university of wisconsin school of medicine and public health progress in cancer control: maximizing...

University of WisconsinSchool of Medicine and Public Health

Progress in Cancer Control: Maximizing Collaboration,

Minimizing Disparities

Patrick Remington, MD, MPHDepartment of Population Health Sciences

2008 Iowa Cancer Summit Des Moines, Iowa

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

CausesCauses TrendsTrends PerspectivesPerspectives

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

CausesCauses Trends Trends Perspectives Perspectives

Causes of Cancer Death, 2008

29%

9%

7%5%

50% LungColonBreastProstateAll other


Source: ACS, Cancer Facts and Figures 2008

Health

Risk Factors

Cancer

Death

Cancer Continuum

Treatment

Screening


Health

Risk Factors

Cancer

Death

Cancer Continuum

Tobacco

Diet, exercise


Health

Risk Factors

Cancer

Death

Cancer Continuum

Cigarette advertising

Poverty


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?


Preventable Causes of Cancer

Lung

Cancer

Colon

Cancer

Breast

Cancer

Prostate

Cancer

Other

Cancer

Tobacco use X X

Alcohol use X X

Diet X X X X

Inactivity X X X X

Obesity X X X

Microbes/toxins X

Other factors X X


Causes of Lung Cancer

88%

10% 2%

Tobacco

Radon

ETS


Causes of Colon Cancer

20%

30%30%

20%High fat diet

Low vegetabledietPhysicalinactivityUnknown


Causes of Breast Cancer

12%

7%

5%2%

74%

Obesity

Late birth

No children

Radiation

Unknown


Causes of Prostate Cancer

20%

5%

75%

Diet?

Occupationalexposures

Unknown


Preventable Causes of Cancer

Lung

Cancer

Colon

Cancer

Breast

Cancer

Prostate

Cancer

Other

Cancer

Tobacco use X X

Alcohol use X X

Diet X X X X

Inactivity X X X X

Obesity X X X

Microbes/toxins X

Other factors X X


“Preventable” Causes Cancer

29%

35%

9%

3%

7%

7%

10%

Tobacco

Diet

Microbes

Toxins

STDs

Alcohol

Other


Post-test: What are the leading causes of cancer death in the US?

Answer: Tobacco use and poor diet


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

CausesCauses TrendsTrends Perspectives Perspectives

Measuring Progress inCancer Control

• Direct measures– incidence– survival– mortality

• Risk factors

• Advances in knowledge

National Cancer Institute. JNCI 1990;82:825-35


Trends in Cancer Incidence,U.S., 1975-2005

370

390

410

430

450

470

490

510

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

Age-adjusted rate/100,000

Year SEER, 2008


Questions• What is responsible for the increase during

the 1980s?

• What is responsible for the sharp decrease in the 1990s?



300

400

500

600

700

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005


Year SEER, 2008


Women

Men


050

100150200250300350400450500

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005


Year SEER, 2008


Prostate

All other sites


0%

50%

100%

150%

200%

250%

300%

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

Percentage of 1975 rate

Year SEER, 2008

?


All other sites

Prostate


0%

50%

100%

150%

200%

250%

300%

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005


Year SEER, 2008

PSA screening


All other sites

Prostate


0

50

100

150

200

250

300

350

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005


Year SEER, 2008


All other sites

Breast


90%

100%

110%

120%

130%

140%

150%

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005


Year SEER, 2008

?


All other sites

Breast


90%

100%

110%

120%

130%

140%

150%

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005


Year SEER, 2008

Mammography


All other sites

Breast

Lead Time and Cancer Screening

Expected: 1000 1000 1000 1000 1000 1000 1000

Year: 1 2 3 4 5 6 7 .



Expected: 1000 1000 1000 700 700 700 700

Year: 1 2 3 4 5 6 7 .

Screen Detected: 0 300 300 300 300 300 300



Expected: 1000 1000 1000 700 700 700 700

Screen Detected: 0 300 300 300 300 300 300

TotalReported: 1000 1300 1300 1000 1000 1000 1000

Year: 1 2 3 4 5 6 7 .


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


B. Cancer Survival• What are the trends in cancer survival?

• Data available– SEER– State cancer registries

• Based on follow-up in registries


Trends in 5-Year Cancer Survival,U.S., Year of Dx (1973-2000)

40

45

50

55

60

65

70

1973

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

Percent Surviving

Year SEER, 2008



0 5 10 15

No cancer Pre-clinical ClinicalDiagnosed Died

5-years

Survival


0 5 10 15

No cancer Pre-clinical Clinical5-years

Diagnosed DiedSurvival

0 5 10 159-years?

Diagnosed Died



0 5 10 15

No cancer Pre-clinical Clinical5-years

0 5 10 20

Diagnosed Died

Diagnosed Died

Survival

14-years?15

0 5 10 159-years?

Diagnosed Died



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


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


Trends in Cancer Mortality in the U.S., 1950-2000

185

190

195

200

205

210

215

220

225

1950 1960 1970 1980 1990 2000


YearHealth U.S., 2006


185

190

195

200

205

210

215

220

225

1950 1960 1970 1980 1990 2000



Bailar 1986

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

1997;336(22):1569-74


185

190

195

200

205

210

215

220

225

1950 1960 1970 1980 1990 2000



Bailar 1986


185

190

195

200

205

210

215

220

225

1950 1960 1970 1980 1990 2000



Bailar 1986

Bailar 1997

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


185

190

195

200

205

210

215

220

225

1950 1960 1970 1980 1990 2000



Bailar 1986

Bailar 1997

Cancer Death Rates, for Men, US,1930-2005

0

20

40

60

80

100

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

Lung & bronchus

Colon & rectum

Stomach

Rate Per 100,000

Prostate

Pancreas

LiverLeukemia

0

20

40

60

80

100

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

Lung & bronchus

Colon & rectum

Uterus

Stomach

Breast

Ovary

Pancreas

Rate Per 100,000

Cancer Death Rates, for Women, US,1930-2005

Trends in Cancer Mortality,By Race, U.S., 1975-2005

050

100150200250300350400450

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005


Year CDC, 2008


Black Men

Black Women

White Women

White Men

Trends in Cancer Mortality,RR Black:White, U.S., 1975-2005

1

1.1

1.2

1.3

1.4

1.5

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

Relative Risk

Year CDC, 2008


Men

Both

Women

Trends in Cancer Deaths,U.S., 1979-2005

0

500

1,000

1,500

2,000

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

85+75-8465-7455-6445-5435-44

Rate/100,000

Year CDC, 2008


Trends in Cancer Deaths,U.S., 1979-2005

60%

70%

80%

90%

100%

110%

120%

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

85+75-8465-7455-6445-5435-44


Year CDC, 2008


Change in the Number of Cancer DeathsU.S., 1990 to 2000


-10000

0

10000

20000

30000

40000

50000

60000

70000

Total Sex Age

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

Change in the Number of Cancer DeathsSelected Sites, U.S., 1990 to 2000


-10000

-5000

0

5000

10000

15000

20000

25000

Lu

ng

(Mal

e)

Pro

stat

e

Bre

ast

Col

orec

tal

Sto

mac

h

Cer

vica

l

Mel

anom

a

NH

L

Liv

er

Lu

ng

(Fem

ale)

89 % of total fewer deaths

Andersen et al, 2002

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


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


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: ?


Post-test: What are the trends in cancer in the United States?

d. All of the above


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


Perspective #1• The progress in cancer control is minimal

compared to other diseases



185

190

195

200

205

210

215

220

225

1950 1960 1970 1980 1990 2000




0

50

100

150

200

1950 1960 1970 1980 1990 2000



Trends in Mortality in the U.S., 1980-2005

0

50

100

150

200

250

300

350

400

1980 1985 1990 1995 2000 2005

HeartCancerStroke


YearCDC WONDER, 2008

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

19.8

180.7

48.1

586.8

193.9

50.0

185.8217.0

0

100

200

300

400

500

600

HeartDiseases

CerebrovascularDiseases

Pneumonia/Influenza

Cancer

1950

2004

Rate Per 100,000

050

100150

200250

300350

400450

1980

1985

1990

1995

2000

2005

2010

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)

0

10

20

30

40

50

1980

1985

1990

1995

2000

2005

2010

Cancer

Heart disease

35-44 years

0

50

100

150

200

1980

1985

1990

1995

2000

2005

2010

Cancer

Heart disease

45-54 years

0100200300400500600

1980

1985

1990

1995

2000

2005

2010

Cancer

Heart disease

55-64 years

0200400600800

100012001400

1980

1985

1990

1995

2000

2005

2010

Cancer

Heart disease

65-74 years

0500

100015002000250030003500

1980

1985

1990

1995

2000

2005

2010

Cancer

Heart disease

75-84 years

0

2000

4000

6000

8000

1980

1985

1990

1995

2000

2005

2010

Cancer

Heart disease

85+ years

MN OR

CO HI

AK

MT

CT

NH VT

SD

KS

NMNE ND

WA

MA

MO

TN

UTOH

WVPAIN

NC

SC

ID

ME

VA

WI NY

LA

MDTX

AR

DE

GA

MI

CA

NJ ALRIWYNV

2000 2010 2020

Number of States

The year cancer becomes the leading cause of death in the 50 states.

IA

FL

IL

AZ

KY

OK MS

1

2

3

4

5

6

2005 2015

Perspective #2• Cancer trends are not the same in all

groups in the population


Trends in Breast Cancer Mortality by Race, U.S., 1980-2005

15

20

25

30

35

40

1980 1985 1990 1995 2000 2005

White



Trends in Breast Cancer Mortality by Race, U.S., 1980-2005

15

20

25

30

35

40

1980 1985 1990 1995 2000 2005

WhiteBlack



10

15

20

25

30

35

1980 1985 1990 1995 2000 2005

White

Year CDC Wonder, 2008

Trends in Colorectal Cancer Deaths,U.S., 1980-2005


10

15

20

25

30

35

1980 1985 1990 1995 2000 2005

BlackWhite

Year CDC Wonder, 2008

Trends in Colorectal Cancer Deaths,U.S., 1980-2005


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


Trends in Smoking by EducationU.S., 1966-2006

0

10

20

30

40

50

1966 1974 1985 1995 2006

< HSHigh schoolSome collegeCollege degree

Percent

Year

Health U.S., 1998 (1966 from SGR 1989), MMWR 56(44), 2006

Trends in Percent of Adults who Smoke, 1965-2020

05

101520253035404550

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020

Percentsmokers

Year

U.S.


05

101520253035404550

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020

Percentsmokers

Year

U.S.

Iowa


05

101520253035404550

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020

Percentsmokers

Year

2010Goal (12%)

Iowa


05

101520253035404550

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020

Percentsmokers

Year

2010Goal (12%) 2020?

(8%)Iowa


05

101520253035404550

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020

Percentsmokers

Year

38%

26% 23%

11%Iowa

05

101520253035404550

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020

Percentsmokers

Year

<HS

HS SomeCollege

CollegeGradIowa

Iowa Smoking Rates by Education

40 Developmental Assets

INTERNAL

• Homework

• Integrity

• Resistance skills

• Self-esteem

EXTERNAL

• Family support

• Service to others

• High expectations

• Youth programs

Percent cigarette smokers, Jefferson County, 1997

0

10

20

30

40

50

60

70

1-10 11-20 21-30 31-40

Number of Developmental ‘Assets’

Percent

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?


Health

Risk Factors

Cancer

Death

Less education?

Cancer Control Continuum

Health

Risk Factors

Cancer

Death

Peer pressure?


Health

Risk Factors

Cancer

Death

Low self esteem?


Health

Risk Factors

Cancer

Death

Developmental assets?


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


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