1. Examining the Evidence & Strategies to Prepare for a Successful Fight Against Cancer in Arkansas Deborah O. Erwin, PhD Roswell Park Cancer Institute Buffalo, NY

2. What do you think is the single most important cancer we should prevent /target to lower cancer incidence in Arkansas? 1. Breast 2. Cervix 3. Colorectal 4. Lung 5. Melanoma/Skin 6. Prostate

3. If we select ….[from responses] What population group may need to be the focus for our efforts? 1. White Males 2. White Females 3. African American Males 4. African American Females 5. Youth – any race/ethnicity 6. Adult- any race/ethnicity 7. Other…

4. What do you think is the second most important cancer we should prevent /target to lower the cancer incidence in Arkansas? 1. Breast 2. Cervix 3. Colorectal 4. Lung 5. Melanoma/Skin 6. Prostate

5. If we select ….[from responses] What population group may need to be the focus for our efforts? 1. White Males 2. White Females 3. African American Males 4. African American Females 5. Youth – any race/ethnicity 6. Adult- any race/ethnicity 7. Other…

6. What do you think is the single most important cancer we should prevent/target to lower the cancer death rate in Arkansas? 1. Breast 2. Cervix 3. Colorectal 4. Lung 5. Melanoma/Skin 6. Prostate

7. If we select ….[from responses] What population group may need to be the focus for our efforts? 1. White Males 2. White Females 3. African American Males 4. African American Females 5. Youth – any race/ethnicity 6. Adult- any race/ethnicity 7. Other…

8. What do you think is the second most important cancer we should prevent/target to lower the cancer death rate in Arkansas? 1. Breast 2. Cervix 3. Colorectal 4. Lung 5. Melanoma/Skin 6. Prostate

9. If we select ….[from responses] What population group may need to be the focus for our efforts? 1. White Males 2. White Females 3. African American Males 4. African American Females 5. Youth – any race/ethnicity 6. Adult- any race/ethnicity 7. Other…

10. I would like to see the Arkansas Cancer Coalition members prioritize… 1. Increasing Screening 2. Increasing Tobacco Cessation 3. Increasing Taxes on Tobacco products 4. Disparities & improving cancer inequities 5. Addressing Obesity & Nutrition issues 6. Increasing Access to Treatment 7. Addressing Palliative Care issues

11. ARKANSAS Cancer Facts & Figures 2011

23. Breast Cancer Arkansas & U.S. rates 13% of new cancers (8.937) 7% of cancer deaths (2,079)

24. Slightly higher incidence for white women, but lower overall incidence than U.S.

26. However, African American women had much higher death rates and later stage at diagnosis, for more than the past decade

27. 2007 Death rate: 26.1 per 100,00 in 2007 Cancer Plan Goal: 23.5 per 100,000 in 2020 To accomplish this goal, you will need to address the death rates in Black women…

29. New risk models for Breast Cancer in Black Women?  Victoria Seewaldt, MD, (Duke Univ)  Low effectiveness of mammograms for diagnosing triple-negative BC (TNBC)  Improved outcomes with MRI  Christine Ambrosone, PhD (Roswell Park)  Parity increased risk of TNBC in Black women  These TNBC risks completely reduced in Black women if they breastfeed Palmer, J. R. et al. (2014). Parity, lactation, and breast cancer subtypes in African American women: Results from the AMBER consortium. Journal of the National Cancer Institute, 106(10), 10.1093/jnci/dju237. Print 2014 Seewaldt VL, Weitzel J. Predicting risk in underserved populations. Podium Presentation at the American Association for Cancer Research; November 2014; San Antonio, Texas.

30. Cervical Cancer Arkansas & U.S. rates Only 1% of incidence and mortality, but…

31. The incidence and higher mortality rates are driven by the disease impact in Black women Cancer Plan : Reduce the death rate from cancer of the uterine cervix. 3.1 per 100,000 to 2.8 per 100,000

33. Cancer Plan….  To reduce the death rate from cancer of the uterine cervix. 3.1 per 100,000 to 2.8 per 100,000  Increase the proportion of women aged 18 years and older who receive a cervical cancer screening based on the most recent guidelines.  80.8 percent 88.9 percent Increasing HPV VACCINATIONS in process … (AR Cancer Plan 3)

34. Colorectal Cancer Arkansas & U.S. rates 11% of new cancers (7,490) 10% of cancer deaths (2,964)

35. Cancer Plan: Increase screening from 55.3% to 60.8%. Decrease incidence of invasive colorectal cancer 45.3 per 100,000 in 2007 to 40.8 per 100,000 in 2020. Colorectal Cancer

36. Cancer Plan: Reduce deaths from colorectal cancer. 18.5 per 100,000(colon, rectum, anus) in 2007 16.7 per100,000 in 2020 So, again, addressing the racial inequities may need to be a priority… for screening & treatment

37. Additional evidence for addressing colorectal cancer screening/treatment practices among Black Arkansans…. Especially since colonoscopy can prevent invasive cancers

38. Prostate Cancer Arkansas & U.S. rates 16% of new cancer cases (11,217) 6% of deaths (1,653)

39. Arkansas rates of new prostate cancers and death rates are comparable to US Rates

40. New cases are decreasing, but Black men continue to have higher incidence rates than white men Death rates continue to decline for all men … but remain 186% higher for Black men than white men (3 x more likely to die)

41. Prostate Cancer Challenges for Cancer Control  Screening/treatment protocols controversial  Over 80% of cases are diagnosed at an early stage (All races/ethnicities)  Steps to change behavior to impact incidence and/or mortality are unclear…  May be more in the area of treatment & research to determine most lethal variants

42. Lung Cancer Arkansas & U.S. rates 19% new cancer cases (12,935) 37% cancer deaths (10,384)

43. Lung cancer death rates in Arkansas are over 25% higher than in the U.S. in general Cancer Control Plan: Reduce the lung cancer death rates 57.2 per 100,000 Is this enough ???

46. Arkansas Cancer Control Plan GOAL for Tobacco/Lung Cancer:  De-normalize all forms of nicotine addiction through comprehensive evidence-based plans to reduce the tobacco industry’s influence on the community and thereby to reduce the future incidence of lung cancer.  NO SPECIFIC PLAN FOR GREATER TAXATION OR FUNDING OF QUITLINE & MARKETING OR SMOKE-LIMITING LEGISLATION

47. Purple counties > SMR

51. Smoke-free laws reduce exposure to secondhand smoke, encourage and increase quitting and cutting back among current smokers, and reduce health care, cleaning and lost productivity costs.

52. Tobacco Cost & Taxation Arkansas  $6.07 (66% of smokers paid <$4.)  Ranked 32 nd – Lowest: Virginia & Missouri at $5.25  2008 Survey:  29.5% no tax increase  25.2%.25-.75/pack  16.4% $1.00- $2.00/pack  28.9% $3.00 or more New York  $9 - $12.85 retail  Tax is $4.35 per pack, Fed is $1.01  Much cheaper for native brands on the reservation (maybe $4 a pack or less). What happens when you tax cigarettes at $5.36/pack…? For more detail http://www.tax.ny.gov/bus/cig/cigidx.htmhttp://www.tax.ny.gov/bus/cig/cigidx.htm

53. Arkansas (2008) 20.7% current smokers Since 2002, down 18% 63.4% seriously considering stopping within next 6 months New York (2013) 16.6% smokers

54. The best news… Smoking rates among high school students in 2012 are down to 11.9%, the lowest in NY since health officials began keeping track in 1997. Arkansas: 23.5% high school students 6.9% middle school students (2010) 34% decrease since 2007 26% of 18-24 y.o High school youth smoking is down by 56% (2000 to 2012) Middle school youth declined by 70% For every 10% increase in the retail price of a pack of cigarettes, youth smoking rates drop by 6.5% and overall cigarette consumption declines by 4%

55. Reducing Smoking & Cancer Rates in Spite of SES...  21 percent of New Yorkers have incomes below the poverty level  21 percent of New Yorkers are enrolled in Medicaid  68 percent of New Yorkers are without a bachelor’s degree  33 percent of New Yorkers report poor mental health  All of these features of New York’s population affect cancer prevention

56. Requiring that health insurance plans for all state employees, Medicaid beneficiaries and other tobacco users cover a comprehensive cessation benefit, including a range of treatment options, will curb tobacco-related death and disease in states and ultimately save money.

57. Other Cancer Control Issues Nutrition, Obesity & Exercise  1/4 to 1/3 of all cancers are tied to poor nutrition, physical inactivity and excess weight.

58. 31.5% of adult Arkansans are obese (BRFSS 2009) Goal 28.6% Target setting method: 10% improvement Cancer Risk Factors

59. See Handout…

60. Policy & Systems Change  Primary approach for addressing obesity  Fructose, Sugar, Fructose, Sugar  USDA, Big Food Producers… Lobby nightmare  Fat Chance: Beating the Odds Against Sugar, Processed food, Obesity and Disease. Robert H. Lustig, MD, MSL. New York, NY: Penguin Group, 2014.

61. Other Cancer Control Issues Nutrition, Obesity & Exercise  1/4 to 1/3 of all cancers are tied to poor nutrition, physical inactivity and excess weight. Tanning & Skin Cancers

62. US rate (men & women) 21.3/100,000

64. Other Cancer Control Issues Nutrition, Obesity & Exercise  1/4 to 1/3 of all cancers are tied to poor nutrition, physical inactivity and excess weight. Tanning & Skin Cancers Palliative Care

66. Based on the evidence… Cancer Control Plans may need to include: Screening, Early Detection & Treatment…  1 in 3 adults from ages 50 to 75 is still not getting screened as recommended Because tobacco use and lung cancer are such a major contributor to disease and death from cancer…  Tobacco control programs including legislation -  reduce tobacco use and tobacco-related disease, resulting in reduced tobacco- related health care costs.

67. The overall cancer mortality rate target for Healthy People 2020 is 160.6 per 100,000 population New York Lung, colorectal, prostate and female breast cancers account for approximately half of all cancer cases and deaths in NYS. 2009, the age-adjusted cancer mortality rate was 161.9 cases per 100,000 New Yorkers. Impacting Mortality Rates Arkansas ca death rate: 200.2 per 100,000 in 2007 Arkansas Cancer Control Plan Goal: 180.2 per 100,000 in 2020 Is this enough…?

68. What do you think is the single most important cancer we should prevent/target to lower the incidence? 1. Breast 2. Cervix 3. Colorectal 4. Lung 5. Melanoma/Skin 6. Prostate

69. If we select ….[from responses] What population group may need to be the focus for our efforts? 1. White Males 2. White Females 3. African American Males 4. African American Females 5. Youth – any race/ethnicity 6. Adult- any race/ethnicity 7. Other…

70. What do you think is the second most important cancer we should prevent/target to lower the incidence? 1. Breast 2. Cervix 3. Colorectal 4. Lung 5. Melanoma/Skin 6. Prostate

71. If we select ….[from responses] What population group may need to be the focus for our efforts? 1. White Males 2. White Females 3. African American Males 4. African American Females 5. Youth – any race/ethnicity 6. Adult- any race/ethnicity 7. Other…

72. What do you think is the single most important cancer we should prevent/target to lower the cancer death rate in Arkansas? 1. Breast 2. Cervix 3. Colorectal 4. Lung 5. Melanoma/Skin 6. Prostate

73. If we select ….[from responses] What population group may need to be the focus for our efforts? 1. White Males 2. White Females 3. African American Males 4. African American Females 5. Youth – any race/ethnicity 6. Adult- any race/ethnicity 7. Other…

74. What do you think is the second most important cancer we should prevent/target to lower the cancer death rate in Arkansas? 1. Breast 2. Cervix 3. Colorectal 4. Lung 5. Melanoma/Skin 6. Prostate

75. If we select ….[from responses] What population group may need to be the focus for our efforts? 1. White Males 2. White Females 3. African American Males 4. African American Females 5. Youth – any race/ethnicity 6. Adult- any race/ethnicity 7. Other…

76. I would like to see the Arkansas Cancer Coalition members prioritize… 1. Increasing Screening 2. Increasing Tobacco Cessation 3. Increasing Taxes on Tobacco products 4. Disparities & improving cancer inequities 5. Addressing Obesity & Nutrition issues 6. Increasing Access to Treatment 7. Addressing Palliative Care issues

77. Questions?

78. Yes, this is what lake effect snow looks like from the outside…