Winning The War On Cancer Building the Bridge Between Public Health & Primary Care

1. Winning The War On CancerBuilding the Bridge Between Public Health & Primary Care Richard C. Wender, MD Alumni Professor and Chair Department of Family & Community Medicine Thomas Jefferson University Philadelphia, PA

2. Eight key challenges and trends will determine the future of cancer in the United States and around the world

3. The changing epidemiology of cancer deaths • The relentless spread of tobacco use • The obesity epidemic • The inversion of the age pyramid • Determining the true value of the early detection of cancer • The emergence of personalized treatment • The growing number of cancer survivors • The urgent need to reduce the cost of care

4. Trend #1 The changing epidemiology of cancer deaths

5. The Global Burden of Cancer Continues to Increase In 2008: 12.7 million cancer cases 7.6 million cancer deaths are estimated to have occurred

6. Cancer is the leading cause of death in economically developed countries and the second leading cause of death in developing countries Jemal A, Bray F, et al. CA:Can J Clin. 2011;61:69-90

7. Affluence Contributes To Cancer • Associated with more obesity and more alcohol intake • Only aggressive counter-tobacco policies have helped to mitigate the interaction of affluence and tobacco use

8. As we develop a global economy and relative affluence reaches more people in more countries, we can expect the westernization of cancer epidemiology

9. The Other Side of the Cancer Epidemiology Story: High resource nations are making dramatic progress in the war on cancer

13. We are making great progress in cancer amenable to prevention or early detection … and very little progress in all other solid tumors

14. Trend #2: The relentless spread of tobacco use

15. Tobacco use remains the leading cause of preventable death and illness in the US • Half of all smokers will die from a smoking related illness • In 2010, 19.3% of US adults were current smokers compared to 20.9% in 2005 • At the rate of decline, US smoking rates will reach approximately 17%

16. 5.4 million people died worldwide from tobacco-related illnesses in 2006 “Unless action is taken, tobacco’s annual death toll will rise to more than eight million” by the year 2020, with over 80% of those deaths occurring in low-income countries WHO Report on the Global Tobacco Epidemic, 2008 The MPOWER Package

17. The Tobacco Wars:We Know What Works • Make it more expensive • Make it hard to get a pack of cigarettes • Counter-advertising • Make it difficult to smoke • Encourage smoking cessation

18. What is the impact of FDA regulation on tobacco use?

19. Trend #3: The worldwide obesity epidemic

20. The Obesity Epidemic If we are going to accelerate cancer prevention, we must find strategies to address the public heath challenge of our time – the epidemic of overeating and sedentary living

21. Obesity Rates

22. The Worldwide Obesity Epidemic • 68% of all Americans are overweight • Close to 34% are obese • Worldwide, obesity rates doubled between 1980 and 2008

23. Obesity and Cancer • 85,000 U.S. cases per year are obesity-related Basen-Engquist K, Chang M. CurrOncol Rep. 2011 Feb;13(1) 71-6.

24. Continuation of the current obesity trend will lead to about 500,000 additional cancer cases in the US by 2030

25. Obesity is Associated With Increased Risk of These Cancers … and Probably Others: • Esophogus • Pancreas • Colon and rectum • Breast (after menopause) • Endometrium • Kidney • Thyroid • Gallbladder http://www.cancer.gov/cancerfactsheet/risk/obesity

26. NCI Best Estimate If every adult reduced their BMI by 1 percent, this could actually result in the avoidance of 100,000 new cases www.cancer.gov/cancertopics/factsheet/risk/obesity

27. Can We Apply the Policies of the Tobacco Wars to the Food Challenge? • Taxes • De-normalization

28. Here’s What We Don’t Know About Losing Weight ( ... the short list) • Can community and family-focused interventions enhance one by one approach? • Will losing weight lower cancer risk? • By how much? • For which cancers? • What primary-care based interventions are effective and at what cost?

29. Managing Obesity in the Office Six minute counseling framework for overweight patients

30. Message 1:“It’s Not Your Fault!”

31. We produce 4,000 calories per person per day in the U.S. The food industry works to make sure each of us eats our share

32. Message 2:Losing weight and keeping it off for the rest of your life is very difficult

33. Message 3:But it can be done!

34. Set a Realistic Goal for Lifelong Weight Loss • Maintaining 10% lower than initial weight is fabulous (24 pounds in the 240 pound patient) • Maintaining 5% lower than initial weight is very good (12 pounds in the 240 pound patient)

35. Message 5:This is just like tobacco and alcohol… • Not a single puff • Not a single sip • Not a single unhealthy portion

36. Message 5:Diets don’t work! Why….? Because they end

37. Can you imagine celebrating 6 months of being tobacco free by smoking a pack? No?

38. But can you imagine celebrating achieving a 20 pound weight loss by having a big steak dinner? …..happens every day!

39. Message 6:Commercial weight loss programs work. Use them. But recognize that the commitment is to life-long change

40. Some smokers reach the phase of no longer craving cigarettes … virtually “cured” of their addiction Very few overweight individuals reach this phase (PIC)

41. Maintaining weight loss (in most people) requires constant support, frequent (preferably daily) weighing, and a concrete plan

42. Message 8:Be as physically active as you can possibly be

43. The key to winning the dangerous food war: HOPE & OPTIMISM

44. Years ago, none of us counseled about smoking because we were sure that nothing worked. People DO lose weight and keep it off. We can help it to happen

45. It’s time to tell the truth. It’s time to tackle the greatest public health challenge confronting our nation.

46. Trend #4: The inversion of the age pyramid

47. Arenson Aging Slide 2008

48. Population Pyramids, USA

49. Population Pyramids, China

50. Geriatric Oncology Demographics • Leading cause of death men/women age 60-79 • 80% cancer-related deaths in US are 65 and older • 20% of US population over age 65 by 2030 • 70% of all cancers • 85% of all cancer related deaths • Behavior of certain cancers change with age