Transcript Slide 1

June 18-19, 2009
Sponsored by
|
Hyatt Regency Chicago
Otis W. Brawley, M.D.
Chief Medical Officer
Executive Vice President
American Cancer Society
Professor of Hematology, Oncology, Medicine and Epidemiology
Emory University
2009 Estimated US Cancer Deaths*
Lung & bronchus
30%
Men
292,540
Women
269,800
26%
Lung & bronchus
15%
Breast
Prostate
9%
Colon & rectum
9%
9%
Colon & rectum
Pancreas
6%
6%
Pancreas
Leukemia
4%
5%
Ovary
Liver & intrahepatic
bile duct
4%
4%
Non-Hodgkin
lymphoma
Esophagus
4%
3%
Leukemia
Urinary bladder
3%
3%
Uterine corpus
Non-Hodgkin
lymphoma
3%
2%
Liver & intrahepatic
bile duct
Kidney & renal pelvis
3%
2%
Brain/ONS
25%
25%
All other sites
ONS=Other nervous system.
Source: American Cancer Society, 2009.
All other sites
US Mortality, 2006
Rank Cause of Death
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Heart Diseases
Cancer
Cerebrovascular diseases
Chronic lower respiratory diseases
Accidents (unintentional injuries)
Diabetes mellitus
Alzheimer disease
Influenza & pneumonia
Nephritis*
Septicemia
No. of
deaths
% of all
deaths
631,636 26.0
559,888 23.1
137,119 5.7
124,583 5.1
121,599 5.0
72,449
3.0
72,432
3.0
56,326
2.3
45,344
1.9
34,234
1.4
*Includes nephrotic syndrome and nephrosis.
Source: US Mortality Data 2006, National Center for Health Statistics, Centers for Disease Control and Prevention,
2009.
Change in US Death Rates*
from 1991 to 2006
Rate Per 100,000
400
1991
313.0
2006
300
215.1
200.2
200
180.7
100
63.3
43.6
34.8
17.8
0
Heart diseases
Cerebrovascular
diseases
Influenza &
pneumonia
Cancer
* Age-adjusted to 2000 US standard population.
Sources: 1950 Mortality Data - CDC/NCHS, NVSS, Mortality Revised.
2006 Mortality Data: US Mortality Data 2006, NCHS, Centers for Disease Control and Prevention, 2009.
Cancer Death Rates* by Sex
US 1975-2005
300
Rate Per 100,000
Men
250
Both Sexes
200
Women
150
100
50
0
1975
1978
1981
1984
1987
1990
1993
1996
1999
2002
2005
*Age-adjusted to the 2000 US standard population.
Source: US Mortality Data 1960-2005, National Center for Health Statistics, Centers for Disease Control and
Prevention, 2008.
Cancer Death Rates*
Among Men, US 1930-2005
100
Rate Per 100,000
Lung & bronchus
80
60
Stomach
Prostate
40
Colon & rectum
20
Pancreas
*Age-adjusted to the 2000 US standard population.
Source: US Mortality Data 1960-2005, US Mortality Volumes 1930-1959,
National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.
2005
2000
1995
1990
1985
1980
1975
1970
1965
1960
Liver
1955
1950
1945
1940
1935
0
1930
Leukemia
Cancer Death Rates* Among
Women, US 1930-2005
100
Rate Per 100,000
80
60
Lung & bronchus
40
Uterus
Breast
Colon & rectum
Stomach
20
Ovary
*Age-adjusted to the 2000 US standard population.
Source: US Mortality Data 1960-2005, US Mortality Volumes 1930-1959,
National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.
2005
2000
1995
1990
1985
1980
1975
1970
1965
1960
1955
1950
1945
1940
1935
Pancreas
1930
0
2009 Estimated US Cancer Cases*
Men
766,130
Prostate
25%
Lung & bronchus
15%
Colon & rectum
10%
Urinary bladder
7%
Melanoma of skin
5%
Non-Hodgkin
lymphoma
5%
Kidney & renal pelvis
5%
Leukemia
3%
Oral cavity
3%
Pancreas
3%
All Other Sites
19%
Women
713,220
27%
Breast
14%
Lung & bronchus
10%
Colon & rectum
6%
Uterine corpus
4%
Non-Hodgkin
lymphoma
4%
Melanoma of skin
4%
Thyroid
3%
Kidney & renal pelvis
3%
Ovary
3%
Pancreas
22%
All Other Sites
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.
Source: American Cancer Society, 2009.
Cancer Incidence Rates*
by Sex US 1975-2005
Rate Per 100,000
700
Men
600
Both Sexes
500
400
Women
300
200
100
0
1975
1978
1981
1984
1987
1990
1993
1996
1999
2002
*Age-adjusted to the 2000 US standard population and adjusted for delays in reporting.
Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database:
SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008.
2005
Cancer Incidence Rates*
Among Men, US 1975-2005
Rate Per 100,000
250
Prostate
200
150
100
Lung & bronchus
Colon and rectum
50
Urinary bladder
Non-Hodgkin lymphoma
0
1975
Melanoma of the skin
1978
1981
1984
1987
1990
1993
1996
1999
2002
2005
*Age-adjusted to the 2000 US standard population and adjusted for delays in reporting.
Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database:
SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008.
Cancer Incidence Rates*
Among Women, US 1975-2005
Rate Per 100,000
250
200
150
Breast
100
Colon and rectum
Lung & bronchus
50
Uterine Corpus
Ovary
0
1975
Non-Hodgkin lymphoma
1978
1981
1984
1987
1990
1993
1996
1999
2002
2005
*Age-adjusted to the 2000 US standard population and adjusted for delays in reporting.
Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database:
SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008.
Cancer Incidence & Death Rates*
in Children 0-14 Years, 1975-2005
18
Rate Per 100,000
16
Incidence
14
12
10
8
6
4
Mortality
2
0
1975
1978
1981
1984
1987
1990
1993
1996
1999
2002
2005
*Age-adjusted to the 2000 Standard population.
Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and
Population Sciences, National Cancer Institute, 2008.
Cancer Incidence Rates* in
Children 0-14 Years by Sex, 2001-2005
Site
Male
Female
Total
All sites
16.1
14.1
15.1
5.4
4.5
5.0
4.3
3.6
3.9
Brain/ONS
3.4
3.1
3.2
Soft tissue
1.1
1.0
1.1
Non-Hodgkin lymphoma
1.2
0.6
0.9
Kidney and renal pelvis
0.8
0.8
0.8
Bone and Joint
0.7
0.7
0.7
Hodgkin lymphoma
0.7
0.4
0.5
Leukemia
Acute Lymphocytic
*Per 100,000, age-adjusted to the 2000 US standard population.
ONS = Other nervous system
Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and
Population Sciences, National Cancer Institute, 2008.
Cancer Death Rates* in Children 0-14 Years
by Sex, US 2001-2005
Site
Male
Female Total
All sites
2.7
2.3
2.5
Leukemia
0.8
0.7
0.8
0.4
0.3
0.4
Brain/ONS
0.8
0.7
0.7
Non-Hodgkin lymphoma
0.1
0.1
0.1
Soft tissue
0.1
0.1
0.1
Bone and Joint
0.1
0.1
0.1
Kidney and Renal pelvis
0.1
0.1
0.1
Acute Lymphocytic
*Per 100,000, age-adjusted to the 2000 US standard population.
ONS = Other nervous system
Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and
Population Sciences, National Cancer Institute, 2008.
100
4500
90
4000
80
3500
70
3000
60
Per capita cigarette
consumption
2500
50
2000
40
1500
1000
Male lung cancer 30
death rate
20
500
10
Year
2000
2005
1995
1985
1990
1975
1980
1970
1960
1965
1950
1955
1940
1945
1935
1925
1930
1915
1920
0
1905
1910
0
Age-Adjusted Lung Cancer Death Rates*
5000
1900
Per Capita Cigarette Consumption
Tobacco Use in the US, 1900-2005
Female lung cancer
death rate
*Age-adjusted to 2000 US standard population.
Source: Death rates: US Mortality Data, 1960-2005, US Mortality Volumes, 1930-1959, National Center for Health
Statistics, Centers for Disease Control and Prevention, 2006. Cigarette consumption: US Department of
Agriculture, 1900-2007.
Current* Cigarette Smoking Prevalence (%)
Among High School Students by Sex and
Race/Ethnicity - US 1991-2007
50
Prevalence (%)
40
40
40
37
32
30
40
39
1991
1995
2005
2007
1997
2001
3536 34
33 32
32
30
2727
23
2003
38
33
31
1999
28
2828
25
23 24
20
19
1112
16
13
12
11
14
27
25
23
22
18
17
10
26
1819
1415
19 19
15
8
0
White, nonHispanic
Female
White, nonHispanic Male
African
African
American, non- American, nonHispanic
Hispanic Male
Female
Hispanic
Female
Hispanic Male
*Smoked cigarettes on one or more of the 30 days preceding the survey.
Source: Youth Risk Behavior Surveillance System, 1991, 1995, 1997, 1999, 2001, 2003, 2005, 2007 National Center for
Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2008.
Trends in Consumption of Five or More
Recommended Vegetable and Fruit Servings for Cancer
Prevention, Adults 18 and Older, US, 1994-2007
35
Prevalence (%)
30
25
24.2
24.4
24.1
24.4
23.6
24.3
24.7
1994
1996
1998
2000
2003
2005
2007
20
15
10
5
0
Year
Note: Data from participating states and the District of Columbia were aggregated to represent the United
States.
Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape
(2000, 2003, 2005, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, 1997, 1999, 2000, 2001, 2004, 2006, 2008.
60
55
50
45
40
35
30
25
20
15
10
5
0
Adults with less than a high school education
2007
2006
2005
2004
2003
2002
2000
1998
1996
1994
All adults
1992
Prevalence (%)
Trends in Prevalence (%) of No Leisure-Time
Physical Activity, by Educational Attainment
Adults 18 and Older - US 1992-2007
Year
Note: Data from participating states and the District of Columbia were aggregated to represent the United
States. Educational attainment is for adults 25 and older.
Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape
(2000, 2002, 2004, 2005, 2006, 2007), National Center for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2003, 2005, 2006, 2007, 2008.
Trends in Obesity* Prevalence (%)
Children and Adolescents, by Age Group
US 1971-2006
20
18
17
16
16
Prevalence (%)
15
12
11
11
10
10
7
5
7
5
6
5
4
5
0
2 to 5 years
NHANES I (1971-74)
NHANES 1999-2002
6 to 11 years
NHANES II (1976-80)
NHANES 2003-2006
12 to 19 years
NHANES III (1988-94)
*Body mass index (BMI) at or above the sex-and age-specific 95th percentile BMI cutoff points from the 2000 sex-specific
BMI-for-age CDC Growth Charts. Note: Previous editions of Cancer Statistics used the term “overweight” to describe
youth in this BMI category.
Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center
for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2006: Ogden CL, et al. High Body
Mass Index for Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05.
Trends in Obesity* Prevalence (%), By Gender
Adults Aged 20 to 74, US, 1960-2006†
45
40
35
33
Prevalence (%)
35
34 35
34
36
32
31
28
30
26
23
25
21
20
15
13
16 17
15 15
11
17
12 13
10
5
0
Both sexes
Men
NHES I (1960-62)
NHANES I (1971-74)
NHANES II (1976-80)
NHANES 1999-2002
NHANES 2003-2004
NHANES 2005-2006
Women
NHANES III (1988-94)
*Obesity is defined as a body mass index of 30 kg/m2 or greater. † Age adjusted to the 2000 US standard population. Source:
National Health Examination Survey 1960-1962, National Health and Nutrition Examination Survey, 1971-1974, 1976-1980,
1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 20032004, 2005-2006: National Health and Nutrition Examination Survey Public Use Data Files, 2003-2004, 2005-2006, National
Center for Health Statistics, Centers for Disease Control and Prevention, 2006, 2007.
Mammogram Prevalence (%), by Educational
Attainment and Health Insurance Status
Women 40 and Older, US, 1991-2006
70
All women 40 and older
60
Prevalence (%)
50
Women with less than a high school education
40
30
Women with no health insurance
20
10
0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2002
2004
2006
Year
*A mammogram within the past year. Note: Data from participating states and the District of Columbia were
aggregated to represent the United States.
Source: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data
Tape (2000, 2002, 2004, 2006), National Centers for Chronic Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, 1997, 1999, 2000, 2000, 2001, 2003, 2005, 2007.
Disparities in Health
• The concept that some populations (however defined)
do worse than others
• Populations can be defined or categorized by race,
culture, area of geographic origin, socioeconomic status
Disparities in Health
• The concept that some populations (however
defined) do worse than others
• The measure can be incidence, mortality, survival,
quality of life
All Sites – Cancer Mortality Rates
1973-2004 By Race, Males and Females
300
African American
250
Rate
Caucasian
200
150
AI/AN
Hispanic
API
100
'75
'78
'81
'84
'87
'90
'93
'96
'99
'02
Year
Incidence and mortality rates per 100,000 and age-adjusted to 2000 US standard population
SEER Cancer Statistics Review 1975-2004.
Disparities in Health
• We need to approach this issue logically and
rationally
• We must focus on what we can change and
not on what we cannot change
• We must define social and logistical issues
versus scientific issues.
My Concern
• “Equal treatment yields equal outcome
among equal patients”
• There is not equal treatment
• There is not enough concern about nor
emphasis on the fact that there is not equal
treatment
How can we provide adequate, high-quality care (to
include preventive care) to a population that has so
often
not received it?
Female Breast Cancer Death Rates
by Race and Ethnicity, US, 1975-2004
45
40
African Americans
Rate per 100,000
35
30
Whites
25
Hispanic/Latina
20
American Indian/Alaska Native
15
10
Asian American/Pacific Islander
5
0
1975
1978
1981
1984
1987
1990
1993
1996
1999
2002 2004
Year
American Cancer Society, Surveillance Research, 2007
Adjusted Breast Cancer Survival by Stages and
Insurance Status, among Patients Diagnosed
in 1999-2000 and Reported to the NCDB
Breast Cancer
• It is estimated that 57,000 breast cancer deaths were
averted between 1990 and 2005 due to screening, early
detection, and aggressive treatment.
• Breast cancer screening rates have actually gone down
during the period 2000 to 2005
Breast Cancer
Imagine a world in which…
• Mammography rates were greater than 80%
• All women with an abnormal screen got it evaluated
• All women with breast cancer got optimal therapy
Screening Guidelines for the Early Detection of
Colorectal Cancer and Adenomas, American Cancer
Society 2008
• Beginning at age 50, men and women should follow one of the
following examination schedules:





A flexible sigmoidoscopy (FSIG) every five years
A colonoscopy every ten years
A double-contrast barium enema every five years
A Computerized Tomographic (CT) colonography every five years
A guaiac-based fecal occult blood test (FOBT) or a fecal immunochemical
test (FIT) every year
 A stool DNA test (interval uncertain)
 Tests that detect adenomatous polyps and cancer
 Tests that primarily detect cancer
People who are at moderate or high risk for colorectal cancer should talk with
a doctor about a different testing schedule
Trends in Recent* Fecal Occult Blood Test Prevalence
(%) by Educational Attainment and Health Insurance Status
Adults 50 Years and Older, US 1997-2006
30
24
Prevalence (%)
25
20
1997
2004
20
21
1999
2006
2001
2002
22
19
18
16
16 16
16
14
15
12
10
12
8
9
9
9
8
5
0
Total
Less than a high school
education
No health insurance
*A fecal occult blood test within the past year. Note: Data from participating states and the District of Columbia were
aggregated to represent the United States.
Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001,
2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control
and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007.
Trends in Recent* Flexible Sigmoidoscopy or Colonoscopy
Prevalence (%), by Educational Attainment and Health
Insurance Status, Adults 50 Years and Older, US 1997-2006
60
56
1999
2001
2002
2004
2006
50
Prevalence (%)
50
45
44 44
41
37
40
43
36 36
30
22 21 21 22
25
20
10
0
Total
Less than a high school
education
No health insurance
*A flexible sigmoidoscopy or colonoscopy within the past ten years. Note: Data from participating states and the
District of Columbia were aggregated to represent the United States.
Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001,
2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control
and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007.
U.S. Colorectal Cancer Mortality 1975-2005
40.0
35.0
25.0
Blalck Male
WhiteMale
20.0
Black Female
White Female
15.0
10.0
5.0
2005
2003
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
1977
0.0
1975
Rate per 100,000
30.0
Adjusted Colorectal Cancer Survival by Stages and
Insurance Status, among Patients Diagnosed in 1999-2000
and Reported to the NCDB
Colorectal Cancer
• It is estimated that 77,000 colorectal cancer deaths were
averted between 1990 and 2005 due to screening, early
detection, and aggressive treatment.
• Colorectal cancer screening rates have actually gone
down during the period 2000 to 2005
Colorectal Cancer
Imagine a world in which…
• Colorectal screening rates were greater than 80%
• All men and women with an abnormal screen got it
evaluated
• All with colorectal cancer got optimal therapy
Sunburn* Prevalence (%) in the Past Year,
Adults 18 and Older, US 2004
50
46.4
Sunburn* Prevalence (%) in the Past Year,
Adults 18 and Older, US, 2004
45
Age-Adjusted Prevalence (%)
40
White nonHispanic
36.3
35
30
25
Other
26.3
24.0
22.5
18.4
20
Hispanic
15
10
5.7
5.8
5
Black nonHispanic
0
Male
Female
*Reddening of any part of the skin for more than 12 hours. Note: The overall prevalence of sunburn
among adult males is 46.4% and among females is 36.3%.
Source: Behavioral Risk Factor Surveillance System Public Use Data Tape , 2004. National Center for
Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2005.
Ultraviolet Radiation Exposure Behaviors*
Prevalence (%), Adults 18 and Older, US, 2005
Total
Male
Female
45
37
35
Prevalence (%)
30
40
40
40
33
30
30
26
24
25
20
19
17
15
12 13 12
10
14
10 11 10
11
5
0
Apply
sunscreen
Seek the shade
Wear a hat
Wear longsleeved shirt
Wear long
pants
Used indoor
tanning
device†
*Proportion of respondents reporting always or often practicing the particular sun protection behavior
on any warm sunny day. †Used an indoor tanning device, including a sunbed, sunlamp, or tanning booth
at least once, in the past 12 months.
Source: National Health Interview Survey Public Use Data File 2005, National Center for Health Statistics,
Centers for Disease Control and Prevention, 2006.
Cancer Survival and Deprivation
in Scotland
5yr survival
Affluent
Deprived
Breast
58%
48%
Colon
40%
34%
Lymphoma
58%
42%
Prostate
45%
36%
Bladder
70%
58%
Melanoma
84%
69%
Survival Rates RMS Titanic
Concept of Dr. Lisa Newman
First Class
60%
Second Class
43%
Third Class
20%
How can we provide adequate, high-quality care (to include
preventive care) to a population that has so often
not received it?
82
5000
81
4500
80
4000
3500
79
3000
78
2500
77
2000
76
1500
1000
75
500
74
0
Life Expectancy – Per Capita Spending
2006 CIA FACTBOOK
Per Capita Spending in USD
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Average Life Expectancy (years)
Higher Per Capita Spending in the U.S. Does Not
Translate into Longer Life Expectancy
The Cost of a Long Life
United States
The Economics of Healthcare
• Healthcare is 17% of the nation’s Gross Domestic
Product and growing
• The country with the second greatest is Israel with 9.5%
of its GDP devoted to healthcare
• The U.S. spends more on healthcare than it spends on
food and clothing
The Economics of Healthcare
• The average Medicare costs per beneficiary
nationwide in 2006 was $8,304
•
•
•
•
New York City
Honolulu
Miami
San Francisco
$9,564
$5,311
$16,351
$8,331
NY Times June 11, 2009
Disparities in Health
• Some consume too much (unnecessary care given)
• Some consume too little (necessary care not given)
• We could decrease the waste and improve overall
health!!
Disparities in Health
There are dramatic geographical differences in use of a
number of expensive screening technologies and therapies
without evidence of difference in outcomes.
•Prostate cancer screening and overtreatment
•Lung cancer screening
•Third and fourth-time chemotherapy of metastatic disease
•Intensity Modulated Radiation Therapy in some cancers
•Overuse of radiologic imaging
Faith-based versus Evidence-based Medicine
• We in medicine have a tendency to adopt things before fully
accessing their benefit or harm.
• We also criticize those who question the benefit and some
even praise/worship advocates with a monetary interest.
•
•
•
•
•
•
Bone marrow transplant for breast cancer
Lung cancer screening with chest X-ray
Neuroblastoma screening with urine VMA
The Halsted Mastectomy
Postmenopausal hormone replacement
Prostate cancer screening
Disparities in Health
• A call for the use of “Evidence-Based Care”
That is:
The rational use of medicine
not the rationing of medicine
We know WHAT to do,
We just need to DO it!!
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