1.  The 2002 Healthcare Conference Surviving or Thriving ? 29 September-1 October 2002 Scarman House, The University of Warwick, Coventry

2. Session A1 : Trends in CI - Cancer nTrends in incidence and mortality rates nWorking Party / Research Sub-party Progress Report nNeil Robjohns & Richard Morris

3. Critical Illness Trends Research Group Our Aims : n To examine underlying trends in the factors influencing UK Insured Critical Illness claim rates, and from these, to assess : nThe historic trend in incidence and death rates for the major CI’s nAny pointers for future trends in Standalone CI, Mortality and hence Accelerated CI. n Formed in March 2001

4. Cancer Sub-Group Members n Actuaries Azim Dinani Richard Morris Neil Robjohns n Medical Experts Professor Rubens - Consultant Oncologist

5. Cancer Trends n England & Wales population trends - recap n Variation by deprivation category n International comparisons n Incidence versus mortality n Lung cancer / modelling impact of smoking n Future trends

6. Cancer Incidence and Mortality Rates, 1971 - 97 All Ages

7. Cancer Incidence and Mortality Rates, 1971 - 97 "Key Insurance Ages"

8. Possible Reasons Behind Observed Trends n Issues with Data Recording n Cancer Screening Initiatives n Behavioural changes n Treatment nof Cancer nof other illnesses n Awareness n Other ?

9. Breast Cancer Changes in Incidence Rates, by age band, over 1971 - 97

10. Prostate Cancer Changes in Incidence Rates, by age band, over 1971 - 97

11. Lung Cancer Changes in Incidence Rates, by age band, over 1971 - 97

12. Malignant Melanoma Changes in Incidence Rates for Males, by age band, over 1971 - 97

13. Breast Cancer Changes in Mortality Rates, by age band, over 1971 - 97

14. Stomach Cancer Changes in Incidence Rates for Males, by age band, over 1971 - 97

15. Testicular Cancer Changes in Incidence Rates, by age band, over 1971 - 97

16. Cancer Incidence Rates by Site of Cancer Females, 1997

17. Cancer Incidence Rates by Site of Cancer Males, 1997

18. Summary of Trends in Cancer Incidence and Mortality Average Change % pa, for Females, aged 40 - 59, over 1971 - 97 Size of Balls Indicates Relative Importance of Cancer Site, measured by Incidence Rates in 1997.

19. Summary of Trends in Cancer Incidence and Mortality Average Change % pa, for Males, aged 40 - 59, over 1971 - 97 Size of Balls Indicates Relative Importance of Cancer Site, measured by Incidence Rates in 1997.

20. Some Thoughts Looking Forwards n Tentative Initial Views : n Cancer Mortality : n “Good News” ? n “Continuing Reductions, at least for ages below 65” ? n Cancer Incidence : n “Bad News” ? n “Underlying, steady increase, plus jumps up” ? !

21. Cancer Trends n England & Wales population trends - recap n Variation by deprivation category n International comparisons n Incidence versus mortality n Lung cancer / modelling impact of smoking n Future trends

22. Variation by deprivation category n Scottish data n Carstairs & Morris deprivation categories: nPostcode based n Categories 1-7 (1=“affluent”; 7=“deprived”) n Classes 1-3 = Insured class? n Key Sites (data limited)

23. Split of Scottish Population by Deprivation Category 1991 Data

24. Link with deprivation category Inception Rates Mortality Rates

25. Link with deprivation code: Lung Cancer n Mortality & Incidence: Positive correlation nLagged link to smoker prevalence n Causes? nSmoking nAir pollution? n Cohort effect (e.g. cigarette smoking) n Temporal effect (e.g. air pollution, cigarette composition (tar content), new treatment) n Sharp fall in mortality over next 5-10 years?

26. Smoker Prevalence 1974-1998: Females England & Wales: General Household Survey 2000

27. Smoker Prevalence 1974-1998: Males England & Wales: General Household Survey 2000

28. Annualised change in inception rate: 1982-2000: Lung Cancer - Males Ages:40-59

29. Annualised change in inception rate: 1982-2000: Lung Cancer - Females Ages:40-59

30. Scottish Population Data : Trends by Deprivation Category, 1982-2000 Rates per 10,000

31. Scottish Population Data : Trends by Deprivation Category, 1982-2000 Index (1982 = 100)

32. Scottish Population Data : Trends by Deprivation Category, 1982-2000 Rates per 10,000

33. Scottish Population Data : Trends by Deprivation Category, 1982-2000 Index (1982 = 100)

34. Link with deprivation code: Breast Cancer n Incidence: negative correlation nScreening related difference? n Social / environmental differences n Reproductive history n Mortality: link inconclusive n Differences in treatment? n Differences in stage of presentation?

35. Scottish Population Data : Trends by Deprivation Category, 1982-2000 Rates per 10,000

37. Scottish Population Data : Trends by Deprivation Category, 1982-2000 Index (1982 = 100)

38. Scottish Population Data : Trends by Deprivation Category, 1982-2000 Rates per 10,000

39. Scottish Population Data : Trends by Deprivation Category, 1982-2000 Index (1982 = 100)

40. Link with deprivation code: Prostate Cancer n Incidence & mortality: negative correlation nScreening related? nHormonal factors? nDiet?

41. Annualised change in inception rate: 1982-2000: Prostate Cancer - Males Ages:40-59

42. Scottish Population Data : Trends by Deprivation Category, 1982-2000 Rates per 10,000

43. Scottish Population Data : Trends by Deprivation Category, 1982-2000 Index (1982 = 100)

44. Link with deprivation code: Cervical Cancer n Incidence & mortality: Positive correlation n Causes? n Sexual activity n Smoking n Parity

45. Scottish Population Data : Trends by Deprivation Category, 1982-2000 Rates per 10,000

46. Scottish Population Data : Trends by Deprivation Category, 1982-2000 Index (1982 = 100)

47. Link with deprivation code: Colo-rectal Cancer n Incidence & mortality: No clear link n Causes? n High-fat diet n Low physical activity n Reproductive history

48. Cancer by Deprivation Code: Trends n Lung cancer nSmoker-related trend to emerge? n Breast cancer n No identifiable difference in trend n Prostate cancer n Reflection of trend in screening? n Cervical cancer n No identifiable difference in trend n Colo-rectal cancer n Inconclusive link to deprivation code

49. Cancer Trends n England & Wales population trends - recap n Variation by deprivation category n International comparisons n Incidence versus mortality n Lung cancer / modelling impact of smoking n Future trends

50. International Comparisons All Cancers ; All Ages

51. International Comparisons All Cancers ; Ages 40 - 59

52. International Comparisons Lung Cancer ; Ages 40 - 59

53. International Comparisons Prostate Cancer ; All Ages

54. Prostate Cancer “Screening”

55. International Comparisons Breast Cancer ; All Ages

56. International Comparisons Malignant Melanoma ; All Ages

57. Cancer Trends n England & Wales population trends - recap n Variation by deprivation category n International comparisons n Incidence versus mortality n Lung cancer / modelling impact of smoking n Future trends

58. Ratio of Mortality Rate to Incidence Rate Males ; England & Wales ; 1998

59. Ratio of Mortality Rate to Incidence Rate Females ; England & Wales ; 1998

60. Ratio of Mortality Rate to Incidence Rate Males ; Ages 40 - 59 ; 1998

61. Ratio of Mortality Rate to Incidence Rate Females ; Ages 40 - 59 ; 1998

62. Cancer Trends n England & Wales population trends - recap n Variation by deprivation category n International comparisons n Incidence versus mortality n Lung cancer / modelling impact of smoking n Future trends

63. Observed Lung Cancer Incidence and Mortality Rates England & Wales

64. Trend in Smoker Proportions in England And Wales All Adult Ages

65. Trend in Smoker Proportions in England And Wales By Age Group

66. Modelling the Impact of Smoking n Build model to simulate population distribution by smoking habit, over time n Use Doll & Peto style formula n Adjust parameters to seek a good fit against observed lung cancer rates over time nFor Males, England & Wales, 1974 - 1998 n Then project forward by making assumptions on trend in smoking habits

67. Modelling the Impact of Smoking n Doll & Peto n Studied mortality / morbidity effects of cigarette smoking by following a cohort of British Doctors n Modelled relationship between lung cancer incidence and level and duration of smoking habit n 1951 – 1971 n Rate = 0.273 * 10 –12 (dose + 6) 2 * (age – 22.5) 4.5

68. Fit of Model against Actual

69. Fit of Actual Rates against Model

71. Model Projection to 2010 Assuming current rates of change in smoker status remain constant

72. The next challenge !!

73. Cancer Trends n England & Wales population trends - recap n Variation by deprivation category n International comparisons n Incidence versus mortality n Lung cancer / modelling impact of smoking n Future trends

74. Future Cancer Trends Impact of Medical Advances : n Prevention nReduce Smoking ; Dietary Advice ; Protect from UV light nOverall, effect positive but likely to be relatively small n Detection nRapid advance in screening / tests nQuestionable value for widespread screening nBut tests likely to be commercially available nPotential for significant step-increases in “incidence” n Treatment nExpect reductions in morbidity, plus slow gains on mortality

75. Session A1 : Trends in CI - Cancer nTrends in incidence and mortality rates nWorking Party / Research Sub-party Progress Report nNeil Robjohns & Richard Morris