Cancer in Idaho: Data Update & Strategic Plan Objectives Idaho Cancer Policy Agenda Meeting April 25, 2014 Chris Johnson, Epidemiologist Cancer Data Registry of Idaho

3 Handouts 2

Cancer 100+ different diseases Since 2008, #1 cause of death in Idaho –About 22% of deaths are from cancer In 2011 in Idaho: 7,263 new invasive cases 849 new in situ cases 2,559 cancer deaths 30% of those diagnosed this year will die of cancer within five years 3

Leading Cause of Death by Age Idaho 2012 Cancer is the leading cause of death among age groups 45-54, and

Trends in Crude Mortality Rates, Idaho 5

Why is Cancer the Leading Cause of Death in Idaho? Competing risks –Why are heart disease/stroke deaths down? “Statins and Smoking” –Decreases in blood cholesterol levels and uncontrolled hypertension (risk factors), mostly through medication –Improvements in medical treatments for blocked arteries, stroke –Lower smoking rates in Idaho 6

Cancer Risk Factors 7

Levels of Disease Prevention Primary Prevention –Aims to prevent the disease from occurring –Reduces incidence Secondary Prevention –After the disease has occurred but before symptoms –Aims to find and treat disease early Tertiary Prevention –Goals are to improve treatment outcomes, prevent complications 8

Measures of cancer burden: incidence, mortality, YPLL Colon & Rectum Cancer Behavior: smoking, physical activity, diet, screening Lung Cancer, Tobacco, other Tobacco-related Cancers MelanomaBreast Cancer 9

Lung Cancer/Smoking Constellation

Lung Cancer Idaho 2011: –838 new cases –616 deaths By far the leading cause of cancer death among both men and women –Each year, more people die of lung cancer than of colon, breast, and prostate cancers combined –Lung cancer has a poor prognosis; nearly 90% of persons with lung cancer die of the disease 11

Lung Cancer Risk Factors Smoking causes ~85% of lung cancer deaths Radon – 2 nd leading cause of lung cancer –About 10% of lung cancer deaths –Leading cause of lung cancer among non- smokers Secondhand smoke Asbestos, arsenic, chromium, nickel, other substances in workplace Air pollution, including diesel exhaust 12

Smoking Accounts for at least 30% of all cancer deaths Population attributable risk varies by cancer site for other smoking-related cancers: –Larynx –Oral Cavity –Nose and Sinuses –Pharynx –Esophagus –Stomach –Pancreas –Cervix –Kidney –Bladder –Ovary –Colon & Rectum –AML 13

Counseling & Interventions The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. –Grade: A recommendation: there is high certainty that the net benefit is substantial. 14

USPSTF Screening Recommendation (Dec 2013) The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. –Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. Screening cannot prevent most lung cancer–related deaths, and smoking cessation remains essential. 15

Drilling Down into CCAI Strategic Plan Measures 2. Reduce the lung cancer death rate 6. Reduce the oropharyngeal cancer death rate 18. Decrease the proportion of adults aged 18+ who are current smokers 19. Reduce tobacco use by adolescents 23. Reduce the proportion of males who use smokeless tobacco 16

Lung Cancer State Map 17

Lung Cancer Trends - Idaho 18

Lung Cancer Age-Specific Rates, Idaho,

Variation and Disparities in Lung Cancer in Idaho Geographic Race/ethnicity Area-based SES measures 20

County Maps of Smoking and Lung Cancer Incidence & Mortality Smoking Inc Mort

Smoking Prevalence, Idaho 2012 * In 2012, about 190,000 adult smokers in Idaho. 22

Smoking Prevalence, Idaho

Smoking Prevalence, Idaho

Area-Based Measures Used methods based on Harvard School of Public Health Disparities Geocoding Project –Geocoded cancer incidence data –Used area-based socioeconomic measures (ABSMs) to characterize both the cases and population –Computed rates stratified by the area-based measure of socioeconomic status –Ran multilevel models and will be showing the effects that were statistically significant 25

Census Tract 2010 Poverty American Community Survey

Census Tract 2010 Uninsured American Community Survey

Lung Cancer Incidence by Census Tract % Uninsured 28

Potentially Averted Lung Cancer Cases,

Lessening the Burden from Lung Cancer Primary Prevention –Don’t smoke! –Test for radon Secondary Prevention –LDCT among high risk population Tertiary Prevention –Ensure quality treatment Access to care Concordant with guidelines (e.g. NCCN) Clinical trials 30

Using the Drill-Down Results Target geographic areas Disparities by: –Income –Education –Uninsured –LGBT 31

Colon & Rectum Cancer Constellation

Colon & Rectum Cancer Idaho 2011: –639 new invasive cases – 17 new in situ cases –222 deaths Of cancers affecting both men and women, second leading cause of cancer death 33

Colon & Rectum Cancer Risk Factors UK (2011) study estimates 54% of colon & rectum cancer cases are attributable to lifestyle factors: Br J Cancer. 2011; 105(Suppl 2): S77–S81. –Red and preserved meat consumption (21%) –Overweight and obesity (13%) –Low fiber diet (12%) –Alcohol (12%) –Tobacco (8%) –Physical inactivity (3%) –Other [infections, radiation] (4%) The percentages reflect the effect of removing one cause of cancer independently of other causes, and there is overlap, so the total is less than the sum 34

USPSTF Recommendation (Oct 2008): The USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults beginning at age 50 years and continuing until age 75 years. –Grade: A recommendation – there is high certainty that the net benefit is substantial. 35

Colorectal Cancer Screening CDC: “If everyone aged 50 years or older had regular screening tests, at least 60% of deaths from this cancer could be avoided.” Colorectal cancer screening helps find precancerous polyps so they can be removed before they turn into cancer. In this way, colorectal cancer is prevented. Screening tests also can find colorectal cancer early, when the chance of cure is better. 36

CCAI Strategic Plan Objectives Pertaining to Colon & Rectum Cancer 5 – Mortality 9 – Incidence 15 – Late stage CRC among persons aged – CRC Screening 21 – Overweight 22 – Physical activity 37

Colon & Rectum Cancer State Map 38

Colorectal Cancer Screening Idaho 2012, Ages

Colorectal Cancer Screening Idaho 2012, Ages

Colorectal Cancer Screening Idaho 2012, Ages

Colon & Rectum Cancer Trends 42

Colon & Rectum Cancer Incidence by Race/Ethnicity,

Colon & Rectum Cancer Incidence by Census Tract % Poverty 44

Potentially Averted Colon & Rectum Cancer Cases,

Lessening the Burden from Colon & Rectum Cancer Primary Prevention –Healthy diet, Healthy BMI, Physical activity –Don’t smoke Secondary Prevention –Colon & rectum cancer screening Tertiary Prevention –Ensure quality treatment Access to care Concordant with guidelines (e.g. NCCN) Clinical trials 46

Using the Drill-Down Results Target geographic areas Disparities by: –Income –Education –Area-based SES 47

Breast Cancer Constellation

Breast Cancer (Female) Idaho 2011: –1,006 new invasive cases – 225 new in situ cases – 194 deaths Among Idaho women, breast cancer is: –the most common cancer (incidence) –2nd most common for mortality 49

Breast Cancer Risk Factors Risk Factors you Cannot Change –Aging –Race and ethnicity –Genetic risk factors 5-10% of breast cancers are hereditary BRCA1 and BRCA2 –Family history 15% of women who get breast cancer have a family history; 85% do not. –Dense breast tissue –Certain other breast conditions (LCIS, DCIS, atypical ductal or lobular hyperplasia) –Number of menstrual cycles –Previous chest radiation –Diethylstilbestrol exposure 50

Breast Cancer Risk Factors Lifestyle-related factors –Birth control –Hormone therapy after menopause –Drinking alcohol –Being overweight or obese after menopause –Lack of physical activity Unclear factors –Chemicals in the environment –Tobacco smoke –Night work 51

Idaho Breast Cancer Trends 52

30% Reduction In Breast Cancer Mortality Since 1980s How much due to screening? –Goal is to treat cancer earlier, when a cure is more likely How much due to treatment? –Adjuvant tamoxifen lowers breast cancer mortality by nearly a third in long term studies of women with ER+ breast cancers (about 75 percent of those diagnosed) There were greater improvements in mortality among women with ER+ than ER- tumors (SEER ). 53

Mammography Screening Recommendations for Women at Average Risk Women at higher risk of breast cancer may need to be screened earlier and more often than other women. American Cancer Society National Cancer Institute National Comprehensive Cancer Network United States Preventive Services Task Force Every year starting at age 40 Every 1-2 years starting at age 40 Every year starting at age 40 Every 2 years Ages

JAMA Review – Pace & Keating April articles from 1960 to 2014 reviewed for evidence on the mortality benefit and chief harms of mammography screening. –Mortality benefit of mammography is “modest” 15% reduction of breast cancer mortality for women in their 40s, and 32% for women in their 60s. –Risks of harm from screening are “significant” Over 10 years of annual mammograms, 61% with false-positive result. 19% of cancers represent overdiagnosis –Clinicians must focus on informed screening decisions based on individual risk of a breast cancer diagnosis. 55

CCAI Strategic Plan Objectives Pertaining to Breast Cancer 3 – Mortality 11 – Late stage incidence rate ages A- Biennial mammogram B- Biennial mammogram

Breast Cancer Mortality 57

Breast Cancer Incidence 58

Mammography Screening Idaho 2012, Females

Lessening the Burden from Breast Cancer Primary Prevention –Overweight and obesity, Physical activity Secondary Prevention –USPSTF – recommends biennial screening mammography for women aged 50 to 74 years Tertiary Prevention –Ensure quality treatment Access to care Concordant with guidelines (e.g. NCCN) Clinical trials 60

Melanoma of the Skin Constellation

Melanoma of the Skin Idaho 2011: –443 new invasive cases –385 new in situ cases – 57 deaths. Melanoma is the 5th most common cancer in Idaho in terms of incidence and 14th most common site for cancer deaths. Unreported cases from in-office labs continues to be an issue for most states. –Meaningful Use 2 may help improve melanoma reporting. 62

USPSTF Recommendations: [2009] Not enough evidence to recommend for or against routine screening (total body examination by a doctor) to find skin cancers early. [2012] Recommends counseling children, adolescents, and young adults aged 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer. –Insufficient evidence to assess the balance of benefits and harms of counseling adults older than age 24 years. 63

CCAI Strategic Plan Objectives Pertaining to Skin Cancer 8 – Mortality 27 – Tanning appliances grades – Sunburn adults 29 – Tanning appliances adults 64

Melanoma of the Skin Mortality 65

Melanoma of the Skin Incidence 66

Melanoma of the Skin Trends 67

Sunburn among Adults, Idaho

Sunburn among Adults, Idaho

Indoor Tanning among Adults Idaho

Indoor Tanning among Adults Idaho

Indoor Tanning among Children Idaho

Lessening the Burden from Melanoma of the Skin Primary Prevention –Avoiding excessive sun exposure –Avoiding intense, intermittent, UV exposure –Preventing sunburns –Prompt self-referral to physician for changing nevi Secondary Prevention –USPSTF – not enough evidence to recommend for or against routine screening Tertiary Prevention –Ensure quality treatment Access to care, guidelines, clinical trials 73

Using the Drill-Down Results Target geographic areas Focus on the young and the affluent for sunburn –Young females for indoor tanning 74

Hospitals & Clinical Trials 75

American College of Surgeons Commission on Cancer (CoC) Cancer Programs in Idaho (n=7) Eastern Idaho Regional Medical Center Kootenai Medical Center Portneuf Medical Center Saint Alphonsus Regional Medical Center St. Joseph Regional Medical Center St. Luke's Magic Valley Medical Center St. Luke’s Regional Medical Center/MSTI –About 70% of Idaho resident cancer cases seen at one of these facilities 76

Clinical Trial Enrollment 77

The Future of Cancer in Idaho As Idaho’s population increases and we live longer, we can expect more cases of cancer and cancer deaths in the future 78

Lessening the Burden Primary Prevention – Decreases Incidence –Don’t smoke! Test for radon –Obesity & physical activity –Skin cancer prevention –Vaccinations for Hep B and HPV Secondary Prevention - Screening –Breast –Colorectal –Lung Tertiary Prevention - Ensure Quality Treatment –Access to care, Clinical trials –Concordant with guidelines (e.g. NCCN) 79