cancer disparities (kevin joseph cullen, m.d.)

8/7/2019 Cancer Disparities (Kevin Joseph Cullen, M.D.)

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University of Maryland Marlene and Stewart

Greenebaum Cancer CenterCancer Disparities

September 15, 2009


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2009 Estimated US Cancer Deaths*

ONS=Other nervous system.Source: American Cancer Society, 2009.

Men292,540

Women269,800

26% Lung & bronchus

15% Breast

9% Colon & rectum

6% Pancreas

5% Ovary

4% Non-Hodgkinlymphoma

3% Leukemia

3% Uterine corpus

2% Liver & intrahepaticbile duct

2% Brain/ONS

25% All other sites

Lung & bronchus 30%

Prostate 9%

Colon & rectum 9%

Pancreas 6%

Leukemia 4%

Liver & intrahepatic 4%bile duct

Esophagus 4%

Urinary bladder 3%

Non-Hodgkin 3%lymphoma

Kidney & renal pelvis 3%

All other sites 25%


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US Mortality, 2006

*Includes nephrotic syndrome and nephrosis.Source: US Mortality Data 2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

1. Heart Diseases 631,636 26.0

2. Cancer 559,888 23.1

3. Cerebrovascular diseases 137,119 5.7

4. Chronic lower respiratory diseases 124,583 5.1

5. Accidents (unintentional injuries) 121,599 5.0

6. Diabetes mellitus 72,449 3.0

7. Alzheimer disease 72,432 3.0

8. Influenza & pneumonia 56,326 2.3

9. Nephritis* 45,344 1.9

10. Septicemia 34,234 1.4

Rank Cause of DeathNo. ofdeaths

% of alldeaths


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Change in US Death Rates* from 1991 to 2006

* 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.

17.8

63.3

34.8

313.0

215.1

43.6

180.7

200.2

0

100

200

300

400

Heart diseases Cerebrovascular

diseases

Influenza &

pneumonia

Cancer

1991

2006

Rate Per 100,000


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Cancer Death Rates* by Sex, US, 1975-2005

*Age-adjusted to the 2000 US standard population.Source: US Mortality Data 1960-2005, National Center for Health Statistics, Centers for Disease Control andPrevention, 2008.

0

50

100

150

200

250

300

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

Men

Both Sexes

Rate Per 100,000

Women


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Tobacco Use in the US, 1900-2005

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

1900

1905

1910

1915

1920

1925

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

Year

PerCapitaCigaretteConsumptio

n

0

10

20

30

40

50

60

70

80

90

100

Age-AdjustedLungCancerDeath

Rates*

*Age-adjusted to 2000 US standard population.

Source: Death rates: US Mortality Data, 1960-2005, US Mortality Volumes, 1930-1959, National Center for HealthStatistics, Centers for Disease Control and Prevention, 2006. Cigarette consumption: US Department ofAgriculture, 1900-2007.

Per capita cigaretteconsumption

Male lung cancerdeath rate

Female lung cancerdeath rate


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7

Cancer is a disease of aging


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8

We are getting older


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9

Obesity, Diet and Cancer Doll and Peto estimated that 35% (or

as high as 70%) of US cancers were

diet related.

High fat, low fiber diet in Westernsocieties implicated in early studies.


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10

Mortality and Body Mass Index

Br r r r Pr r r r NY Ar r r Sr r r 1988 r r r 1


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11

Obesity and Cancer Mortality

Dr r r r r r r r r Mr r r r r r r r r 44r 24r 1995 Rr r 2


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Trends in Obesity* Prevalence (%), Children and Adolescents,by Age Group, US, 1971-2006

*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 overweightto 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.

54

65

7

5

7

11 1110

16 16

12

1718

0

5

10

15

20

2 to 5 years 6 to 11 years 12 to 19 years

Pre

valence(%)

NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94)

NHANES 1999-2002 NHANES 2003-2006


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Trends in Obesity* Prevalence (%), By Gender, AdultsAged 20 to 74, US, 1960-2006

*Obesity is defined as a body mass index of 30 kg/m 2 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. 2003-2004, 2005-2006: National Health and Nutrition Examination Survey Public Use Data Files, 2003-2004, 2005-2006, NationalCenter for Health Statistics, Centers for Disease Control and Prevention, 2006, 2007.

13

11

1615

12

1715

13

17

23

21

26

31

28

343332

3535 3436

0

5

10

15

20

25

30

35

40

45

Both sexes Men Women

Preva

lence(%)

NHES I (1960-62) NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94)

NHANES 1999-2002 NHANES 2003-2004 NHANES 2005-2006


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14

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI 30, or ~ 30 lbs overweight for 5 4 woman)


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15




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20




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23Source: Behavioral Risk Factor Surveillance System, CDC

Or r r r r r Tr r r r r r Ar r r r Ur Sr Ar r r r rBRFSSr 2002

(*BMI 30, or ~ 30lbs overweight for 5 4 r r r r r r


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24

Obesity Trends* Among U.S. Adults(*BMI 30, or ~ 30 lbs overweight for 5 4 woman)

Source: Behavioral Risk Factor Surveillance System, CDC

20021989


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Mammogram Prevalence (%), by Educational Attainment andHealth Insurance Status, Women 40 and Older, US, 1991-2006

*A mammogram within the past year. Note: Data from participating states and the District of Columbia wereaggregated to represent the United States.Source: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use DataTape (2000, 2002, 2004, 2006), National Centers for Chronic Disease Prevention and Health Promotion, Centers forDisease Control and Prevention, 1997, 1999, 2000, 2000, 2001, 2003, 2005, 2007.

0

10

20

30

40

50

60

70

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2004 2006

Year

Pre

valence(%)

Women with less than a high school education

Women with no health insurance

All women 40 and older


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Disparities in Health

The concept that some populations (howeverdefined) do worse than others

Populations can be defined or categorized by:

Race

Culture

Area of geographic origin

Socioeconomic Status


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Disparities in Health

The concept that some populations (howeverdefined) do worse than others

The measure can be:

Incidence

Mortality

Survival

Quality of life


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All Sites Cancer Mortality Rates 1973-2004By Race, Males and Females

100

150

200

250

300

' 75 '78 ' 81 ' 84 ' 87 '90 ' 93 ' 96 '99 ' 02

Year

Ra

te

Incidence and mortality rates per 100,000 and age-adjusted to 2000 US standard populationSEER Cancer Statistics Review 1975-2004.

African American

Caucasian

AI/ANHispanic

API


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My Concern

Equal treatment yields equal outcome amongequal patients

There is not equal treatment

There is not enough concern about noremphasis on the fact that there is not equal

treatment


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Studies of differences amongpopulations

Should focus on individuals and families andgenetic markers (personalized medicine)

Should not focus on race A sociopolitical categorization

Not based on biology

A categorization Americans are fixated on


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Studies of differences amongpopulations

Advocacy for such studies should notdrown out concerns about lack of adequatetreatment

Concerns about genetic differences shouldnot become excuses allowing us to acceptdisparities in health


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Adjusted Breast Cancer Survival by Stages andInsurance Status, among Patients Diagnosed in

1999-2000 and Reported to the NCDB


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Breast Cancer

It is estimated that 57,000 breast cancer deathswere averted between 1990 and 2005 due toscreening, early detection, and aggressivetreatment.

Breast cancer screening rates have actuallygone down during the period 2000 to 2005


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44

37

22

44

36

21

45

36

21

50

41

22

56

43

25

0

10

20

30

40

50

60

Total Less than a high schooleducation

No health insurance

Prev

alence(%)

1999 2001 2002 2004 2006

Trends in Recent* Flexible Sigmoidoscopy or ColonoscopyPrevalence (%), by Educational Attainment and Health

Insurance Status, Adults 50 Years and Older, US, 1997-2006

*A flexible sigmoidoscopy or colonoscopy within the past ten years. Note: Data from participating states and theDistrict 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 Controland Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007.


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U.S. Colorectal Cancer Mortality 1975-2005

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1

975

1

977

1

979

1

981

1

983

1

985

1

987

1

989

1

991

1

993

1

995

1

997

1

999

2

001

2

003

2

005

Rateper100,000

Blalck Male

WhiteMale

Black Female

White Female


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Adjusted Colorectal Cancer Survival by Stagesand Insurance Status, among Patients Diagnosed

in 1999-2000 and Reported to the NCDB


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Cancer Survival and Deprivationin Scotland

5yr survival Affluent Deprived

Breast 58% 48%

Colon 40% 34%Lymphoma 58% 42%

Prostate 45% 36%

Bladder 70% 58%Melanoma 84% 69%


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Survival Rates RMS TitanicConcept of Dr. Lisa Newman

First Class 60%

Second Class 43%

Third Class 20%


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RACIAL DISPARITIES IN HEAD ANDNECK CANCER


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RACIAL DISPARITIES IN HEAD ANDNECK CANCER

If you get cancer, whether you live or die shouldnt be determined byyour zip code. Stewart Greenebaum


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Race a neglected biomarker incancer

African American men with cancer are 30% morelikely to die than whites

African American women with breast cancer are17% more likely to die than whites


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Cancer Prev Res 2009;2(9) September 2009


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Impact of Race on SurvivalTAX 324 Study

All Patients Racial Disparities

Racial disparity is due to large number of white patients withgood prognosis HPV positive tumors rate of HPV positive tumorsvery low in blacks.


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Or r r Wr Br r r r r r r Mr DrCr r r r Mr r r r r r Or r r r r rEr r r r r r r r Vr r r Pr r r r r r r rAr r r r r r r Cr r r r r Sr r r r r r

Pr r r r r r r r r r Hr r r r r r r r r r Or r r r r r r rMr r r r r r r r r r Er r r r r r r r r r rEr r r r Ur r r r r r r r r


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Perhaps advances in ourunderstanding of biology will lead usaway from concerns about race and

we will better define high-riskpopulations using pathological

markers of disease. Otis Brawley

cancer disparities (kevin joseph cullen, m.d.)

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