1. 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

2. 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

3. 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

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

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

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

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

8. 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

9. Preventable Causes of Cancer Causes Trends Perspectives

10. Causes of Lung Cancer Causes Trends Perspectives

11. Causes of Colon Cancer Causes Trends Perspectives

12. Causes of Breast Cancer Causes Trends Perspectives

13. Causes of Prostate Cancer Causes Trends Perspectives

14. Preventable Causes of Cancer Causes Trends Perspectives

15. “Preventable” Causes Cancer Causes Trends Perspectives

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

17. 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

18. Measuring Progress in Cancer Control Direct measures –incidence –survival –mortality Risk factors Advances in knowledge National Cancer Institute. JNCI 1990;82:825-35 Causes Trends Perspectives

19. Trends in Cancer Incidence, U.S., 1975-2005 Age-adjusted rate/100,000 Year SEER, 2008 Causes Trends Perspectives

20. Trends in Cancer Incidence, U.S., 1975-2005 Age-adjusted rate/100,000 Year SEER, 2008 Causes Trends Perspectives

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

22. Trends in Cancer Incidence, U.S., 1975-2005 Age-adjusted rate/100,000 Year SEER, 2008 Causes Trends Perspectives Women Men

23. Trends in Cancer Incidence, U.S., 1975-2005 Age-adjusted rate/100,000 Year SEER, 2008 Causes Trends Perspectives Prostate All other sites

24. Trends in Cancer Incidence, U.S., 1975-2005 Percentage of 1975 rate Year SEER, 2008 ? Causes Trends Perspectives All other sites Prostate

25. Trends in Cancer Incidence, U.S., 1975-2005 Percentage of 1975 rate Year SEER, 2008 PSA screening Causes Trends Perspectives All other sites Prostate

26. Trends in Cancer Incidence, U.S., 1975-2005 Age-adjusted rate/100,000 Year SEER, 2008 Causes Trends Perspectives All other sites Breast

27. Trends in Cancer Incidence, U.S., 1975-2005 Percentage of 1975 rate Year SEER, 2008 ? Causes Trends Perspectives All other sites Breast

28. Trends in Cancer Incidence, U.S., 1975-2005 Percentage of 1975 rate Year SEER, 2008 Mammography Causes Trends Perspectives All other sites Breast

29. Lead Time and Cancer Screening Expected: 1000100010001000100010001000 Year: 1 2 3 4 5 6 7. Causes Trends Perspectives

30. Lead Time and Cancer Screening Expected: 100010001000 700 700 700 700 Year: 1 2 3 4 5 6 7. Screen Detected: 0 300 300 300 300 300 300 Causes Trends Perspectives

31. Lead Time and Cancer Screening Expected: 100010001000 700 700 700 700 Screen Detected: 0 300 300 300 300 300 300 Total Reported:1000130013001000100010001000 Year: 1 2 3 4 5 6 7. Causes Trends Perspectives

32. 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

33. 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

34. Trends in 5-Year Cancer Survival, U.S., Year of Dx (1973-2000) Percent Surviving Year SEER, 2008 Causes Trends Perspectives

35. Lead Time and Cancer Screening 051015 No cancer Pre-clinicalClinical DiagnosedDied 5-years Survival Causes Trends Perspectives

36. 051015 No cancer Pre-clinicalClinical 5-years DiagnosedDied Survival 051015 9-years? DiagnosedDied Lead Time and Cancer Screening Causes Trends Perspectives

37. 051015 No cancer Pre-clinicalClinical 5-years 051020 DiagnosedDied Diagnosed Died Survival 14-years? 15 051015 9-years? DiagnosedDied Lead Time and Cancer Screening Causes Trends Perspectives

38. 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

39. 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

41. Trends in Cancer Mortality in the U.S., 1950-2000 Age-adjusted rate/100,000 Year Health U.S., 2006

42. Trends in Cancer Mortality in the U.S., 1950-2000 Age-adjusted rate/100,000 Year Health U.S., 2006 Bailar 1986

43. 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

44. 1997;336(22):1569-74

45. Trends in Cancer Mortality in the U.S., 1950-2000 Age-adjusted rate/100,000 Year Health U.S., 2006 Bailar 1986

46. Trends in Cancer Mortality in the U.S., 1950-2000 Age-adjusted rate/100,000 Year Health U.S., 2006 Bailar 1986 Bailar 1997

47. 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

48. Trends in Cancer Mortality in the U.S., 1950-2000 Age-adjusted rate/100,000 Year Health U.S., 2006 Bailar 1986 Bailar 1997

49. Trends in Cancer Mortality in the U.S., 1950-2000 Age-adjusted rate/100,000 Year Health U.S., 2006 Bailar 1986 Bailar 1997

51. Cancer Death Rates, for Men, US,1930-2005 Lung & bronchus Colon & rectum Stomach Rate Per 100,000 Prostate Pancreas LiverLeukemia

52. Lung & bronchus Colon & rectum Uterus Stomach Breast Ovary Pancreas Rate Per 100,000 Cancer Death Rates, for Women, US,1930-2005

53. Trends in Cancer Mortality, By Race, U.S., 1975-2005 Age-adjusted rate/100,000 Year CDC, 2008 Causes Trends Perspectives Black Men Black Women White Women White Men

54. Trends in Cancer Mortality, RR Black:White, U.S., 1975-2005 Relative Risk Year CDC, 2008 Causes Trends Perspectives Men Both Women

55. Trends in Cancer Deaths, U.S., 1979-2005 Rate/100,000 Year CDC, 2008 Causes Trends Perspectives

56. Trends in Cancer Deaths, U.S., 1979-2005 Percentage of 1979 rate Year CDC, 2008 Causes Trends Perspectives

57. 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

58. 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

59. 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

60. 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

61. 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

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

63. 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

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

65. Trends in Cancer Mortality in the U.S., 1950-2000 Age-adjusted rate/100,000 Year Health U.S., 2006

66. Trends in Cancer Mortality in the U.S., 1950-2000 Age-adjusted rate/100,000 Year Health U.S., 2006

67. Trends in Mortality in the U.S., 1980-2005 Age-adjusted rate/100,000 Year CDC WONDER, 2008

68. 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. 2004 Mortality Data: US Mortality Public Use Data Tape, 2004, NCHS, Centers for Disease Control and Prevention, 2006 Heart Diseases Cerebrovascular Diseases Pneumonia/ Influenza Cancer 1950 2004 Rate Per 100,000

69. Cancer Heart disease Trends in Age-Adjusted Death Rates, 1980-2005 and Projected from 2006-2010. Chairez E, Jones N, and Remington P (submitted for publication)

76. 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 20002010 2020 Number of States The year cancer becomes the leading cause of death in the 50 states. IA FL IL AZ KY OKMS 1 2 3 4 5 6 20052015

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

78. Trends in Breast Cancer Mortality by Race, U.S., 1980-2005 Age-adjusted rate/100,000 Year CDC WONDER, 2008

79. Trends in Breast Cancer Mortality by Race, U.S., 1980-2005 Age-adjusted rate/100,000 Year CDC WONDER, 2008

80. Year CDC Wonder, 2008 Trends in Colorectal Cancer Deaths, U.S., 1980-2005 Age-adjusted rate/100,000

81. Year CDC Wonder, 2008 Trends in Colorectal Cancer Deaths, U.S., 1980-2005 Age-adjusted rate/100,000

82. 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

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

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

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

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

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

88. Trends in Percent of Adults who Smoke, 1965-2020 Percent smokers Year U.S.

89. Trends in Percent of Adults who Smoke, 1965-2020 Percent smokers Year U.S.Iowa

90. Trends in Percent of Adults who Smoke, 1965-2020 Percent smokers Year 2010 Goal (12%) Iowa

91. Trends in Percent of Adults who Smoke, 1965-2020 Percent smokers Year 2010 Goal (12%) 2020? (8%) Iowa

92. Trends in Percent of Adults who Smoke, 1965-2020 Percent smokers Year 38%26%23%11%Iowa

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

94. 40 Developmental Assets INTERNAL Homework Integrity Resistance skills Self-esteem EXTERNAL Family support Service to others High expectations Youth programs

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

96. 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

97. Health Risk Factors Cancer Death Less education? Cancer Control Continuum

98. Health Risk Factors Cancer Death Peer pressure? Cancer Control Continuum

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

100. Health Risk Factors Cancer Death Developmental assets? Cancer Control Continuum

101. 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