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Determing the Future Course of Cancer in the World
Richard C. Wender, MDChief Cancer Control Officer
American Cancer Society
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• Eight key challenges and trends will determine the future of cancer in Denmark and around the world
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1. The changing epidemiology of cancer deaths2. The relentless spread of tobacco use3. The obesity epidemic4. The inversion of the age pyramid5. Determining the true value of the early detection of
cancer6. The emergence of personalized treatment7. The growing number of cancer survivors8. The urgent need to reduce the cost of care
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Trend #1: The changing epidemiology of cancer deaths
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The Global Burden of Cancer Continues to Increase
In 2012:14.1 million cancer cases8.2 million cancer deathsare estimated to have occurred
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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
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In 2012, 57% of cases and 65% of deaths occurred in the economically developed world
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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
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Countries With The Top 10 Cancer RatesRank Country Age-standardized rate (W) per
100,000 both sexes1 Denmark 338.12 France 324.63 Australia 323.04 Belgium 321.15 Norway 318.36 United States of America 318.07 Ireland 307.98 Republic of Korea 307.89 The Netherlands 304.810 New Caledonia 297.9
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In general, lower income countries are disproportionately impacted by cancers caused by infectious agents
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As we develop a global economy and relative affluence reaches more people in more countries, we can expect the transition of cancer epidemiology
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Colorectal Cancer Incidence
Sedentary life-styles, increase in red meat consumption and obesity increase risk for colorectal cancer
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Cervical Cancer Incidence
Yet infection-related cancer burden is still high
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The Other Side of the Cancer Epidemiology Story
High resource nations are making dramatic progress in the war on cancer
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All Cancers Mortality Rates in Denmark
143
113
Estimated annual change latest 10 years: -1.5%
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Cancer Mortality Rates in Denmark, by Major Cancer, Men
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Cancer Mortality Rates in Denmark, by Major Cancer, Women
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We are making great progress in cancer amenable to prevention or early detection … and very little progress in all other solid tumors
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Trend #2: The relentless spread of tobacco use
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• 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)
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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)
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Key Questions In The Worldwide Tobacco Fight
Policy change is paramount• Are there global, national or regional
policies that can: – Put restrictions on the tobacco industry– Reduce access to youth– Encourage reduction or cessation – De-normalize tobacco use– Raise the price of tobacco products
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Trend #3: The worldwide obesity epidemic
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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
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Select Countries’ Obesity Rates
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Obesity and the economics of prevention – Fit not fat. OECD 2010
Denmark: Men 11% of adultsand Women 12% of adults are obese
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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
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Obesity and Cancer
• 85,000 U.S. cases per year are obesity-related
Basen-Engquist K, Chang M. Curr Oncol Rep. 2011 Feb;13(1) 71-6.
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Continuation of the current obesity trend will lead to about 500,000 additional cancer cases in the US by 2030
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Obesity is Associated With Increased Risk of These Cancers … and Probably Others:
• Esophogus• Gallbladder• Colon and rectum• Breast (after menopause)• Endometrium• Kidney• Thyroid• Pancreas
www.cancer.gov/cancertopics/factsheet/risk/obesity
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Does weight loss reduce cancer risk?
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Bariatric surgery offers the most provocative data linking weight loss and reduction in cancer risk
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McGill University
1,000 surgery patients and 5,700 matched controls followed for 5 years
Cancer diagnosisSurgery group 2%Controls 8.5%
Christov NV, et.al.: Surg Obes Relat Dis. 2008 4(6) 691-5.
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The Swedish Obese Subjects (SOS) Study
Surgery Group: 2,010
ContemporaneouslyMatched controls: 2,037
Sjostrom L, et.al. Lancet Oncology 2006. Vol. 10(7) 653-662.
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S.O.S. (cont’d)Surgery Group Controls
Weight loss 19.9 kg 1.3 kg
Number of new cancers 117 169
CI 0.53-0.85p=0.0009
• Entire beneficial effect seen in women• Eliminating cancers found in the first 3
years did not change results
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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
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Obesity and Policy ResearchAre Taxes An Answer To The Obesity Epidemic?
Denmark2011 • 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
drinkshttp://www.oecd.org/dataoecd/1/61/497/6427.pdf
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Are Taxes An Answer To The Obesity Epidemic?
Hungary• 2011: Tax on high sugar, salt, and caffeine
foodsFinland• 2011: Tax on confectionary products, biscuit
buns, and pastries France• 2012: Tax on soft drinks
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Trend #4: The inversion of the age pyramid
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US population
2008
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Population Pyramids, USA
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Population Pyramids, China
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Population Pyramids, Denmark
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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
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Our aging population will lead to a tsunami of cancer
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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
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Challenge #5: Determine the true value of the early detection of cancer
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• 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
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“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
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Why are we moving away from screening?
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Randomized Trials of Cancer Screening Usually Underestimate Benefit
• Randomized trials of cancer screening are imperfect– 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
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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
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Estimating mortality reduction and over-diagnosis from a clinical trial is very difficult – requiring 15 to 20 years of follow-up for slower moving cancers
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Comparing 9- to 11-Year Follow-up9-year 11-year
Reduction in risk of death from prostate cancer 0.71 per 1000 men 1.07 per 1000 men
Number needed to invite to prevent 1 death
1410 936
Number needed to diagnose to prevent 1 death
48 33
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European Prostate Screening Trial
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Data suggest that peak benefit will not be seen till 15-20 years of follow-up
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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
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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”
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Cancers With Rising Incidence
• 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
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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.
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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
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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
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NLST – Initial Results
20% fewer lung cancer deaths in spiral CT group
Results were highly statistically significant … 7% reduction in all-cause mortality!
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Deaths Associated with Diagnostic Workup
LDC T CXRTotal Deaths: 16 10• With cancer 10 10
• Without cancer 6
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A Fundamental Challenge With Cancer Screening
The people who stand to benefit are different than the people who may experience harm
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I believe that research directed at the early detection of solid tumors offers our best opportunity to convert survivorship into cure
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Trend #6: The emergence of personalized therapy
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• 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
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We Need Personalized Treatment Not Just Personalized Therapy
Treat the right patients with the right therapies at the right stage
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Are there any models that make it acceptable and safe to choose less treatment?
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Can we subject treatment decisions to the same type of risk-benefit analysis that we apply to screening decisions?
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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
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Trend #7: The growing number of cancer survivors
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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
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Cancer Survivors
In the Danish population of 5.4 million people, more than 300 000 are cancer survivors.
USA
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The IOM Report on Cancer Survivorship
1. Recognize the distinct needs of survivors2. Comprehensive care summaries and
follow-up plans3. Clinical practice guideline4. Quality measures5. Research to test models of care
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The IOM Report (cont’d)
6. Comprehensive state and national cancer control plans
7. Educate health care providers8. Eliminate discrimination in employment9. Ensure access to care10.Increase survivorship research
Ganz P. Prim Care Clin Office Pract 36(2009), 721-741.
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Challenge #8: The urgent need to reduce the cost of care
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The Urgent Need to Reduce the Cost of Care
Our current rate of health care spending is unsustainable
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Health expenditure in Denmark
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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
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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
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Palliative care involvement at the time of diagnosis is critical…but not adequate
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The Redefinition of Hope
Hope is not another round of chemo or another day in an ICU
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In Summary …
Our success or failure in improving world wide cancer care will largely be determined by our proactive, forward-thinking approach to these 8 cancer trends
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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.