1. 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

2. Disclosures Dr. Brawley has nothing to disclose.

3. WHO (2003) Global Deaths (millions per annum)

4. 7 million Deaths 11 million New Cases 25 million Living with Cancer CANCER – WORLDWIDE BURDEN (2005)

5. 17 million Deaths 27 million New Cases 75 million Living with Cancer CANCER – WORLDWIDE BURDEN (2030)

6. Outline Observations on the US Economy The need to redefine cancer for the 21 st century Trends in cancer epidemiology Interventions that can save lives

7. U.S. Health Care Spending In 2009, the U.S. spent $2.53 TRILLION on Health Care

8. U.S. Health Care Spending How Big is a Trillion? 1 million secondsLast week 1 billion secondsRichard Nixon’s resignation 1 trillion seconds30,000 BCE

9. 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

10. 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)

11. 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)

12. Overall Quality: Life Expectancy at 65 The US is ranked 12 th for Males and 16 th for Females Source: OECD, 2006 data

13. 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

14. Rudolph Ludwig Karl Virchow 1821- 1902

15. 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

17. 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.

18. Overdiagnosis Cure is Possible but not Necessary Prostate Cancer Breast Cancer Lung Cancer (NSCLC) Cervical Disease Renal Cancer Melanoma Colon Cancer

19. 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

20. A Genomic Definition of Cancer Genetics vs Genomics GeneticsGenetics 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. GenomicsGenomics 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.genes

21. 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.

22. Cancer Incidence Rates* Among Men, US, 1975-2006 Prostate Lung & bronchus Colon and rectum Urinary bladder Non-Hodgkin lymphoma Rate Per 100,000 Melanoma of the skin *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.

23. Cancer Death Rates* Among Men, US,1930-2006 *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. Lung & bronchus Colon & rectum Stomach Rate Per 100,000 Prostate Pancreas LiverLeukemia

24. Cancer Incidence Rates* Among Women, US, 1975-2006 *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. Colon and rectum Rate Per 100,000 Breast Lung & bronchus Uterine corpus Melanoma Non-Hodgkin lymphoma

25. Cancer Death Rates* Among Women, US,1930-2006 *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. Lung & bronchus Colon & rectum Uterus Stomach Breast Ovary Pancreas Rate Per 100,000

26. Cancer Death Rates* by Sex, US, 1975-2006 *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. Men Both Sexes Rate Per 100,000 Women

27. African American men White men African American women White women Rate Per 100,000 Cancer Death Rates* by Sex and Race, US, 1975-2006 *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.

28. Cancer Incidence & Death Rates* in Children 0-14 Years, 1975-2006 Incidence Mortality Rate Per 100,000 *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.

29. Trends in Five-year Relative Survival (%)* Rates, US, 1975-2005 *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. Site1975-1977 1984-1986 1999-2005 All sites505468 Breast (female)757990 Colon 525966 Leukemia354254 Lung and bronchus131316 Melanoma828793 Non-Hodgkin lymphoma485369 Ovary3740 46 Pancreas33 6 Prostate6976100 Rectum495769 Urinary bladder747882

30. Trends in the Number of Cancer Deaths Among Men and Women, US, 1930-2007 Women Men Number of Cancer Deaths Men Women Source: US Mortality Data, 1930-2007, National Center for Health Statistics, Centers for Disease Control and Prevention, 2010.

31. Deaths averted from 1991-2020 in males and 1992- 2020 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).

32. Trends in Cigarette Smoking Prevalence* (%), by Sex, Adults 18 and Older, US, 1965-2008 *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. Men Women

33. Current* Cigarette Smoking Prevalence (%) Among High School Students by Sex and Race/Ethnicity, US, 1991-2007 *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.

34. 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)

36. 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.

37. 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

38. 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

39. 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.”

40. “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.” The American Cancer Society 2010 Prostate Cancer Screening Guideline

41. 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!!!

42. Mammogram Prevalence (%), by Educational Attainment and Health Insurance Status, Women 40 and Older, US, 1991-2008 *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. Women with less than a high school education Women with no health insurance All women 40 and older

43. 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)

45. Breast Cancer Odds that Mammography will save a woman’s life over a ten year period Age 40-49 0.05% Age 50-590.07% Age 60-692.7%

46. 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

47. Breast Cancer Screening in the U.S. The Ten Year Potential 64,673 deaths averted Age Number in Population USPSTF Estimate of Number Needed to Screen Avertable Deaths Lives Lost due to Non- Compliance 40's22,327,5921,90011,7514,113 50's20,542,3631,34015,3305,366 60's13,909,27737037,59213,157

48. 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

49. 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

50. 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

51. 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

52. 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

54. Trends in Recent* Fecal Occult Blood Test Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50 Years and Older, US, 1997-2008 *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.

55. Trends in Recent* Flexible Sigmoidoscopy or Colonoscopy Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50 Years and Older, US, 1997-2008 *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.

56. 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

57. 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. Trends in Consumption of Five or More Recommended Vegetable and Fruit Servings for Cancer Prevention, Adults 18 and Older, US, 1994-2007

58. Trends in Prevalence (%) of No Leisure-Time Physical Activity, by Educational Attainment, Adults 18 and Older, US, 1992-2008 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. Adults with less than a high school education All adults

59. Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20 to 74, US, 1960-2008 † *Obesity is defined as a body mass index of 30 kg/m 2 or 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.

60. Trends in Obesity* Prevalence (%), Children and Adolescents, by Age Group, US, 1971-2008 *Body mass index (BMI) at or above the sex-and age-specific 95 th percentile BMI cutoff points from the 2000 sex-specific BMI- for-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.

61. Sunburn* Prevalence (%) in the Past Year, Adults 18 and Older, US, 2005 *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.

62. 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