Transcript Enfermedades Mas Frecuentes en Puerto Rico

Cancer
Affecting Puerto Rico
Norman Maldonado MD
April 2015
Conflict of Interest Statement
• No Conflict of Interest
Objectives
• Present the most common cancers affecting our
population
• Present the incidence and epidemiology of these
conditions
• Present the mortality of these conditions
• Emphasize the prevention strategies
• Treatment options for these diseases
.
Population Aging continues
(median age in years)
Vital Statistics
(Thousands)
Incidence of Diseases
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Coronary Disease 8.2%
Hypertension 34%
(15th)
Diabetes 12.8%
(2nd)
Obesity 34.4%
(29th)
Metabolic Syndrome 43.3%
Asthma 7.5%
Stroke 2.0%
Cancer
Causes of Death 2000-2008
•
2008
• Total causes adjusted 694.0
• Heart
126.4
• Cancer
117.7
• Diabetes
67.0
• Alzheimer
38.0
• Cerebrovascular
36.4
• Respiratory
28.7
. Accidents, renal, pneumonia , sepsis
2000
850.5
189.2
138.9
69.7
23.7
49.9
35.9
Cancer
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Breast Cancer
Prostate Cancer
Colon and Rectum Cancer
Lung Cancer
Pancreatic Cancer and Biliary System
Thyroid Cancer
Lymphoma
Head and Neck Cancer
Burden of Cancer in Puerto Rico
2000-2004
• Cancer 2nd leading cause of death
• Accounts for approximately 25% of all deaths
• In 2004, an estimated 11,211 new cancer
cases were diagnosed
• In 2004, an estimated 4,826 died from cancer
Top Ten Incidence Cancer Sites
In Puerto Rico, 2007-2008
Males (N=13,344) %
Females (N=12,555) %
Prostate
37.7
Breast
33.2
Colon and Rectum
13.9
Colon and Rectum
12.5
Lung and Bronchus
6.2
Thyroid
8.1
Oral Cavity and Pharynx
4.3
Corpus and Uterus
7.0
Urinary Bladder
4.2
Lung and Bronchus
3.8
Non-Hodgkin Lymphoma
3.4
Cervix Uteri
3.5
Liver and Intrahepatic Bile
3.1
Non-Hodgkin Lymphoma
3.4
Stomach
2.9
Ovary
2.4
Kidney and Renal Pelvis
2.1
Stomach
2.2
Larynx
2.0
Leukemia
1.8
Other Locations
20.2
Other Locations
23.9
*Cases with age unknown were included/ Statistics were generated from malignant cases only/ Statistics are an average of the years 2007-2008
Rates are per 100,000 and age-adjusted to the 2000 PR population
Data Source: Puerto Rico Central Cancer Registry, Preliminary Puerto Rico Cancer Incidence File (December, 2011)
Top Ten Mortality Cancer Sites
in Puerto Rico, 2007-2008
Males (N=5,653)
Females (N=4,319)
%
%
Prostate
18.4%
Breast
19.3%
Lung and Bronchus
13.2%
Colon and Rectum
12.8%
Colon and Rectum
12.8%
Lung and Bronchus
10.2%
Liver and Intrahepatic Bile Duct
6.4%
Liver and Intrahepatic Bile Duct
5.5%
Stomach
4.8%
Pancreas
5.3%
Oral Cavity and Pharynx
3.8%
Corpus and Uterus, NOS
4.6%
Pancreas
3.7%
Ovary
4.2%
Esophagus
3.6%
Lymphoma
3.9%
Lymphoma
3.6%
Stomach
3.8%
Leukemia
3.3%
Leukemia
3.5%
Other Locations
26.5%
Other Locations
26.9%
*Cases with age unknown were included/ Statistics were generated from malignant cases only/ Statistics are an average of the years 2007-2008
Rates are per 100,000 and age-adjusted to the 2000 PR population
Data Source: Puerto Rico Department of Health and National Center for Health Statistics using the Medical Mortality Data System (MMDS) for
the years 2000-2008.
Causes of Cancer
 Approximately 75% of cancer could be prevented by
eliminating
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Smoking
(60%)
Obesity
(10%)
Other dietary factors
(10-30%)
Infectious Agents
(18%)
• Developed Countries (8%)
 Developing Countries (26%)
Alcohol
(1.4%)
Sunlight
(1.4%)
Air pollution
(1.4%)
Occupation
(1.4%)
Physical activity
(1.4%)
Cancer Prevention
• Prevention offers the most cost-effective long-term
strategy for the control of cancer
• At least one-third of all cancer cases are preventable.
– Reduction of tobacco use
– Healthy Diet
– Reduction obesity
– Increase in physical activity
– Control of cancer-related infectious agents:
• HPV
• HBV & HBC
HIV
• H. Pylori
Cancer Prevention
• Past two decades, good progress in
developing and using effective:
– Cancer prevention strategies
– Early detection interventions
– Treatments
• Largely through public health efforts we have
seen reduction in mortality from cancer:
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Cervical
Breast
Colorectal cancer
Lung Cancer
Cancer Risk Factors in U.S.
And Puerto Rico, BRFSS 2010
Risk Factor
U.S.
(Md %)
Puerto Rico
Diabetes
Overweigh/Obesity
8.7%
63.7%
12.8%*
65.6%
Physical Activity last
month
76.1%
57.7%$
Fruit & Vegetables
5+/day
23.4%
(2009)
17.7%$
(2009)
* Highest/$Lowest in the U.S.; @ 3rd Lowest in the U.S.
Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta,
Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008.
Cancer Screening Behaviors in
Puerto Rico, BRFSS 1996 & 2010
Puerto Rico
1996
70%
Puerto Rico
2010
75%
Mammography
40+ years
50+ years
60%
61%
77%
80%
Colonoscopy
28%1
43%
FOBT
12%1
10%
PSA
65%2
63%
Screening Test
Pap Smear
1
1999; 2 2002
Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta,
Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.
Ten Recommendations for
Cancer Prevention:
WCRF/AICR Second Expert Report
1. Be as lean as possible without becoming underweight
2. Be physically active for at least 30 minutes every day
3. Avoid sugary drinks/Limit consumption of energy-dense
foods
4. Eat a variety of vegetables, fruits, whole grains and
legumes such as beans
5. Limit consumption of red meats (such as beef, pork and
lamb) and avoid processed meats
Ten Recommendations for
Cancer Prevention:
WCRF/AICR Second Expert Report
6. Limit alcoholic drinks to 2 for men and 1 for women a day
7. Limit consumption of salty foods and foods processed with
salt (sodium).
8. Don't use supplements to protect against cancer
9. Best for mothers to breastfeed exclusively for up to 6 months
and then add other liquids and foods. (*)
10. After treatment, cancer survivors should follow the
recommendations for cancer prevention (*)
*Special Population Recommendations
And always remember – do not smoke or chew tobacco
HPV Vaccines
• Protect against HPV infection and HPV-related diseases.
• Gardasil® and Cervarix® have been shown to protect
against most cervical cancers in women.
• HPV vaccines offer the greatest health benefits to
individuals who receive all three doses before having
any type of sexual activity.
• Recommended for preteen girls and boys aged 11 or
12 years.
• Initiation and completion of HPV vaccination is still low.
• PARENTS, HEALTHCARE PROVIDERS AND IMMUNIZATION
PARTNERS HAVE A ROLE IN PREVENTING HPV DISEASE
Prostate Cancer
Prostate Cancer Bone Scan
Treatment of Prostate Cancer
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Surgery
Radiation, IMRT
Cryotherapy and others
Brachytherapy seed
Androgen Deprivation therapy leuprolide,
bicalutamide, abiraterone
. Chemotherapy , Docetaxel+ Prednisone
.Observation in low risk, elderly
Breast Cancer
• Examination
• Mammography, Sonomammography, MRI, PET
• Biopsy or FNA
• Markers ER, PR, HER 2 neu, Ki67
. Chemistries, Bone Scan,CEA, CA15-3 others
. Surgery or Neoadjuvant Chemotherapy
. Oncotype
. Adjuvant Chemotherapy
. Radiotherapy
. Hormonal Therapy
Breast Cancer
ER positive
HER-2 Positive
Herceptin
Colon Carcinoma
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Fecal Occult Blood
Endoscopies and Biopsies
CT Scans
PET CT
Liver function tests, CEA
Surgery, staging, positive nodes
Adjuvant Chemotherapy( FOLFOX)
Chemotherapy- Metastatic Disease( FOLFIRI),
bevacizumab, cetuximab
Frequency
Comparison of CRC through age groups and Sex
Distribution
40
35
30
25
20
15
10
5
0
Male
Female
30-40
41-50
51-60
61-70
Years
71-80
81-90 91-100
Lung Carcinoma
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Smoker or not
Radiographic Studies CT, PETCT, Brain CT
Diagnostic Studies
Staging
New Immunologic Markers EGFR, ALK
Surgery
Adjuvant Chemotherapy or Immunologic
Radiotherapy
Lung Carcinoma
Lung Cancer and PET/CT scan
Non-Small Cell Lung Cancer
Adenocarcinoma
Squamous Cell Carcinoma
ALK-inhibitor
Pancreatic and Biliary Cancer
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Symptoms
Radiological Studies CT, PET CT, ERCP
Biopsies
Markers CA 19-9, CEA
Whipples, chledocoduodenostomy
Trans hepatic stent o THC
Chemotherapy or Palliation, Hospice
Pain Management
Anticoagulation
Thyroid Cancer
• Symptoms
. Scintigrams or sonograms
• FNA, Function
• Pathology
• Bone Scan
• Surgery
. Radioyodine131
. New therapies
Papillary and Follicular Thyroid Cancer
Lymphoma
Lymphoma
Therapy of Hodgkin's Disease
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Early Stage I & II Chemo+ Radiation
Stage III & IV Chemotherapy ABVD
BEACOPP
Bone Marrow Transplant in Relapse
Research Treatments
Cure 80 to 90%
Non Hodgkin’s Lymphoma
• Staging, LDH, B2 microglobulin, Immune
markers, CD20
• PET CT
• Large Cell
• Therapy Rituximab CHOP 21
• Indolent I &II Radiation
• Indolent III& IV R- CVP 21
• Relapses,Other treatments
Gracias