1. Cancer Affecting Puerto Rico Norman Maldonado MD April 2015

2. Conflict of Interest Statement No Conflict of Interest

3. Objectives Present the most common cancers affecting our population Present the incidence and epidemiology of these conditions Present the mortality of these conditions Emphasize the prevention strategies Treatment options for these diseases.

4. Population Aging continues (median age in years)

5. Vital Statistics (Thousands)

6. Incidence of Diseases Coronary Disease 8.2% Hypertension 34% (15 th ) Diabetes 12.8% (2 nd ) Obesity 34.4% (29 th ) Metabolic Syndrome 43.3% Asthma 7.5% Stroke 2.0% Cancer

7. Causes of Death 2000-2008 2008 2000 Total causes adjusted 694.0 850.5 Heart 126.4 189.2 Cancer 117.7 138.9 Diabetes 67.0 69.7 Alzheimer 38.0 23.7 Cerebrovascular 36.4 49.9 Respiratory 28.7 35.9. Accidents, renal, pneumonia, sepsis

8. Cancer Breast Cancer Prostate Cancer Colon and Rectum Cancer Lung Cancer Pancreatic Cancer and Biliary System Thyroid Cancer Lymphoma Head and Neck Cancer

9. Burden of Cancer in Puerto Rico 2000-2004 Cancer 2 nd leading cause of death Accounts for approximately 25% of all deaths In 2004, an estimated 11,211 new cancer cases were diagnosed In 2004, an estimated 4,826 died from cancer

10. Top Ten Incidence Cancer Sites In Puerto Rico, 2007-2008 Prostate37.7 Colon and Rectum13.9 Lung and Bronchus 6.2 Oral Cavity and Pharynx 4.3 Urinary Bladder 4.2 Non-Hodgkin Lymphoma 3.4 Liver and Intrahepatic Bile 3.1 Stomach 2.9 Kidney and Renal Pelvis 2.1 Larynx 2.0 Other Locations20.2 Breast33.2 Colon and Rectum12.5 Thyroid8.1 Corpus and Uterus7.0 Lung and Bronchus3.8 Cervix Uteri3.5 Non-Hodgkin Lymphoma3.4 Ovary2.4 Stomach2.2 Leukemia 1.8 Other Locations23.9 Males (N=13,344) Females (N=12,555)% % *Cases with age unknown were included/ Statistics were generated from malignant cases only/ Statistics are an average of the years 2007-2008 Rates are per 100,000 and age-adjusted to the 2000 PR population Data Source: Puerto Rico Central Cancer Registry, Preliminary Puerto Rico Cancer Incidence File (December, 2011)

11. Top Ten Mortality Cancer Sites in Puerto Rico, 2007-2008 Males (N=5,653) Females (N=4,319) % % *Cases with age unknown were included/ Statistics were generated from malignant cases only/ Statistics are an average of the years 2007-2008 Rates are per 100,000 and age-adjusted to the 2000 PR population Data Source: Puerto Rico Department of Health and National Center for Health Statistics using the Medical Mortality Data System (MMDS) for the years 2000-2008. Prostate18.4% Lung and Bronchus13.2% Colon and Rectum12.8% Liver and Intrahepatic Bile Duct6.4% Stomach4.8% Oral Cavity and Pharynx3.8% Pancreas3.7% Esophagus3.6% Lymphoma3.6% Leukemia3.3% Other Locations26.5% Breast19.3% Colon and Rectum12.8% Lung and Bronchus10.2% Liver and Intrahepatic Bile Duct5.5% Pancreas5.3% Corpus and Uterus, NOS4.6% Ovary4.2% Lymphoma3.9% Stomach3.8% Leukemia3.5% Other Locations26.9%

12. Causes of Cancer Approximately 75% of cancer could be prevented by eliminating Smoking (60%) Obesity (10%) Other dietary factors (10-30%) Infectious Agents(18%) Developed Countries (8%) Developing Countries (26%) Alcohol (1.4%) Sunlight (1.4%) Air pollution (1.4%) Occupation (1.4%) Physical activity (1.4%)

13. Cancer Prevention Prevention offers the most cost-effective long-term strategy for the control of cancer At least one-third of all cancer cases are preventable. –Reduction of tobacco use –Healthy Diet –Reduction obesity –Increase in physical activity –Control of cancer-related infectious agents: HPV HBV & HBC HIV H. Pylori

14. Cancer Prevention Past two decades, good progress in developing and using effective: –Cancer prevention strategies –Early detection interventions –Treatments Largely through public health efforts we have seen reduction in mortality from cancer: –Cervical –Breast –Colorectal cancer –Lung Cancer

15. Cancer Risk Factors in U.S. And Puerto Rico, BRFSS 2010 Risk FactorU.S. (Md %) Puerto Rico Diabetes8.7%12.8%* Overweigh/Obesity63.7%65.6% Physical Activity last month 76.1%57.7% $ Fruit & Vegetables 5+/day 23.4% (2009) 17.7% $ (2009) Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008. * Highest/ $ Lowest in the U.S.; @ 3 rd Lowest in the U.S.

16. Cancer Screening Behaviors in Puerto Rico, BRFSS 1996 & 2010 Screening Test Puerto Rico 1996 Puerto Rico 2010 Pap Smear70%75% Mammography 40+ years 50+ years 60% 61% 77% 80% Colonoscopy28% 1 43% FOBT12% 1 10% PSA65% 2 63% Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 1 1999; 2 2002

17. Ten Recommendations for Cancer Prevention: WCRF/AICR Second Expert Report 1.Be as lean as possible without becoming underweight 2.Be physically active for at least 30 minutes every day 3.Avoid sugary drinks/Limit consumption of energy-dense foods 4.Eat a variety of vegetables, fruits, whole grains and legumes such as beans 5.Limit consumption of red meats (such as beef, pork and lamb) and avoid processed meats

18. Ten Recommendations for Cancer Prevention: WCRF/AICR Second Expert Report 6.Limit alcoholic drinks to 2 for men and 1 for women a day 7.Limit consumption of salty foods and foods processed with salt (sodium). 8.Don't use supplements to protect against cancer 9.Best for mothers to breastfeed exclusively for up to 6 months and then add other liquids and foods. (*) 10.After treatment, cancer survivors should follow the recommendations for cancer prevention (*) *Special Population Recommendations And always remember – do not smoke or chew tobacco

19. HPV Vaccines Protect against HPV infection and HPV-related diseases. Gardasil® and Cervarix® have been shown to protect against most cervical cancers in women. HPV vaccines offer the greatest health benefits to individuals who receive all three doses before having any type of sexual activity. Recommended for preteen girls and boys aged 11 or 12 years. Initiation and completion of HPV vaccination is still low. P ARENTS, HEALTHCARE PROVIDERS AND IMMUNIZATION PARTNERS HAVE A ROLE IN PREVENTING HPV DISEASE

23. Prostate Cancer

24. Prostate Cancer Bone Scan

27. Treatment of Prostate Cancer Surgery Radiation, IMRT Cryotherapy and others Brachytherapy seed Androgen Deprivation therapy leuprolide, bicalutamide, abiraterone. Chemotherapy, Docetaxel+ Prednisone.Observation in low risk, elderly

28. Breast Cancer Examination Mammography, Sonomammography, MRI, PET Biopsy or FNA Markers ER, PR, HER 2 neu, Ki67. Chemistries, Bone Scan,CEA, CA15-3 others. Surgery or Neoadjuvant Chemotherapy. Oncotype. Adjuvant Chemotherapy. Radiotherapy. Hormonal Therapy

29. Breast Cancer

34. ER positive

36. HER-2 Positive

37. Herceptin

39. Colon Carcinoma Fecal Occult Blood Endoscopies and Biopsies CT Scans PET CT Liver function tests, CEA Surgery, staging, positive nodes Adjuvant Chemotherapy( FOLFOX) Chemotherapy- Metastatic Disease( FOLFIRI), bevacizumab, cetuximab

45. Lung Carcinoma Smoker or not Radiographic Studies CT, PETCT, Brain CT Diagnostic Studies Staging New Immunologic Markers EGFR, ALK Surgery Adjuvant Chemotherapy or Immunologic Radiotherapy

46. Lung Carcinoma

49. Lung Cancer and PET/CT scan

50. Non-Small Cell Lung Cancer AdenocarcinomaSquamous Cell Carcinoma

53. ALK-inhibitor

54. Pancreatic and Biliary Cancer Symptoms Radiological Studies CT, PET CT, ERCP Biopsies Markers CA 19-9, CEA Whipples, chledocoduodenostomy Trans hepatic stent o THC Chemotherapy or Palliation, Hospice Pain Management Anticoagulation

55. Thyroid Cancer Symptoms. Scintigrams or sonograms FNA, Function Pathology Bone Scan Surgery. Radioyodine131. New therapies

59. Papillary and Follicular Thyroid Cancer

60. Lymphoma

63. Therapy of Hodgkin's Disease Early Stage I & II Chemo+ Radiation Stage III & IV Chemotherapy ABVD BEACOPP Bone Marrow Transplant in Relapse Research Treatments Cure 80 to 90%

64. Non Hodgkin’s Lymphoma Staging, LDH, B2 microglobulin, Immune markers, CD20 PET CT Large Cell Therapy Rituximab CHOP 21 Indolent I &II Radiation Indolent III& IV R- CVP 21 Relapses,Other treatments

75. Gracias