Transcript 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.

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.
Global Deaths (millions per annum)
8
7
6
5
4
3
2
1
0
TB
AIDS
Malaria
All 3
Cancer
WHO (2003)
CANCER – WORLDWIDE BURDEN (2005)
11 million
New Cases
7 million
Deaths
25 million
Living with Cancer
CANCER – WORLDWIDE BURDEN (2030)
27 million
New Cases
17 million
Deaths
75 million
Living with Cancer
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 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)
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.
Overdiagnosis
Cure is Possible but not Necessary
Prostate Cancer
Breast Cancer
Lung Cancer (NSCLC)
Cervical Disease
Renal Cancer
Melanoma
Colon Cancer
Overdiagnosis
Cure 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 Cancer
Genetics 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
Rate Per 100,000
250
Prostate
200
150
Lung & bronchus
100
Colon and rectum
50
Urinary bladder
Non-Hodgkin lymphoma
Melanoma of the skin
0
1975
1978
1981
1984
1987
1990
1993
1996
1999
2002
*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.
2005
Cancer Death Rates* Among Men, US,1930-2006
100
Rate Per 100,000
Lung & bronchus
80
60
Stomach
Prostate
40
Colon & rectum
20
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.
2005
2000
1995
1990
1985
1980
1975
1970
1965
1960
Liver
1955
1950
1945
1940
1935
0
1930
Leukemia
Cancer Incidence Rates* Among Women, US, 1975-2006
Rate Per 100,000
150
Breast
100
Colon and rectum
Lung & bronchus
50
Uterine corpus
Non-Hodgkin lymphoma
Melanoma
0
1975
1978
1981
1984
1987
1990
1993
1996
1999
2002
*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.
2005
Cancer Death Rates* Among Women, US,1930-2006
100
Rate Per 100,000
80
60
Lung & bronchus
40
Uterus
Breast
Colon & rectum
Stomach
20
Ovary
*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.
2005
2000
1995
1990
1985
1980
1975
1970
1965
1960
1955
1950
1945
1940
1935
Pancreas
1930
0
Cancer Death Rates* by Sex, US, 1975-2006
300
Rate Per 100,000
Men
250
Both Sexes
200
Women
150
100
50
0
1975
1978
1981
1984
1987
1990
1993
1996
1999
2002
2005
*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.
Cancer Death Rates* by Sex and Race, US, 1975-2006
500 Rate Per 100,000
450
African American men
400
350
300
White men
250
African American women
200
150
White women
100
50
0
1975
1978
1981
1984
1987
1990
1993
1996
1999
2002
2005
*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.
Cancer Incidence & Death Rates* in Children 0-14 Years, 1975-2006
18
16
Rate Per 100,000
Incidence
14
12
10
8
6
4
Mortality
2
0
1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005
*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
1975-1977
50
1984-1986
54
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
Site
All sites
1999-2005
68
*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.
Trends in the Number of Cancer Deaths Among Men and
Women, US, 1930-2007
300,000
295,000
290,000
Men
285,000
250,000
280,000
Women
275,000
200,000
270,000
Women
265,000
150,000
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
Number of Cancer Deaths
Men
100,000
50,000
0
1930
1940
1950
1960
1970
1980
1990
2000
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 19922020 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
60
Prevalence (%)
50
40
Men
30
20
Women
10
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1995
1994
1992
1990
1985
1983
1979
1974
1965
0
Year
*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.
Current* Cigarette Smoking Prevalence (%) Among High School
Students by Sex and Race/Ethnicity, US, 1991-2007
50
40
40
Prevalence (%)
40
37
32
30
40
39
1991
1995
2005
2007
1997
2001
3536 34
33 32
32
30
2727
23
2003
38
33
31
1999
28
2828
25
23 24
20
19
1112
16
13
12
11
14
27
25
23
22
18
17
10
26
1819
1415
19 19
15
8
0
White, nonHispanic
Female
White, nonHispanic Male
African
African
American, non- American, nonHispanic
Hispanic Male
Female
Hispanic
Female
Hispanic Male
*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.
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.”
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.”
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
70
60
All women 40 and older
62
54
Prevalence (%)
50
Women with less than a high school education
40
36
30
Women with no health insurance
20
10
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2004 2006 2008
Year
*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.
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 Cancer
Odds 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 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
Breast Cancer Screening in the U.S.
The Ten Year Potential 64,673 deaths averted
Age
Number in
Population
USPSTF
Estimate of
Lives Lost due
Number Needed Avertable
to Nonto Screen
Deaths
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 Cancer
Taskforce 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
Trends in Recent* Fecal Occult Blood Test Prevalence (%), by
Educational Attainment and Health Insurance Status, Adults 50
Years and Older, US, 1997-2008
30
24
Prevalence (%)
25
20
1997
2004
20
21
1999
2006
2001
2008
2002
22
19
18
16
15
15
16 16
16
14
12 13
10
12
8
9
9 9
8 7
5
0
Total
Less than a high school
education
No health insurance
*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.
Trends in Recent* Flexible Sigmoidoscopy or Colonoscopy
Prevalence (%), by Educational Attainment and Health Insurance
Status, Adults 50 Years and Older, US, 1997-2008
70
60
60
1999
2006
2001
2008
2002
2004
56
Prevalence (%)
50
50
44 44 45
37 36 36
40
41
43 42
30
22 21 21 22
25
26
20
10
0
Total
Less than a high school
education
No health insurance
*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
Trends in Consumption of Five or More Recommended Vegetable
and Fruit Servings for Cancer Prevention, Adults 18 and Older,
US, 1994-2007
35
Prevalence (%)
30
25
24.2
24.4
24.1
24.4
23.6
24.3
24.7
1994
1996
1998
2000
2003
2005
2007
20
15
10
5
0
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 (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.
60
55
50
45
40
35
30
25
20
15
10
5
0
Adults with less than a high school education
2008
2007
2006
2005
2004
2003
2002
2000
1998
1996
1994
All adults
1992
Prevalence (%)
Trends in Prevalence (%) of No Leisure-Time Physical Activity, by
Educational Attainment, Adults 18 and Older, US, 1992-2008
Year
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.
Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20
to 74, US, 1960-2008†
45
40
35
33
Prevalence (%)
35
34
33 33
31
35 36
28
30
26
23
25
21
20
15
13
16 17
15 15
11
17
12 13
10
5
0
Both sexes
Men
NHES I (1960-62)
NHANES I (1971-74)
NHANES II (1976-80)
NHANES 1999-2002
NHANES 2003-06
NHANES 2007-08
kg/m2 or
Women
NHANES III (1988-94)
*Obesity is defined as a body mass index of 30
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.
Trends in Obesity* Prevalence (%), Children and Adolescents, by
Age Group, US, 1971-2008
25
20
Prevalence (%)
20
16
18 18
17
16
15
12
10
11
10
11
10
7
5
5
5
7
4
6
5
0
2 to 5 years
6 to 11 years
12 to 19 years
NHANES I (1971-74)
NHANES II (1976-80)
NHANES III (1988-94)
NHANES 1999-2002
NHANES 2003-06
NHANES 2007-08
*Body mass index (BMI) at or above the sex-and age-specific 95th percentile BMI cutoff points from the 2000 sex-specific BMIfor-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.
Sunburn* Prevalence (%) in the Past Year, Adults 18 and
Older, US, 2005
50
44
45
41
Total
38
Age-Adjusted Prevalence (%)
40
35
36
34
32
White nonHispanic
30
25
22
20
Other
22 22
22
19
20
Hispanic
15
10
8
10
6
Black nonHispanic
5
0
Total
Male
Female
*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 Society
Professor of Hematology, Medical
Oncology, Medicine and Epidemiology
Emory University