Kara P Wiseman MPH Division of Epidemiology Department of family medicine and Population Health April 6 2015 Outline What is cancer Cancer statistics Cancer prevention and early detection ID: 1041147
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1. CancerEPID 624 - Epidemiology of Chronic DiseaseKara P. Wiseman, MPHDivision of Epidemiology, Department of family medicine and Population HealthApril 6, 2015
2. OutlineWhat is cancer?Cancer statisticsCancer prevention and early detectionCancer disparitiesCancer survivorshipCancer research
3. What is cancer?Disease in which abnormal cells divide without control and are able to invade other tissuesMore than 100 types of cancer1,655,540 new cases expected in 2014Causes of cancerCancer arises from malfunctions in genes that control cell growth and divisionExternal and internal factors impact risk of genetic mutationsExternal factor could be exposure to radiationInternal factors would be inherited genetic mutationsBRCA1 and BRCA2Inherited mutations among different races/ethnicities like prostate cancer risk in African American men
4. Who is at risk?Approximately 13.7 million Americans with a history of cancer were alive on Jan 1, 2012Anyone can develop cancerRisk increases with age77% of all cancers diagnosed in people ≥55 years of age
5. Different ways to talk about cancer riskLifetime riskRelative risk
6. Cancer incidence Incident ratesRisk of new cases among population at riskImportant for cancer epidemiology.
7. Incidence graphs for men and women
8. Cancers with increasing incidence trends
9. Cancer with decreasing incidence trends
10. Estimated number of new cases of cancer by state, 2014
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12. Cancer prevalenceWho has cancer right now out of everyone in the populationIncludes people who are living with cancerIncidence and survival impact specific cancer prevalence.
13. MalesFemalesProstate - 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%)Estimated numbers of survivors for the 10 most prevalent cancer
14. Cancer mortalityIn 2014, about 585,720 Americans are expected to die of cancer Cancer is second most common cause of cancer death in the US
15. Mortality graphs for men and women
16. Stage of diagnosisCan be expressed as numbersI, II, III, IVCan be expressed as description of disease spreadLocalized, regional, distantLower number or more localized = better chances of benefiting from treatmentTracking the rates of late-stage (distant) cancers is a good way to monitor the impact of cancer screening. When more cancers are detected in early stages, fewer should be detected in late stages.
17. Rate of cancers diagnosed at a later stage
18. Cancer survival5-year relative survival rate for all cancers diagnosed between 2003 and 2009 is 68%Was 49% in 1975-1977 What leads to improvements in cancer survival?Progress in diagnosing cancers at an earlier stage Improvements in treatmentSurvival varies by cancer type and stage of diagnosisHow is survival measured?Relative survival – compare survival among cancer patients to people not diagnosed with cancer with same age, race, and sexUsually examined 5 years after diagnosisCan look at survival by year at diagnosisCan look at survival by years since diagnosis
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20. Five-year Relative Survival Rates (%) by Race and Stage at Diagnosis, 2003-2009
21. How can cancer be prevented?What are non-modifiable risk factors of cancer?AgeCancer specific factorsInherited genetic mutationsBRCA 1 and BRCA2What are modifiable risk factors of cancer?Modifiable risk factors for cancer in general.ExerciseDietSpecific examplesLung cancer and smoking
22. Early detection of cancerFinding cancer at an earlier stage when it is easier to treatWhy is early detection important?Reduces cancer mortalityCan sometimes prevent cancer and decrease cancer incidenceNational recommendations are made by US Preventive Services Task ForceCritical review of the literature on each screening test Consider the evidence for efficacy/effectiveness as well as potential harms of screening Strict criteria on study designs of evidence that is consideredUSPSTF guidelines set precedent for what screening tests are covered by Medicare/private insurance
23. USPSTF screening guidelines – Colorectal cancer
24. USPSTF screening guidelines – Lung & prostate cancer
25. USPSTF screening guidelines – Breast cancer
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27. Early detection, continuedOther organizations also put out screening guidelines. Don’t always match with USPSTFWhat difficulties could this cause?USPSTFAmerican Cancer Society
28. Cancer Health disparitiesWhat is a cancer health disparity?Different types of groups can be used to identify/examine cancer health disparitiesSocioeconomic statusGeographic regionRace/ethnicityGenderCauses of health disparitiesComplex interaction of many factorsSocialCulturalEconomicEnvironmentalHealth care-related
29. Socioeconomic status (SES)People with lower SES have disproportionately higher cancer death rates than those with higher SES, regardless of demographic factors such as race/ethnicity. 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.Why might this be?People with lower SES have increased risk of getting cancer and worse outcomes once diagnosedBut really, why?
30. Race/ethnicityWhat are we really looking at when we compare cancer rates be different racial groups?Genetic factors?Social factors?Behavioral factors? Reflection of obstacles to receiving healthcare services including cancer prevention, early detection and good quality cancer treatmentPovertyPercent living below the poverty line28% African Americans25% Hispanics10% non-Hispanic whites DiscriminationCultural/inherited factors
31. Different ways to measure health disparitiesLook for differences in IncidenceLate stage-diagnosisMortalitySurvival
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33. Incidence by race - Men
34. Mortality by race - Men
35. Incidence rates by race - Women
36. Mortality rates by race - Women
37. Cancer disparities – diagnosed at later stage
38. Cancer disparities - Cancer survival
39. Cancer disparities - Geography
40. Cancer survivorshipDefinition variesSurvivor from time of diagnosis?Survivor after completing treatment?Survivor after surviving 5 years after treatment?~ 14.5 million adult or childhood cancer survivors in the US on Jan 1, 2014~ 19 million estimated for 2024
41. Post treatment follow-up careMonitoring after completion of cancer treatmentLate-effectsLong-term effectsEvidence-based guidelines for post-treatment care existNational Comprehensive Care Network (NCCN)American Society of Clinical Oncology (ASCO)Provider responsible for follow-up is not explicitly statedSpecialist vs. primary care follow-up careSpecialist is traditional source of careBreast cancer: Two RCTs of oncology vs. primary care follow-up showed similar outcomes
42. Follow-up care patterns – breast cancerExisting research on who breast cancer survivors see for their care post-treatment is limitedOnly include early stage breast cancerOnly examined follow-up care until 5 years after treatment completionPatient populations not representative of USUse of registry, claims, or medical records dataOne study assessed patients’ perception of the provider responsible for their follow-up care 4 years after diagnosis (N=844)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
43. Who do breast cancer survivors see for the majority of their care?Wiseman, KP (2015)
44. Wiseman, KP (2015)
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46. Priority research areas in cancerHow would you learn about cancer research priorities?
47. NCI Cancer research prioritiesBuilding on cancer genomics discoveriesImmunotherapyPreventing childhood cancersDeveloping therapies for RAS-driven cancersNew strategies for cancer prevention