Transcript stage 4 prostate cancer

Cancer: early detection or ‘Big C to little c’
Ian Cox
CMO Gen Re
© General Reinsurance AG
Brief
> Early Detection
> Diagnostic techniques and prevention – less invasive ways of diagnosing
Screening programmes & impact on claims
Geographical factors & impact. Environmental factors
> Claims have requested:
> Screening programmes: we are aware of breast, cervical, bowel, prostate, are there
others planned?
> How effective are the programmes (bearing in mind recent publicity re false
positives, and number of people receiving possibly unnecessary treatment) Does
more screening = more claims queries?
> What impact might the following factors have: age, family history, geography?
> UW have requested:
> Prostate cancers - They are aware of recent developments in treatment; including
genetic testing and hormone treatments that aren't covered by the manuals. An
update on these developments would be very useful as would help on establishing
stagings
> Family history - A family history of 2 or more family members with cancer is an area
not fully covered by the manuals. Instruction here would be useful as would details
of any familial links that we should know about.
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Cancer risk Scotland
> More than 1 in 3 people in Scotland will develop some form of
cancer during their lifetime
> Around 1 in 9 males and 1 in 7 females will develop some form of
cancer before the age of 65
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Cancer survival
Survival rates in UK are still lagging behind other countries
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Age-standardised five-year relative survival
trends, by cancer and by country
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Why is early diagnosis important?
> Principle that earlier diagnosis will mean:
• More diagnosed at earlier stage
• Easier to treat
• Surgery possible
• Less mortality
• Less morbidity
• Lower cost
• ‘Lives saved’
•
90% of cancers present with symptoms
•
Many at an advanced stage
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Cancer
type
Stage
%yrs
Survival
Colorectal
Stage A
93
Stage B
77
Stage C
47
Stage D
7
Stage I
90
Stage II
70
Stage III
50
Stage IV
13
Stage I
42
Stage II
23
Stage III
10
Stage IV
2
Breast
Lung
6
Stage at presentation/diagnosis 2009 East
England
Stage not
known
Cancer site
Stage 1
Stage 2
Stage 3
Stage 4
Oesophagus
5.5
10.9
18.5
26.6
38.5
Colon
13.8
30.7
25.5
18.4
11.7
Lung
11.1
5.8
28.3
39
15.7
Melanoma
62.1
18.7
13.5
1.5
4.2
Breast
38.3
41.7
8.8
4.9
6.2
Cervix
68
9.9
9.5
7.4
5.3
Ovary
33.6
3.3
42.7
10.7
9.8
Prostate
1.1
68.3
11
14.3
5.4
Kidney
33.4
10.9
17.8
28.3
9.5
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Delays to diagnosis
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Delay in referral with symptoms - Scotland
Delayed diagnosis of cancer; Thematic review
Data from the first Scottish Primary Care Group report showing the average number
of days delay in cancer diagnosis in primary care.
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Delay seeking help
Percentage saying that they would contact the doctor in <2
weeks for each warning sign by socio-economic group
British Journal of Cancer (2009) 101(S2), S18
– S23
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Improving early detection
>
>
>
>
Faster referral to hospital
Faster appointment times– ‘2 week rule’ for suspected cancer
Faster investigation
18 weeks treatment target
> Public education re symptoms
> Screening
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Lead time or increase in life expectancy
Cancer
starts
Detectable by
screening
Death
Symptoms
Time
Prolonged
survival or Cure
Survival after diagnosis
from symptoms
Survival after diagnosis from screening
Apparent increase in survival
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Cancer Screening UK
> Breast
1988 - Mammography every 3 years from age 47 to 73
> Cervical
1989 - Smears from age 25 every 3 years, from age 50 every 5
years
> Colorectal
2006 - Faecal Occult blood test every 2 years 60-68
> Prostate
No screening in place
> Lung cancer Watch this space!
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Cervical Screening
> Established screening programme in1989
> Smears from age 25 every 3 years
> from age 50 every 5 years
> Changed to liquid based cytology
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Cervical Cancer screening
Percentage with severe dyskaryosis or worse
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Outcomes of referral for abnormal smear
Single occurrence of
potentially significant
abnormality
Persistent ‘non-negative’
test result
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Cervical screening turnaround times - Scotland
50
2007 - 2011
45
Q1
Q2
Q3
Q4
Average turnaround time (days)
40
35
30
25
20
15
10
5
0
Scotland
(Former)
Argyll &
Clyde*
Ayrshire &
Arran
Fife
Forth Valley
Grampian
Greater
Glasgow*
Highland*
Lanarkshire
Lothian
Tayside
http://www.isdscotland.org/Health-Topics/Cancer/Cervical-Screening/
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Time from screening to availability of report (%)
Changes in time from screening to availability of smear report England
2006/7
Up to 2 weeks
2007/8
2008/9
2009/10 2010/11
11
21
45
82.8
Up to 4 weeks
48
60
65
72
97.4
4-6 weeks
26
23
21
14
1.8
6-8 weeks
14
9
8
7
0.5
8-10 weeks
7
4
4
5
0.1
10-12 weeks
4
2
1
2
0.1
>12 weeks
2
1
0
0.6
0.1
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Breast Cancer screening
> Mammography every 3 years from age 47 to 73
> Attendance rate 74%
http://news.bbcimg.co.uk/
media/images/59720000/
gif/_59720340_c0027305
mammography_examin.gi
f
> 2,133,189 women screened
> 17,013 cancers detected
– 13,672 (80%) invasive
– 3,196 (19%) non-invasive
– 137 (1%) micro-invasive
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Size screen detected Breast cancers
Cancer detection rate
•Overall 8.0 per 1,000 women screened
•Invasive 6.4 per 1,000 women screened
•Non/micro-invasive 1.6 per 1,000 women
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15 year survival trend with screen detected
breast cancer
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Overdiagnosis cancer and screening
> Diagnosis of a cancer that would not have been diagnosed
without screening
> Previously thought that all cancers would progress inevitably
> Between 15 and 30% could be ‘overdiagnosed’
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Diagnosis, symptoms, screening and
overdiagnosis
Screening
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Breast Cancer Overdiagnosis
http://www.bmj.c
om/highwire/files
tream/423608/fie
ld_highwire_frag
ment_image_l/0.j
pg
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Incidence breast cancer Fife
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Nordic Cochrane report for patients
> If 2000 women are screened regularly for 10 years
> One will benefit from the screening, as she will avoid dying from
breast cancer.
> At the same time, 10 healthy women will become ‘cancer patients’
and will be treated unnecessarily.
• These women will have either a part of their breast or the
whole breast removed, and they will often receive
radiotherapy, and sometimes chemotherapy.
> Furthermore, about 200 healthy women will experience a false
alarm.
• The psychological strain until one knows whether or not it was
cancer, and even afterwards, can be severe.
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British review
> The absolute benefits were estimated as 5.7 breast cancer deaths
prevented per1000 women screened for 20 years starting at age 50
> The corresponding estimated numbers of cases overdiagnosed
per 1000 women screened for 20 years were 2.3 per 1000.
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Rates of new diagnosis and death for five types of
cancer in the US, 1975-2005.
Moynihan R et al. BMJ 2012;344:bmj.e3502
©2012 by British Medical Journal Publishing Group
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Breast Cancer Mortality Scotland
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Overdiagnosis and claims
 How much overdiagnosis is present?
 How much is carcinoma-in-situ?
 How much is already in our claims
portfolio?
 May be more important for newer
screening programmes
 We cannot distinguish those cancers
that are overdiagnosed from those that
would have been diagnosed eventually
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Bowel cancer & screening
> Faecal Occult blood testing offered to all aged 60-69 every 2 years
> Extending to all up to age 75 – depends on area but can request
> In Scotland age 50-75
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Results Bowel cancer screening Scotland
Uptake
Positive
test
50%
3.0
1.05
Females
57.2%
1.8
Overall
53.7%
2.3
Males
Adenoma
Cancer
rate
detection
rate
% Dukes
A
% Dukes
B
0.19
29
22.5
0.41
0.09
25.3
26.9
0.71
0.14
27.7
(8.7%)
24.1
(24.2%)
Positive Predictive Value
Cancer
Adenoma
Males
8.0
44.0
Females
6.3
29.6
Overall
7.3
36.1
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http://www.is
dscotland.or
g/HealthTopics/Canc
er/Publicatio
ns/2011-0830/KPI_repor
t.pdf
34
Duke’s stage of bowel cancers detected after
first million people screened in England
http://gut.bmj.com/content/early/2011/
11/22/gutjnl-2011-300843.full.pdf+html
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Prostate cancer screening UK
Conclusions from NHS cancer screening committee:
• The harms from prostate cancer screening using PSA
are currently likely to outweigh the benefits.
• In this circumstance screening for prostate cancer cannot
be justified on the current evidence.
•PSA is a poor test for prostate cancer
and a more specific and sensitive test is
needed
•Currently unable to correctly identity
those cancers which will progress and
those which are indolent and may be
safely watched
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Prostate cancer screening - US latest
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Prostate Cancer staging
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Family History
Question: A Family History of 2 or more family members with cancer
is an area not fully covered by the manuals
Life cover –
Interventions may reduce the risk considerably
Critical illness Need to understand the percentage of claims from that particular
cancer
Overall need to use information carefully
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Risk Colon cancer by family history
4
% risk of developing cancer by age 79
8
9
15
16
http://delgadomd.com/colon-cancer-screening/
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Breast cancer and family history
Probability % women developing breast cancer by age 50
Number first degree relatives affected
Current age
None
One
Two
20
1.7
3.7
8.0
30
1.7
3.5
7.4
40
1.3
2.5
5.2
Probability % women developing breast cancer by age 80
Number first degree relatives affected
Current age
None
One
Two
20
7.8
13.3
21.1
30
7.7
13.0
20.7
40
7.3
12.0
18.9
50
6.1
9.8
14.7
60
4.5
7.1
10.4
2.5
4.2
5.7
70
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Breast Cancer & FH by age
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Prostate cancer and family History
Family history
Relative risks
Brother with Prostate cancer
3.4
Father with Prostate cancer
2.2
One First Degree Relative (FDR) at any age
2.6
One Second Degree Relative at any age
1.7
FDR diagnosed <65 yrs
3.3
FDR diagnosed >65 yrs
2.4
2 or more FDRs diagnosed at any age
5.1
http://www.cancer.gov/cancertopics/pdq/genetics/pr
ostate/HealthProfessional#Section_13
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Changes in Family History with time/age
JAMA, July 13,
2011—Vol 306,
No. 2
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Lung Cancer Screening
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Lung Cancer screening with CT scans Vs CXR
Cumulative Numbers of Lung Cancers and of Deaths from Lung Cancer.
> 53,000 current and former
smokers ages 55 to 74
> Low dose spiral CT Vs CXR
> 20% relative reduction death
from lung cancer
> 7% overall mortality fall
> 24% positive results
96% were false positive results
The National Lung Screening Trial Research Team . N
Engl J Med 2011;365:395-409.
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EarlyCDT
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Lung Cancer screening Scotland 2012
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EarlyCDT Lung cancer screening
> With a Pre-test likelihood of 4% risk for age and smoking history
group a positive result indicates:
> 1 out of 14.3 people who test positive from a CT diagnostic
imaging scan will truly have the presence of lung cancer
> 1 out of 7 people with positive results from the EarlyCDT™-Lung
test will truly have the presence of lung cancer
> 1 out of 4.3 people who test positive from both the EarlyCDT™Lung test and a CT scan will truly have the presence of lung
cancer
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