Transcript Cancer diagnosis

Determing the Future Course of
Cancer in the World
Richard C. Wender, MD
Chief Cancer Control Officer
American Cancer Society
• Eight key challenges and trends will
determine the future of cancer in
Denmark and around the world
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The changing epidemiology of cancer deaths
The relentless spread of tobacco use
The obesity epidemic
The inversion of the age pyramid
Determining the true value of the early detection of
cancer
6. The emergence of personalized treatment
7. The growing number of cancer survivors
8. The urgent need to reduce the cost of care
Trend #1: The changing epidemiology of
cancer deaths
The Global Burden of Cancer Continues to Increase
In 2012:
14.1 million cancer cases
8.2 million cancer deaths
are estimated to have occurred
Cancer is the leading cause of death in
economically developed countries and the
second leading cause of death in developing
countries
Jemal A, Bray F, et al. CA:Can J Clin. 2011;61:69-90
In 2012, 57% of cases and 65% of deaths
occurred in the economically developed
world
Affluence Contributes To Cancer
• Associated with more obesity and more
alcohol intake
• Only aggressive counter-tobacco policies
have helped to mitigate the interaction
of affluence and tobacco use
Countries With The Top 10 Cancer Rates
Rank
Country
Age-standardized rate (W) per
100,000 both sexes
1
Denmark
338.1
2
France
324.6
3
Australia
323.0
4
Belgium
321.1
5
Norway
318.3
6
United States of America
318.0
7
Ireland
307.9
8
Republic of Korea
307.8
9
The Netherlands
304.8
10
New Caledonia
297.9
In general, lower
income countries are
disproportionately
impacted by cancers
caused by infectious
agents
As we develop a global economy and relative
affluence reaches more people in more
countries, we can expect the transition of
cancer epidemiology
Colorectal Cancer Incidence
Sedentary lifestyles, increase in
red meat
consumption and
obesity increase risk
for colorectal cancer
Cervical Cancer Incidence
Yet infectionrelated cancer
burden is still high
The Other Side of the Cancer Epidemiology Story
High resource nations are making dramatic
progress in the war on cancer
All Cancers Mortality Rates in Denmark
Estimated annual change
latest 10 years: -1.5%
143
113
Cancer Mortality Rates in Denmark, by
Major Cancer, Men
Cancer Mortality Rates in Denmark, by
Major Cancer, Women
We are making great progress in cancer
amenable to prevention or early detection …
and very little progress in all other solid
tumors
Trend #2: The relentless spread of tobacco
use
• Tobacco use remains the leading cause of
preventable death and illness in Denmark, with
24% of deaths attributed to smoking in 2007
(Risk factors and Public Health in Denmark – Summary Report)
• Half of all smokers will die from a smoking
related illness
• The proportion of smokers has fallen steadily in
recent decades – for men from 68% in 1970 to
31% in 2006; for women it fell from 47% to 25%.
(The Public Health Report Denmark 2007)
The Future Tobacco Worldwide Toll
“Unless action is taken, tobacco’s annual
death toll will rise to more than eight
million” by the year 2030, with over 80%
of those deaths occurring in low-income
countries (WHO Report on the Global Tobacco Epidemic, 2008
The MPOWER Package)
Key Questions In The Worldwide Tobacco Fight
Policy change is paramount
• Are there global, national or regional
policies that can:
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Put restrictions on the tobacco industry
Reduce access to youth
Encourage reduction or cessation
De-normalize tobacco use
Raise the price of tobacco products
Trend #3: The worldwide obesity epidemic
The Obesity Epidemic
If we are going to accelerate cancer
prevention, we must find strategies to
address the public heath challenge of our
time – the epidemic of overeating and
sedentary lifestyle
Select Countries’ Obesity Rates
Denmark: Men 11% of adults
and Women 12% of adults are
obese
Obesity and the
economics of
prevention – Fit not fat.
OECD 2010
Danish and Global Obesity
• 41% men and 26% women were overweight in
Denmark
• 12% and 11%, respectively, obese (SUSY-2005, in The
Public Health Report Denmark 2007)
• Worldwide, obesity rates doubled between
1980 and 2008
Obesity and Cancer
• 85,000 U.S. cases per year are obesityrelated
Basen-Engquist K, Chang M. Curr Oncol Rep. 2011 Feb;13(1) 71-6.
Continuation of the current obesity trend will
lead to about 500,000 additional cancer cases
in the US by 2030
Obesity is Associated With Increased Risk
of These Cancers … and Probably Others:
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Esophogus
Gallbladder
Colon and rectum
Breast (after menopause)
Endometrium
Kidney
Thyroid
Pancreas
www.cancer.gov/cancertopics/factsheet/risk/obesity
Does weight loss reduce cancer risk?
Bariatric surgery offers the most
provocative data linking weight loss and
reduction in cancer risk
McGill University
1,000 surgery patients and 5,700 matched
controls followed for 5 years
Cancer diagnosis
Surgery group
2%
Controls
8.5%
Christov NV, et.al.: Surg Obes Relat Dis. 2008 4(6) 691-5.
The Swedish Obese Subjects (SOS) Study
Surgery Group:
2,010
Contemporaneously
Matched controls: 2,037
Sjostrom L, et.al. Lancet Oncology 2006. Vol. 10(7) 653-662.
S.O.S. (cont’d)
Weight loss
Number of new cancers
Surgery Group
Controls
19.9 kg
1.3 kg
117
169
CI 0.53-0.85
p=0.0009
• Entire beneficial effect seen in women
• Eliminating cancers found in the first 3
years did not change results
NCI Best Estimate
If every adult reduced their BMI by 1 percent,
this could actually result in the avoidance of
100,000 new cases
www.cancer.gov/cancertopics/factsheet/risk/obesity
Obesity and Policy Research
Are Taxes An Answer To The Obesity Epidemic?
Denmark
2011
• Tax on foods containing more than 2.3%
saturated fats
– Up to 30% more for a pack of butter; 8% more on
chips; 7% more on olive oil
2010
• 25% tax on chocolate, ice cream, and sugary
drinks
http://www.oecd.org/dataoecd/1/61/497/6427.pdf
Are Taxes An Answer To The Obesity Epidemic?
Hungary
• 2011: Tax on high sugar, salt, and caffeine
foods
Finland
• 2011: Tax on confectionary products, biscuit
buns, and pastries
France
• 2012: Tax on soft drinks
Trend #4: The inversion of the age pyramid
US population
2008
Population Pyramids, USA
Population Pyramids, China
Population Pyramids, Denmark
Geriatric Oncology
Demographics
– Leading cause of death men/women age 60-79
– 80% cancer-related deaths in US are 65 and
older
– 20% of US population over age 65 by 2030
• 70% of all cancers
• 85% of all cancer related deaths
– Behavior of certain cancers change with age
Our aging population will lead to a tsunami
of cancer
A New Team-Based Approach To Care Is Emerging:
Senior Adult Oncology
• Oncologist addresses different disease
characteristics, different pharmaco-dynamics,
and difference response to treatment
• Geriatrician addresses goals of care, geriatric
syndromes, co-morbidities, nutrition, and
ability to tolerate therapy
• Involvement of geriatrician has led to a
change in management in 50% of patients
Challenge #5: Determine the true value of
the early detection of cancer
• Based on what we know about cancer
today, there are only two ways to reduce
mortality from the solid cancers that
affect adults
– Stop carcinogenesis
– Block metastasis through early detection
and destruction or removal of the primary
cancer
“Any cancer can be cured if it’s caught
early enough”
“Cancer develops in a place in the body, in
any organ. As long as it hasn’t spread to
other organs, it generally can be removed”
- Bert Vogelstein
Why are we moving away from screening?
Randomized Trials of Cancer Screening
Usually Underestimate Benefit
• Randomized trials of cancer screening
are imperfect
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They are trials of invitation, not of screening
Some usual care patients get screened
Some intervention patients don’t get screened
Trials require very long follow-up
Screening is only offered for a few years
Mounting Concern About Over-diagnosis
Cancers that, had they not been diagnosed,
would never have become clinically
meaningful and would not have resulted in
death or disability
Estimating mortality reduction and overdiagnosis from a clinical trial is very difficult –
requiring 15 to 20 years of follow-up for
slower moving cancers
Comparing 9- to 11-Year Follow-up
9-year
Reduction in risk of death
from prostate cancer
Number needed to invite
to prevent 1 death
Number needed to
diagnose to prevent 1
death
0.71 per 1000 men
11-year
1.07 per 1000 men
1410
936
48
33
European Prostate Screening Trial
Data suggest that peak benefit will not be
seen till 15-20 years of follow-up
Observational Trials of Cancer
Screening Are Undervalued
Observational studies are subject to lead
and length time bias and also require long
follow-up … but it is possible to compare a
program of screening to no screening over
many years
USPSTF – Looking at Trends
“The reversal in the upward trend for death
rates from prostate cancer is unlikely to be
from screening. A more likely explanation is
the improvement of health care in general
and in the treatment of prostate cancer
specifically.
Other cancers for which screening is not
commonly performed also shared declines in
death rates over the same period”
Cancer Mortality in U.S. Men
Cancers With Rising Incidence
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HPV – related oropharynx
Esophageal adenocarcinoma
Pancreas cancer
Liver and intrahepatic bile duct
Thyroid cancer in men
Kidney and renal pelvis
Melanoma of the skin
Testicular cancer
Testicular cancer rising in Europe
+24% new cases in
Europe between
2005 and 2025
Testicular cancer incidence to rise by
25% by 2025 in Europe? Le Cornet et al.
European Journal of Cancer 2013.
For cancers with a high case-mortality rate
and rapid progression, like lung and pancreas,
we must detect the cancers very early
Detecting cancers early will harm some
people
National Lung Screening Trial
53,000 current or ex-smokers in the US
(≥ 30 pack-year) ages 55-74
Randomly Assigned
Low dose helical (spiral)
CT
Chest X-Ray
NLST – Initial Results
20% fewer lung cancer deaths in spiral CT
group
Results were highly statistically significant …
7% reduction in all-cause mortality!
Deaths Associated with Diagnostic Workup
Total Deaths:
• With cancer
• Without cancer
LDC T
16
10
6
CXR
10
10
A Fundamental Challenge With Cancer
Screening
The people who stand to benefit are different
than the people who may experience harm
I believe that research directed at the early
detection of solid tumors offers our best
opportunity to convert survivorship into
cure
Trend #6: The emergence of personalized
therapy
• Research will increasingly allow us to:
– Use molecular markers to identify cancers
that will and will not respond to therapy
– Use tailored, targeted therapies given by
mouth with tolerable adverse effects
– Convert a certain and rapid death into a
chronic seige
We Need Personalized Treatment Not
Just Personalized Therapy
Treat the right patients with the right
therapies at the right stage
Are there any models that make it acceptable
and safe to choose less treatment?
Can we subject treatment decisions to the
same type of risk-benefit analysis that we
apply to screening decisions?
Personalized therapy must move beyond
genetic profiling of tumors
– We must find effective ways to
communicate the risks and benefits of
therapy
– This is the essence of a patient-centric
approach to care
Trend #7: The growing number of cancer
survivors
As cancer diagnosis
increases and
survival improves…
Cancer survival in Australia, Canada, Denmark …
1995-2007 (the International Cancer
Benchmarking Partnership). Coleman et al.
Lancet 2011
Cancer Survivors
USA
In the Danish population of 5.4 million people, more than
300 000 are cancer survivors.
The IOM Report on Cancer
Survivorship
1. Recognize the distinct needs of survivors
2. Comprehensive care summaries and
follow-up plans
3. Clinical practice guideline
4. Quality measures
5. Research to test models of care
The IOM Report (cont’d)
6. Comprehensive state and national cancer
control plans
7. Educate health care providers
8. Eliminate discrimination in employment
9. Ensure access to care
10.Increase survivorship research
Ganz P. Prim Care Clin Office Pract 36(2009), 721-741.
Challenge #8: The urgent need to reduce
the cost of care
The Urgent Need to Reduce the Cost
of Care
Our current rate of health care
spending is unsustainable
Health expenditure in Denmark
Very Sick Patients Cost A Lot
“…more than $1 in every $5 healthcare
dollars went to treat one out of every
100 people” in the USA
“The top 5% accounted for half of all
healthcare expenditures” in the USA
www.healthleadersmedia.com 1/12/2012
30% of Medicare expenditures are
attributable to the 5% who die each year
One third of this is spent in the last
month. Terminal hospitalizations
account for ~
~ 7.5% of all inpatient costs,
the majority for ICU care
Palliative care involvement at the time of
diagnosis is critical…but not adequate
The Redefinition of Hope
Hope is not another round of chemo or
another day in an ICU
In Summary …
Our success or failure in improving world
wide cancer care will largely be
determined by our proactive, forwardthinking approach to these 8 cancer trends
Each nation will address these problems in
a somewhat different way. Working
together, we have the opportunity to more
effectively reduce the worldwide burden
of cancer.