Health Promotion and Disease Prevention-focus on Cancer Edward Anselm, MD Assistant Professor of Medicine Icahn School of Medicine at Mount Sinai Medical Director Health Republic Insurance of New Jersey

Outline: learning objectives Know the most common causes of preventable cancer Describe the epidemiology of cancer nationally, state wide and locally Understand the primary and secondary prevention measures for each cancer Understand the evidence for the effectiveness of screening procedures utilizing USPSTF guidelines Understand the risks of screening procedures Understand the role of genetics and environment in cancer Discuss some of the Public Health measures to address cancer prevention

Common Cancers Difference between incidence rates and death rates Male v Female Differences among the races

Common Cancers in Men

Common Cancers in Women

Cancer Causation Spontaneous mutations Exposure to chemicals, radiation, or toxins Inflammation, certain infections Populations with higher genetic risk Conditions with higher risk Effects of hormones

Cancer Prevention Don’t smoke/stop smoking Diet/weight Avoid solar radiation Immunize Hepatitis B Human Papilloma Virus Prevention in high risk groups Hormones Surgery

Early Detection and Treatment of Cancer Screening of populations at risk Age and gender Genetic markers Specific medical conditions Breast Colorectal cancer and polyps Lung Cancer Prostate

Risks of screening and subsequent investigations Anxiety Inconvenience Pain Complications of radiation and other procedures Cost Finding a cancer may not improve health or help a patient live longer. False-negative test results can occur. False-positive test results can occur.

Risk for Breast Cancer Gender and Age Genetics BRACA 1/2 Family History Race Non-cancerous breast conditions/dense breasts Radiation treatment Hormonal effects Early menarche, late menopause Child-bearing, breast feeding Use of oral contraceptives, hormone replacement therapy

Mammography: Number needed to screen to prevent one death Age bandNNSNNI 40 and and and Annual screening of women between 40 and 84 years yields an NNS of 84 Biennial screening of women ages yields an NNS of 144 AJR Am J Roentgenol Mar;198(3): doi: /AJR Mammography screening: a new estimate of number needed to screen to prevent one breast cancer death. Hendrick RE1, Helvie MA.

Estimated Benefits and Harms of Mammography Screening for 10,000 Women Who Undergo Annual Screening Mammography Over a 10-Year Period Age, y No. of Breast Cancer Deaths Averted With Mammography Screening Over Next 15 y b No. (95% CI) With ≥1 False-Positive Result During the 10 y c No. (95% CI) With ≥1 False Positive Resulting in a Biopsy During the 10 y c No. of Breast Cancers or DCIS Diagnosed During the 10 y That Would Never Become Clinically Important (Overdiagnosis) d 401–166,130 (5,940–6,310)700 (610–780)?–104 e 503–326,130 (5,800–6,470)940 (740–1,150)30– –494,970 (4,780–5,150)980 (840–1,130)64–194 Table 2. Estimated Benefits and Harms of Mammography Screening for 10,000 Women Who Undergo Annual Screening Mammography Over a 10-Year Period a

Persuading doctors to screen Overcoming cultural bias Overcoming controversy Overcoming expediency/Electronic reminders Performance measurement Performance incentives Reimbursement rates

Persuading patients to screen De-stigmatization of cancer Explain advantages of early detection Lowering barriers to access Insurance/Insurance copayment Referral requirements Appointment access Workplace programs Increasing public awareness