Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.3.0 Statistical Research and Applications Branch, NCI, 2008. http://srab.cancer.gov/devcan

21. Cancer Survival*(%) by Race,1996-2004 Absolute Difference African Site White American All Sites 68 58 10 Breast (female) 91 78 13 Colon 66 55 11 Esophagus 18 11 7 Leukemia 52 42 10 Non-Hodgkin lymphoma 66 58 8 Oral cavity 62 42 20 Prostate 99 96 3 Rectum 67 59 8 Urinary bladder 82 66 16 Uterine cervix 74 65 9 Uterine corpus 86 61 25 *5-year relative survival rates based on cancer patients diagnosed from 1996 to 2004 and followed through 2005. Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

22. Trends in Five-year Relative Survival (%)* Rates, US, 1975-2004 1984-1986 1996-2004 Site 1975-1977 • All sites 50 54 66 • Breast (female) 75 79 89 • Colon 52 59 65 • Leukemia 35 42 51 • Lung and bronchus 13 13 16 • Melanoma 82 87 92 • Non-Hodgkin lymphoma 48 53 65 • Ovary 37 40 46 • Pancreas 3 3 5 • Prostate 69 76 99 • Rectum 49 57 67 • Urinary bladder 74 78 81 *5-year relative survival rates based on follow up of patients through 2005. Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

23. 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.

24. 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.

25. 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.

26. Trends in Cancer Survival by Age Group, Children 0-14 Years,1975-2004 Year ofDiagnosis Age 5 - Year Relative Survival Rates * 0 - 4 Years 1975 - 1977 1996 - 2004 1975 - 19771996 - 2004 5 - 9 Years 10 - 14 Years 1975 - 1977 1996 - 2004 *5-year relative survival rates, based on follow up of patients through 2005.Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. Less than 50% 50 to 55% More than 55% State did not participate in survey Trends in Overweight* Prevalence (%), Adults 18 and Older, US, 1992-2007 1992 1995 1998 2007 *Body mass index of 25.0 kg/m2or greater. Source: Behavioral Risk Factor Surveillance System, CD-ROM (1984-1995, 1998) and Public Use Data Tape (2004-2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 2000, 2005, 2007, 2008.

33. Screening tests applied at moderately long intervals (2-5 years). Cases with a long pre-clinical phase are more likely to be detected than tumors of shorter pre-clinical phase (faster growing). This could lead to an assumption that a screening test is effective when survival differences are really due to detecting less aggressive cases through screening.

34. Lead-time Bias - • If an individual is screened (asymptomatic) and has disease detected earlier than it would have been in the absence of screening, the amount of time by which diagnosis is advanced is the Lead-time. • Example 16.6 → page 373

35. Lung Cancer Significance • Leading Cause of Cancer Death • Most Common Cancer in U.S. and World (incidence) • 5 Year Survival: 14-15% - all stages

36. Localized stage; 50% • Estimated U.S. Incidence 2008: 219,500 • Estimated U.S. Deaths 2008: 159,500

37. Descriptive Epidemiology • Mortality 2+ times higher in males than females • Since 1987, lung a leading cause of death in women, passing breast cancer • Black/white differences Mortality rates: black men 2.3 times higher black/white women similar • Incidence higher in lower SES groups

38. Family history, nonmalignant lung disease and smoking are risk factors • Place analyses on Kentucky • Male mortality declining, female mortality increasing • Risk Factors – Table 12.3 87% Smoking

39. Prevention Primary Cessation and initiation prevention Secondary Chest X-Rays? CT Scans? Tertiary ?

40. Breast Cancer The Numbers • Most frequently diagnosed cancer in women in U.S. → 192,000 invasive cases in 2008 • Plus 55,700 cases insitu breast cancer, 85% are DCIS. • Breast cancer incidence began increasing in the 1980’s into the 1990’s and the rate of increase slowed WHY?

41. Breast cancer ranks 2nd in # of cancer deaths among women in U.S. to ?? • Mortality, 40,500 deaths expected in 2008

42. Who is the most at risk of developing/dying from breast cancer? Age • As for most epithelial tumors, the most important risk factor is increasing age.

43. Kentucky Age Specific Incidence Rate Aged 35-39 Years 61 per 100,000 Aged 40-44 Years 114 per 100,000 Aged 60-64 Years 337 per 100,000 Aged 75-79 Years 432 per 100,000

44. B. Hormones • Cumulative exposure to ovarian hormones, estrogen and perhaps progesterone • Action is by increasing the rate of all division

45. C. Early Age at Menarche • Usually defined at age 12 years or younger • Risk decreases 20% (from case-control studies) for each year menarche is delayed • Regular menarche versus nonregular (anovular cycle) impacts risk • Why?? Cumulative exposure to estrogen

46. D. Physical Activity • Strenuous physical activity in young women (teens), reduces risk by delaying menarche • Risk decreased in young women who participate in strenuous physical activity. One study showed relative risk was 60% lower in women who averaged 4+ hours of strenuous physical activity per week as compared to inactive women.

47. E. Age at menopause • Menopause at age 45 years versus age 55 years; risk is half among women who experience natural menopause at age 45 • Artificial menopause, from oophorectomy or pelvic radiation also reduces risk, maybe even greater reduction than natural menopause Why?? Abrupt cessation of hormone production versus gradual reduction

48. F. Parity and Age at first birth • As early as 1970, studies showed single and null, parous women had a 1.4 times greater risk of developing breast cancer than parous married women • Earlier first birth is significantly protective • Increased number of births (1-4) is slightly protective; 5+ births significantly protective

49. Married women who have a late first full-term pregnancy have an elevated risk, compared to null, parous women • Why?? • First trimester abortion, spontaneous or induced, associated with an increased risk

50. G. Weight • Women under age 50 years, little or no increased risk of breast cancer with increases in weight • Women aged 60+ years,  weight equals increased risk; 10kg increase in weight, results in a large increase in risk • Question: Is it age or hormonal status (menopause) • In post-menopausal women, what is the • primary source of estrogen?