Transcript Cancer EPID 624 - Epidemiology of Chronic Disease

April 6, 2015
o What is cancer?
o Cancer statistics
o Cancer prevention and early detection
o Cancer disparities
o Cancer survivorship
o Cancer research
o Disease in which abnormal cells divide without control and are able
to invade other tissues
o More than 100 types of cancer
o 1,655,540 new cases expected in 2014
o Causes of cancer
o Cancer arises from malfunctions in genes that control cell growth
and division
o External and internal factors impact risk of genetic mutations
o External factor could be exposure to radiation
o Internal factors would be inherited genetic mutations
o BRCA1 and BRCA2
o Inherited mutations among different races/ethnicities like prostate
cancer risk in African American men
o Approximately 13.7 million Americans with a history of cancer were
alive on Jan 1, 2012
o Anyone can develop cancer
o Risk increases with age
o 77% of all cancers diagnosed in people ≥55 years of age
o Lifetime risk
o Relative risk
o Incident rates
o Risk of new cases among population at risk
o Important for cancer epidemiology.
o Who has cancer right now out of everyone in the
population
o Includes people who are living with cancer
o Incidence and survival impact specific cancer prevalence.
Males
Females
Prostate - 2,975,970 (43%)
Breast - 3,131,440 (41%)
Colon & rectum - 621,430 (9%)
Uterine corpus - 624,890 (8%)
Melanoma - 516,570 (8%)
Colon & rectum - 624,340 (8%)
Urinary bladder - 455,520 (7%)
Melanoma - 528,860 (7%)
Non-Hodgkin lymphoma - 297,820 (4%)
Thyroid - 470,020 (6%)
Testis - 244,110 (4%)
Non-Hodgkin lymphoma - 272,000 (4%)
Kidney - 229,790 (3%)
Cervix - 244,180 (3%)
Lung and bronchus - 196,580 (3%)
Lung and bronchus - 233,510 (3%)
Oral cavity and pharynx - 194,140 (3%)
Ovary - 199,900 (3%)
Leukemia - 177,940 (3%)
Kidney - 159,280 (2%)
o In 2014, about 585,720 Americans are expected to die of cancer
o Cancer is second most common cause of cancer death in the US
o Can be expressed as numbers
o I, II, III, IV
o Can be expressed as description of disease spread
o Localized, regional, distant
o Lower number or more localized = better chances of benefiting from
treatment
o Tracking the rates of late-stage (distant) cancers is a good way to
monitor the impact of cancer screening.
o When more cancers are detected in early stages, fewer should be
detected in late stages.
o 5-year relative survival rate for all cancers diagnosed
between 2003 and 2009 is 68%
o Was 49% in 1975-1977
o What leads to improvements in cancer survival?
o Progress in diagnosing cancers at an earlier stage
o Improvements in treatment
o Survival varies by cancer type and stage of diagnosis
o How is survival measured?
o Relative survival – compare survival among cancer patients to
people not diagnosed with cancer with same age, race, and sex
o Usually examined 5 years after diagnosis
o Can look at survival by year at diagnosis
o Can look at survival by years since diagnosis
o What are non-modifiable risk factors of cancer?
o Age
o Cancer specific factors
o Inherited genetic mutations
o BRCA 1 and BRCA2
o What are modifiable risk factors of cancer?
o Modifiable risk factors for cancer in general.
o Exercise
o Diet
o Specific examples
o Lung cancer and smoking
o Finding cancer at an earlier stage when it is easier to treat
o Why is early detection important?
o Reduces cancer mortality
o Can sometimes prevent cancer and decrease cancer incidence
o National recommendations are made by US Preventive Services
Task Force
o Critical review of the literature on each screening test
o Consider the evidence for efficacy/effectiveness as well as
potential harms of screening
o Strict criteria on study designs of evidence that is considered
o USPSTF guidelines set precedent for what screening tests are
covered by Medicare/private insurance
o Other organizations also put out screening guidelines.
o Don’t always match with USPSTF
o What difficulties could this cause?
USPSTF
American Cancer Society
o What is a cancer health disparity?
o Different types of groups can be used to identify/examine cancer
health disparities
o Socioeconomic status
o Geographic region
o Race/ethnicity
o Gender
o Causes of health disparities
o Complex interaction of many factors
o Social
o Cultural
o Economic
o Environmental
o Health care-related
o People with lower SES have disproportionately higher cancer death rates
than those with higher SES, regardless of demographic factors such as
race/ethnicity.
o For example, cancer mortality rates for African American and non-Hispanic
white men with ≤ high school education is ~ 3 times higher than those with a
college degree.
o Why might this be?
o People with lower SES have increased risk of getting cancer and worse outcomes
once diagnosed
o But really, why?
o What are we really looking at when we compare cancer
rates be different racial groups?
o Genetic factors?
o Social factors?
o Behavioral factors?
o Reflection of obstacles to receiving healthcare services
including cancer prevention, early detection and good
quality cancer treatment
o Poverty
o Percent living below the poverty line
o 28% African Americans
o 25% Hispanics
o 10% non-Hispanic whites
o Discrimination
o Cultural/inherited factors
o Look for differences in
o Incidence
o Late stage-diagnosis
o Mortality
o Survival
o Definition varies
o Survivor from time of diagnosis?
o Survivor after completing treatment?
o Survivor after surviving 5 years after treatment?
o ~ 14.5 million adult or childhood cancer survivors in the US on Jan 1,
2014
o ~ 19 million estimated for 2024
o Monitoring after completion of cancer treatment
o Late-effects
o Long-term effects
o Evidence-based guidelines for post-treatment care exist
o National Comprehensive Care Network (NCCN)
o American Society of Clinical Oncology (ASCO)
o Provider responsible for follow-up is not explicitly stated
o Specialist vs. primary care follow-up care
o Specialist is traditional source of care
o Breast cancer: Two RCTs of oncology vs. primary care follow-up
showed similar outcomes
o Existing research on who breast cancer survivors see for
their care post-treatment is limited
o Only include early stage breast cancer
o Only examined follow-up care until 5 years after treatment
completion
o Patient populations not representative of US
o Use of registry, claims, or medical records data
o One study assessed patients’ perception of the provider
responsible for their follow-up care 4 years after
diagnosis (N=844)
o No previous studies have examined the patterns of
physician follow-up among a large population of U.S.
breast cancer survivors of varying survival time
Wiseman, KP (2015)
Wiseman, KP (2015)
o How would you learn about cancer research priorities?
o Building on cancer genomics discoveries
o Immunotherapy
o Preventing childhood cancers
o Developing therapies for RAS-driven cancers
o New strategies for cancer prevention