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Cancer Prevention in the United States
Workshop on Non-Communicable Diseases
May 5, 2012
Jo Ivey Boufford, M. D.
Communicable, maternal, perinatal and nutritional conditions NCDs Injuries
Males
0
2M
4M
6M
8M
AFR AMR EMR EUR SEAR WPR AFR AMR EMR EUR SEAR WPR
Females
Mill
ion
s o
f d
eath
s (i
n 2
00
8)
Global burden of NCDs: 36 million deaths
Premature NCD deaths before the age of 60 (2008 estimates)
0 M
5 M
10 M
15 M
20 M
25 M
30 M
35 M
Low-income
Countries
Lower-
Middle-income
Countries
Upper-
Middle-income
Countries
High-income
Countries
Communicable conditions NCDs < 60 Injuries NCDs > 60
NCD Risk Factors
Dahlgren G, Whitehead M. 1991. Policies and Strategies to Promote Social Equity in Health. Stockholm, Sweden: Institute for
Futures Studies.
Context: How Health Improvement is Produced
5
The Public Health System
Community Health care
delivery system
Employers &
Business
Governmental Public
Health Infrastructure
Academics The Media
Assuring the Conditions
for Population Health
INSTITUTE OF MEDICINE
Millennium Development Goals
Goal 1: Eradicate extreme poverty and hunger
Goal 2: Achieve universal primary education
Goal 3: Promote gender equality and empower women
Goal 4: Reduce child mortality
Goal 5: Improve maternal health
Goal 6: Combat HIV/AIDS, malaria and other diseases
Goal 7: Ensure environmental sustainability
Goal 8: Develop a Global Partnership for Development
What about NCDs?
Behavioral
Factors
50%
Inadequate
Access to
Medical Care
10%
Genetic Factors
20%
Environmental
Factors
20%
Causes of Premature Mortality
The Core Function Project: U.S. Public Health Service, 1993
Public Health as Percentage of Health Expenditures
(Institute of Medicine)
Public Health Expenditures
3%
Total Health Expenditures
97%
Prevention for a Healthier America:
Financial Return on Investment?
INVESTMENT: $10 per person per year
HEATH CARE
COST NET
SAVINGS:
$16 Billion annually
within 5 years
RETURN ON
INVESTMENT
(ROI):
$5.60 for every $1
With a Strategic Investment in Proven Community-Based Prevention Programs to Increase Physical Activity and Good Nutrition and Prevent Smoking and Other Tobacco Use
Cancer in the United States
• 1.5 million cases diagnosed each year
• Second leading cause of death behind CVD
Age-adjusted death rate by race/ethnicity per 100,000
for all types of cancer, combined (2007):
African Americans 216
Whites 177
American Indians/Alaska Natives 119
Hispanics 117
Asians/Pacific Islanders 108
Tobacco use and cancer risk
• There is solid evidence that smoking causes cancers of the long, oral cavity, pharynx, larynx, esophagus, bladder, kidney, pancreas, stomach, uterine cervix, and acute myeloid leukemia.
• Cigarette smoking causes an estimated 30% of all cancer deaths in the United States
Benefits of smoking cessation compared to continuing smokers
• Cessation by age 50 reduces the risk of dying within 15 years by up to 50%
• The risk of lung cancer is 30-50% lower after 10 years of abstinence
• Risk of oral and esophageal cancer is reduced by 50% within 5 years of cessation
Systematic reviews of epidemiologic evidence
Obesity and Cancer Risk
• Obesity is convincingly linked to postmenopausal
breast cancer, cancers of the esophagus, pancreas, colorectum, endometrium, and kidney
• Body fat is a probable risk factor for gallbladder cancer
• Weight loss has yet to be shown to reduce the risk of obesity-associated malignancies
Alcohol and Cancer Risk
• There is convincing evidence that drinking alcohol increases the risk of cancers of the mouth, esophagus, breast, and colorectum
• There is probable evidence that drinking alcohol increases the risk of liver cancer and, in women, colorectal cancer
• Daily consumption of around 50g of alcohol doubles or triples the risk for mouth, larynx, throat cancer compared to nondrinkers
Diet and Cancer Risk
• Both fruits and non-starchy vegetables are associated with probable decreased risk for cancers of the mouth, esophagus, and stomach
• Fruits but not not-starchy vegetables are associated with probable decreased risk of lung cancer
• Vitamin and dietary supplement use have no proven benefit
Physical Activity and Cancer Risk
• There is convincing evidence that increased physical activity protects against colorectal cancer
• There is probable evidence that physical activity is associated with lower risk of postmenopausal breast cancer and endometrial cancer
Patient Protection and Affordable Care Act
Enacted into law on March 23, 2010
ACA - Clinical Preventive Services include:
•Expanded support for primary care, including immunizations and screening
•Full coverage for age-appropriate preventive services
•Free annual wellness visits for Medicare beneficiaries
ACA and Community Based Prevention
• Community Transformation Grants and Place Based Initiatives across government
• Prevention and Public Health Trust
• Restaurant Menu Calorie Labelling
• National Prevention, Health Promotion and Public Health Council
• National Prevention Strategy
• National Health Disparities Strategy
New York City
• Population: 8.4 million
• Size: 305 square miles (790 km2)
• Diversity
– 800 languages
– 46% speak a language other than English at home
• Disparities
Leading Causes of Death New York City, 2009
Source: NYC DOHMH Bureau of Vital Statistics 2009
Implementing Take Care New York 2012
New York City aims to: 1. Promote Quality Health Care for All 2. Be Tobacco Free 3. Promote Physical Activity and Healthy Eating 4. Be Heart Healthy 5. Stop the Spread of HIV and Other Sexually Transmitted
Infections 6. Recognize and Treat Depression 7. Reduce Risky Alcohol Use and Drug Dependence 8. Prevent and Detect Cancer 9. Raise Healthy Children 10. Make All Neighborhoods Healthy Places
Take Care New York 2012 Objective 8: Prevent and detect cancer
Smoking Mass Media Campaign: Suffering Every Minute
• Shows how smoking can cause long-term suffering
• Focuses on emphysema and stroke, which can require family members to care for loved ones
Pe
rce
nt
of
adu
lts
NYC and NYS tax increases
Smoke-free workplaces
Free patch programs start
3-yr average 3-yr average 3-yr average
Hard-hitting media campaigns
NYS tax increase
Federal tax increase
NYS tax increase
Source: New York City Community Health Survey
Effect of Environmental Approaches to Smoking Prevention
NYC, 2002-2010
New York City Health Department Campaign Against Trans Fat
• Regulations since 2006 to eliminate artificial trans fat from all restaurants
• Legal requirement to post calorie counts on menus and menu boards
NYC Green Carts: Promoting Access to Fresh Fruits and Vegetables
Media Messages About Sugary Drinks
Decline in Sugary Drink Consumption in NYC 2005-2009
*Youth Risk Behavior Survey data refers to soda only **Take Care New York baseline ***Includes adults who can be reached by cell phone Sources: NYC Community Health Survey 2002-2009. NYC Youth Risk Behavior Survey 2005, 2007, 2009.
Community Health Survey
Promoting Physical Activity
Improving Air Quality in Times Square
SOCIETY AND
INSTITUTIONS
COMMUNITY
INDIVIDUALS ILLNESS
TARGET OF
INTERVENTION
TYPE OF INTERVENTION
Hospital
Care
Intersectoral Working: Jobs/Housing/
Education
Public Advocacy Health
Promotion/
Prevention
HEALTH
Primary
Care