University of Wisconsin School of Medicine and Public Health Progress in Cancer Control: Maximizing Collaboration, Minimizing Disparities Patrick Remington, MD, MPH Department of Population Health Sciences 2008 Iowa Cancer Summit Des Moines, Iowa

Overview 1.Causes of cancer -Cancer continuum -Attributable risk 2.Trends in cancer -Incidence, survival, mortality, risk factors 3.Three perspectives on approaches to cancer control Causes Trends Perspectives

Pre-test: What is the leading cause of cancer death in the US? a. Breast cancer b. Lung cancer c. Colon cancer d. Prostate cancer e. None of the above Causes Trends Perspectives

Causes of Cancer Death, 2008 Causes Trends Perspectives Source: ACS, Cancer Facts and Figures 2008

Health Risk Factors Cancer Death Cancer Continuum Treatment Screening Causes Trends Perspectives

Health Risk Factors Cancer Death Cancer Continuum Tobacco Diet, exercise Causes Trends Perspectives

Health Risk Factors Cancer Death Cancer Continuum Cigarette advertising Poverty Causes Trends Perspectives

Cancer Epidemiology Determinants –What are the “causes of cancer” –Is screening effective in reducing the risk of dying from cancer? Distribution –What are the trends in cancer? –Which persons are at greatest risk? –What places have higher cancer rates? Causes Trends Perspectives

Preventable Causes of Cancer Causes Trends Perspectives

Causes of Lung Cancer Causes Trends Perspectives

Causes of Colon Cancer Causes Trends Perspectives

Causes of Breast Cancer Causes Trends Perspectives

Causes of Prostate Cancer Causes Trends Perspectives

Preventable Causes of Cancer Causes Trends Perspectives

“Preventable” Causes Cancer Causes Trends Perspectives

Post-test: What are the leading causes of cancer death in the US? Answer: Tobacco use and poor diet Causes Trends Perspectives

II. What are the trends in cancer in the United States? a. Increasing incidence & mortality b. Increasing incidence but decreasing mortality c. Decreasing incidence & mortality d. All of the above e. None of the above Causes Trends Perspectives

Measuring Progress in Cancer Control Direct measures –incidence –survival –mortality Risk factors Advances in knowledge National Cancer Institute. JNCI 1990;82: Causes Trends Perspectives

Trends in Cancer Incidence, U.S., Age-adjusted rate/100,000 Year SEER, 2008 Causes Trends Perspectives

Trends in Cancer Incidence, U.S., Age-adjusted rate/100,000 Year SEER, 2008 Causes Trends Perspectives

Questions What is responsible for the increase during the 1980s? What is responsible for the sharp decrease in the 1990s? Causes Trends Perspectives

Trends in Cancer Incidence, U.S., Age-adjusted rate/100,000 Year SEER, 2008 Causes Trends Perspectives Women Men

Trends in Cancer Incidence, U.S., Age-adjusted rate/100,000 Year SEER, 2008 Causes Trends Perspectives Prostate All other sites

Trends in Cancer Incidence, U.S., Percentage of 1975 rate Year SEER, 2008 ? Causes Trends Perspectives All other sites Prostate

Trends in Cancer Incidence, U.S., Percentage of 1975 rate Year SEER, 2008 PSA screening Causes Trends Perspectives All other sites Prostate

Trends in Cancer Incidence, U.S., Age-adjusted rate/100,000 Year SEER, 2008 Causes Trends Perspectives All other sites Breast

Trends in Cancer Incidence, U.S., Percentage of 1975 rate Year SEER, 2008 ? Causes Trends Perspectives All other sites Breast

Trends in Cancer Incidence, U.S., Percentage of 1975 rate Year SEER, 2008 Mammography Causes Trends Perspectives All other sites Breast

Lead Time and Cancer Screening Expected: Year: Causes Trends Perspectives

Lead Time and Cancer Screening Expected: Year: Screen Detected: Causes Trends Perspectives

Lead Time and Cancer Screening Expected: Screen Detected: Total Reported: Year: Causes Trends Perspectives

A. Summary: Cancer Incidence Increasing cancer incidence due mostly to increased screening--that’s good –Diagnosing ‘future’ cases due to lead time –Diagnosing tumors that might not have ever progressed Not a good summary measure of progress in cancer control Causes Trends Perspectives

B. Cancer Survival What are the trends in cancer survival? Data available –SEER –State cancer registries Based on follow-up in registries Causes Trends Perspectives

Trends in 5-Year Cancer Survival, U.S., Year of Dx ( ) Percent Surviving Year SEER, 2008 Causes Trends Perspectives

Lead Time and Cancer Screening No cancer Pre-clinicalClinical DiagnosedDied 5-years Survival Causes Trends Perspectives

No cancer Pre-clinicalClinical 5-years DiagnosedDied Survival years? DiagnosedDied Lead Time and Cancer Screening Causes Trends Perspectives

No cancer Pre-clinicalClinical 5-years DiagnosedDied Diagnosed Died Survival 14-years? years? DiagnosedDied Lead Time and Cancer Screening Causes Trends Perspectives

B. Summary: Cancer Survival Cancer survival rates are improving-- that’s good But changes in cancer cancer survival are hard to interpret –Lead time from screening-detected cancers –Increased detection of non-invasive cancers Causes Trends Perspectives

C. Cancer Mortality What are the trends in cancer mortality? Data from vital statistics –Based on death certificates –Completed by physicians/coroners/ medical examiners at the time of death Causes Trends Perspectives

Trends in Cancer Mortality in the U.S., Age-adjusted rate/100,000 Year Health U.S., 2006

Trends in Cancer Mortality in the U.S., Age-adjusted rate/100,000 Year Health U.S., 2006 Bailar 1986

Bailar’s Conclusion The best single measure is the age- adjusted mortality rate associated with all cancers According to this measure, we are losing the war against cancer A shift in research emphasis, from research on treatment to research on prevention, seems necessary if substantial progress against cancer is to be forthcoming

1997;336(22):

Trends in Cancer Mortality in the U.S., Age-adjusted rate/100,000 Year Health U.S., 2006 Bailar 1986

Trends in Cancer Mortality in the U.S., Age-adjusted rate/100,000 Year Health U.S., 2006 Bailar 1986 Bailar 1997

What are the recent trends in cancer mortality in the United States? a.Increasing b.Decreasing c.No change d.None of the above e.Not sure

Trends in Cancer Mortality in the U.S., Age-adjusted rate/100,000 Year Health U.S., 2006 Bailar 1986 Bailar 1997

Trends in Cancer Mortality in the U.S., Age-adjusted rate/100,000 Year Health U.S., 2006 Bailar 1986 Bailar 1997

Cancer Death Rates, for Men, US, Lung & bronchus Colon & rectum Stomach Rate Per 100,000 Prostate Pancreas LiverLeukemia

Lung & bronchus Colon & rectum Uterus Stomach Breast Ovary Pancreas Rate Per 100,000 Cancer Death Rates, for Women, US,

Trends in Cancer Mortality, By Race, U.S., Age-adjusted rate/100,000 Year CDC, 2008 Causes Trends Perspectives Black Men Black Women White Women White Men

Trends in Cancer Mortality, RR Black:White, U.S., Relative Risk Year CDC, 2008 Causes Trends Perspectives Men Both Women

Trends in Cancer Deaths, U.S., Rate/100,000 Year CDC, 2008 Causes Trends Perspectives

Trends in Cancer Deaths, U.S., Percentage of 1979 rate Year CDC, 2008 Causes Trends Perspectives

Change in the Number of Cancer Deaths U.S., 1990 to 2000 Causes Trends Perspectives 64,100 fewer deaths Male: 51,900 Female: 12,200 Under age 75: 66,300 Over age 75: 2,200 more deaths Andersen et al, 2002

Change in the Number of Cancer Deaths Selected Sites, U.S., 1990 to 2000 Causes Trends Perspectives 89 % of total fewer deaths Andersen et al, 2002

C. Summary: Cancer Mortality Cancer mortality rates are decreasing among younger persons--that’s good –Better treatment of childhood cancers –Lower smoking rates among young adults Cancer mortality rates are increasing among women and older persons-that’s bad –Long-term tobacco exposure Causes Trends Perspectives

C. Cancer Mortality, cont. The summary measure of age-adjusted mortality has limitations Need to examine trends by: –Age, gender, race –Type of cancer –Region Causes Trends Perspectives

D. Summary: Risk Factors Smoking: Prevalence declined from 42% in 1960s to 25% in 1995 Diet: Less red meat, more chicken, more fiber Exercise: No data. Rates of obesity are increasing Environmental exposures: ? Causes Trends Perspectives

Post-test: What are the trends in cancer in the United States? d. All of the above Causes Trends Perspectives

Summary Epidemiology has uncovered many risk factors for cancer (e.g. tobacco use, poor diet, alcohol). The challenge is to understand the ‘upstream’ causes of these risk factors Then develop effective strategies to prevent cancer--especially for those groups at the highest risk Causes Trends Perspectives

Perspective #1 The progress in cancer control is minimal compared to other diseases Causes Trends Perspectives

Trends in Cancer Mortality in the U.S., Age-adjusted rate/100,000 Year Health U.S., 2006

Trends in Cancer Mortality in the U.S., Age-adjusted rate/100,000 Year Health U.S., 2006

Trends in Mortality in the U.S., Age-adjusted rate/100,000 Year CDC WONDER, 2008

Change in the US Death Rates* by Cause, 1950 & 2004 * Age-adjusted to 2000 US standard population. Sources: 1950 Mortality Data - CDC/NCHS, NVSS, Mortality Revised Mortality Data: US Mortality Public Use Data Tape, 2004, NCHS, Centers for Disease Control and Prevention, 2006 Heart Diseases Cerebrovascular Diseases Pneumonia/ Influenza Cancer Rate Per 100,000

Cancer Heart disease Trends in Age-Adjusted Death Rates, and Projected from Chairez E, Jones N, and Remington P (submitted for publication)

MN OR CO HI AK MT CT NHVT SD KS NMNEND WA MA MO TN UTOH WVPAIN NC SC ID ME VA WINY LA MDTX AR DE GA MI CA NJAL RI WYNV Number of States The year cancer becomes the leading cause of death in the 50 states. IA FL IL AZ KY OKMS

Perspective #2 Cancer trends are not the same in all groups in the population Causes Trends Perspectives

Trends in Breast Cancer Mortality by Race, U.S., Age-adjusted rate/100,000 Year CDC WONDER, 2008

Trends in Breast Cancer Mortality by Race, U.S., Age-adjusted rate/100,000 Year CDC WONDER, 2008

Year CDC Wonder, 2008 Trends in Colorectal Cancer Deaths, U.S., Age-adjusted rate/100,000

Year CDC Wonder, 2008 Trends in Colorectal Cancer Deaths, U.S., Age-adjusted rate/100,000

Cancer Risk Factors and SES Smoking: Higher smoking rates among the poor and less educated Diet and obesity: Higher fat diets, lower consumption of fruits and vegetables among the poor Cancer screening: Later access to and use of breast and cervical cancer screening services Causes Trends Perspectives

Trends in Smoking by Education U.S., Percent Year Health U.S., 1998 (1966 from SGR 1989), MMWR 56(44), 2006

Trends in Smoking by Education U.S., Percent Year Health U.S., 1998 (1966 from SGR 1989), MMWR 56(44), 2006

Trends in Smoking by Education U.S., Percent Year Health U.S., 1998 (1966 from SGR 1989), MMWR 56(44), 2006

Trends in Smoking by Education U.S., Percent Year Health U.S., 1998 (1966 from SGR 1989), MMWR 56(44), 2006

Trends in Smoking by Education U.S., Percent Year Health U.S., 1998 (1966 from SGR 1989), MMWR 56(44), 2006

Trends in Percent of Adults who Smoke, Percent smokers Year U.S.

Trends in Percent of Adults who Smoke, Percent smokers Year U.S.Iowa

Trends in Percent of Adults who Smoke, Percent smokers Year 2010 Goal (12%) Iowa

Trends in Percent of Adults who Smoke, Percent smokers Year 2010 Goal (12%) 2020? (8%) Iowa

Trends in Percent of Adults who Smoke, Percent smokers Year 38%26%23%11%Iowa

Percent smokers Year <HSHS Some College Grad Iowa Iowa Smoking Rates by Education

40 Developmental Assets INTERNAL Homework Integrity Resistance skills Self-esteem EXTERNAL Family support Service to others High expectations Youth programs

Percent cigarette smokers, Jefferson County, 1997 Number of Developmental ‘Assets’ Percent

Perspective #3 We need to monitor trends “upstream” from cancer and cancer risk factors For example, what are the “causes” of tobacco use among children? Causes Trends Perspectives

Health Risk Factors Cancer Death Less education? Cancer Control Continuum

Health Risk Factors Cancer Death Peer pressure? Cancer Control Continuum

Health Risk Factors Cancer Death Low self esteem? Cancer Control Continuum

Health Risk Factors Cancer Death Developmental assets? Cancer Control Continuum

Conclusions, 2008 We are making minimal progress in the war against cancer A shift in emphasis—from treatment to prevention—is essential We must focus more attention on the unacceptable cancer health disparities among the lower class Causes Trends Perspectives