1. 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

2. 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

3. Common Cancers http://apps.nccd.cdc.gov/uscs/toptencancers.aspx Difference between incidence rates and death rates Male v Female Differences among the races

4. Common Cancers in Men

5. Common Cancers in Women

6. 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

7. 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

8. 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 http://www.uspreventiveservicestaskforce.org/adultrec.htm#cancer

9. 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.

10. 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

11. Mammography: Number needed to screen to prevent one death Age bandNNSNNI 40 and 49 7461904 50 and 59 351 1339 60 and 69 233 377 Annual screening of women between 40 and 84 years yields an NNS of 84 Biennial screening of women ages 50-74 yields an NNS of 144 AJR Am J Roentgenol. 2012 Mar;198(3):723-8. doi: 10.2214/AJR.11.7146. Mammography screening: a new estimate of number needed to screen to prevent one breast cancer death. Hendrick RE1, Helvie MA.

12. Estimated Benefits and Harms of Mammography Screening for 10,000 Women Who Undergo Annual Screening Mammography Over a 10-Year Period http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/Table2 http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/Table2 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)30–137 605–494,970 (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

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

14. 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