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Cancer Epidemiology and Cancer Epidemiology and Cancer PreventionCancer Prevention
Epidemiology 242Epidemiology 242
December 2, 2009December 2, 2009
Age Standardized Incidence Rates (/100,000)Age Standardized Incidence Rates (/100,000)
US China World
Site Males Females Males Females Males Females
Stomach 7.2 3.3 41.4 19.2 22.0 10.3
Lung 61.9 36.1 42.4 19.0 35.5 12.1
Liver 5.5 2.0 37.9 14.2 15.7 5.8
Esophagus 4.9 1.3 27.4 12.0 11.5 4.7
Colon/Rectum 44.6 33.1 13.6 9.2 20.1 14.6
Breast ─ 101.1 ─ 18.7 ─ 37.5
Leukemia 11.2 7.4 5.7 4.1 5.9 4.1
Pancreas 8.3 6.3 3.9 2.6 4.6 3.3
Cervix 0 7.7 0 6.8 0 16.2
Brain 6.5 4.5 3.9 2.8 3.7 2.6
Prostate 124.8 0 1.6 0 25.3 0
Source: GLOBOCAN 2002
The Major CancersThe Major Cancers
Lung (ICD-10 C33 and C34)Lung (ICD-10 C33 and C34) Breast (female, C50)Breast (female, C50) Colon/rectum (C18-C20)Colon/rectum (C18-C20) Stomach (C16)Stomach (C16) Prostate (C61)Prostate (C61) Liver (C22)Liver (C22) Cervix uteri (C53)Cervix uteri (C53) Esophagus (C15)Esophagus (C15)
2009 Estimated US Cancer Cases*2009 Estimated US Cancer Cases*
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2009.Source: American Cancer Society, 2009.
MenMen766,130766,130
WomenWomen713,220713,220
27%27% BreastBreast
14%14% Lung & bronchusLung & bronchus
10%10% Colon & rectumColon & rectum
6%6% Uterine corpus Uterine corpus
4%4% Non-HodgkinNon-Hodgkin lymphoma lymphoma
4%4% Melanoma of skinMelanoma of skin
4% Thyroid4% Thyroid
3%3% Kidney & renal pelvisKidney & renal pelvis
3%3% OvaryOvary
3%3% PancreasPancreas
22%22% All Other SitesAll Other Sites
ProstateProstate 25%25%
Lung & bronchusLung & bronchus 15%15%
Colon & rectumColon & rectum 10%10%
Urinary bladderUrinary bladder 7%7%
Melanoma of skinMelanoma of skin 5%5%
Non-HodgkinNon-Hodgkin5% 5% lymphoma lymphoma
Kidney & renal pelvisKidney & renal pelvis 5%5%
Leukemia Leukemia 3%3%
Oral cavityOral cavity 3%3%
PancreasPancreas 3%3%
All Other SitesAll Other Sites 19%19%
2009 Estimated US Cancer Deaths*2009 Estimated US Cancer Deaths*
ONS=Other nervous system.ONS=Other nervous system.Source: American Cancer Society, 2009.Source: American Cancer Society, 2009.
MenMen292,540292,540
WomenWomen269,800269,800
26%26% Lung & bronchusLung & bronchus
15%15% BreastBreast
9%9% Colon & rectumColon & rectum
6%6% PancreasPancreas
5%5% OvaryOvary
4%4% Non-HodgkinNon-Hodgkin lymphoma lymphoma
3%3% LeukemiaLeukemia
3%3% Uterine corpusUterine corpus
2%2% Liver & intrahepatic Liver & intrahepaticbile ductbile duct
2%2% Brain/ONSBrain/ONS
25% All other sites25% All other sites
Lung & bronchusLung & bronchus 30%30%
ProstateProstate 9%9%
Colon & rectum Colon & rectum 9%9%
PancreasPancreas 6%6%
LeukemiaLeukemia 4%4%
Liver & intrahepaticLiver & intrahepatic 4%4%bile ductbile duct
EsophagusEsophagus 4%4%
Urinary bladderUrinary bladder 3% 3%
Non-Hodgkin 3% Non-Hodgkin 3% lymphoma lymphoma
Kidney & renal pelvisKidney & renal pelvis 3%3%
All other sites 25%All other sites 25%
Cigarette Smoking Cigarette Smoking and Cancer Riskand Cancer Risk
Adult Per Capita Cigarette Consumption and Adult Per Capita Cigarette Consumption and Major Smoking and Health Events – United States, Major Smoking and Health Events – United States,
1900-20011900-2001
0
1000
2000
3000
4000
5000
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000YEAR
Nu
mb
er o
f C
igar
ette
s
Source: United States Department of Agriculture
End of WW II
1st Smoking-Cancer Concern
Fairness Doctrine Messages on TV
and Radio
Non-Smokers Rights Movement
Begins
Federal Cigarette Tax Doubles
Surgeon General’s Report on ETS
1st Surgeon General’s
Report
1st World Conference on Smoking and Health
Broadcast Ad Ban
1st Great American Smoke-out
OTC Nicotine Medications
Master Settlement Agreement
Great Depression
Tobacco Use in the US, 1900-2005Tobacco 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
Per
Cap
ita
Cig
aret
te C
on
sum
pti
on
0
10
20
30
40
50
60
70
80
90
100
Ag
e-A
dju
sted
Lu
ng
Can
cer
Dea
th
Rat
es*
*Age-adjusted to 2000 US standard population. *Age-adjusted to 2000 US standard population.
Source: Death rates: US Mortality Data, 1960-2005, US Mortality Volumes, 1930-1959, National Center for Source: Death rates: US Mortality Data, 1960-2005, US Mortality Volumes, 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006. Cigarette consumption: US Department of Health Statistics, Centers for Disease Control and Prevention, 2006. Cigarette consumption: US Department of Agriculture, 1900-2007.Agriculture, 1900-2007.
Per capita cigarette Per capita cigarette consumptionconsumption
Male lung cancer Male lung cancer death ratedeath rate
Female lung Female lung cancer death ratecancer death rate
MenMen
Women
0
10
20
30
40
50
60
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
YEAR
% C
UR
RE
NT
SM
OK
ER
STrends in cigarette smoking* among adults aged
>18 years, by sex - United States, 1955-2002
Source: 1955 Current Population Survey; 1965-2002 National Health Interview Survey; 2002 estimates for first quarter only
*Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day day or some days.
24.5%
18.8%
Smoking and Other CancersSmoking and Other Cancers
Head and neck cancers (oral, laryngeal Head and neck cancers (oral, laryngeal and pharyngeal cancers)and pharyngeal cancers)
Esophageal cancerEsophageal cancer Stomach cancerStomach cancer Pancreatic CancerPancreatic Cancer Bladder cancerBladder cancer Cervical cancerCervical cancer Liver cancerLiver cancer
Environmental Tobacco SmokeEnvironmental Tobacco Smoke
3,000 nonsmoking Americans die of 3,000 nonsmoking Americans die of lung cancerlung cancer
300,000 children suffer from lower 300,000 children suffer from lower respiratory tract infections.respiratory tract infections.
Major Infection-Associated Major Infection-Associated MalignanciesMalignancies
In 2002, 17.8% of the global cancer burden (1.9 In 2002, 17.8% of the global cancer burden (1.9 million cases) were infection-attributablemillion cases) were infection-attributable
Malignancy (infection)Malignancy (infection) Stomach cancer (Stomach cancer (Helicobactor pyloriHelicobactor pylori)) Cervical cancer (human papillomavirus)Cervical cancer (human papillomavirus) Liver cancer (hepatitis B and C viruses)Liver cancer (hepatitis B and C viruses) Burkitt’s lymphoma and nasopharyngeal cancer Burkitt’s lymphoma and nasopharyngeal cancer
(Epstein-Barr virus)(Epstein-Barr virus) Kaposi sarcoma and Non-Hodgkin lymphoma Kaposi sarcoma and Non-Hodgkin lymphoma
(HIV/HHV-8)(HIV/HHV-8) Bladder and colon cancer (schistosomiasis)Bladder and colon cancer (schistosomiasis) Adult T-cell leukemia/lymphoma (human T-cell Adult T-cell leukemia/lymphoma (human T-cell
lymphotropic virus type I)lymphotropic virus type I)
Mechanisms of Infection-Induced Mechanisms of Infection-Induced MalignancyMalignancy
Chronic Inflammation and CarcinogenesisChronic Inflammation and Carcinogenesis Chronic host-pathogen interactionChronic host-pathogen interaction
ImmunosuppressionImmunosuppression Chronic inflammationChronic inflammation
Oxidative StressOxidative StressDNA damage and mutationsDNA damage and mutationsCell injuryCell injuryCell divisionCell division
Infection inducing Cell proliferationInfection inducing Cell proliferation
Production of Oncogenic ProteinsProduction of Oncogenic Proteins
Genomic Instability from Viral Genomic IntegrationGenomic Instability from Viral Genomic Integration
Cancers attributable to infections Cancers attributable to infections worldwide, 2002worldwide, 2002
Source: Parkin, Source: Parkin, 20062006
3131
9 Possible Mechanisms How Alcohol Intake Increase Cancer Risk9 Possible Mechanisms How Alcohol Intake Increase Cancer Risk
According to Blot et al (1992)According to Blot et al (1992)
1. Contain congeners and other contaminants that 1. Contain congeners and other contaminants that may be carcinogenic may be carcinogenic
2. Generated metabolites that are carcinogenic to 2. Generated metabolites that are carcinogenic to humans humans
3. Act as solvent, increasing penetration of other 3. Act as solvent, increasing penetration of other carcinogens into target tissue carcinogens into target tissue
4. Reduce intake and bioavailability of nutrition 4. Reduce intake and bioavailability of nutrition 5. Inhibit the detoxification of carcinogenic 5. Inhibit the detoxification of carcinogenic
compoundscompounds6. Catalyze the metabolic activation of some 6. Catalyze the metabolic activation of some
compounds into carcinogens compounds into carcinogens 7. Affect hormonal status 7. Affect hormonal status 8. Increase cellular exposure to oxidants 8. Increase cellular exposure to oxidants 9. Suppress immune function 9. Suppress immune function
3232
What is What is ““a Drinka Drink””??
Despite the differences in concentration, the Despite the differences in concentration, the average intake of ethanol per drink is average intake of ethanol per drink is approximately constant across beverage types.approximately constant across beverage types.
A standard drink is:A standard drink is:• One 12-ounce bottle of beer* or wine cooler One 12-ounce bottle of beer* or wine cooler • One 5-ounce glass of wine One 5-ounce glass of wine • 1.5 ounces of 80-proof1.5 ounces of 80-proof++ distilled spirits. distilled spirits.
* Different beers have different alcohol content. Malt liquor has a higher alcohol content than most * Different beers have different alcohol content. Malt liquor has a higher alcohol content than most other brewed beverages.other brewed beverages.
++ 80-proof== 40% ABV (alcohol by volume) 80-proof== 40% ABV (alcohol by volume)
Cancer PreventionCancer Prevention
S Lippman, Cancer Res. 2009 Jul 1;69(13):5269-84S Lippman, Cancer Res. 2009 Jul 1;69(13):5269-84
Known risk factorsKnown risk factors
Smoking causes most cancers in Smoking causes most cancers in smokers.smokers.
Among non-smokers, most cancers Among non-smokers, most cancers are of unknown cause.are of unknown cause.
Infection causes most cancers in the Infection causes most cancers in the lowest-income countries.lowest-income countries.
Avoidable Known Cancer Risks USAAvoidable Known Cancer Risks USA
Proven Cancer Prevention StrategiesProven Cancer Prevention StrategiesCompelling non-RCT EvidenceCompelling non-RCT Evidence
Risk Factor AvoidanceRisk Factor AvoidanceSmoking prevention/cessation counselingSmoking prevention/cessation counselingWorker exposure reduction (asbestos, etc.)Worker exposure reduction (asbestos, etc.)
ImmunizationImmunizationHepatitis BHepatitis B
HPVHPV ScreeningScreening
Cervical PAP testingCervical PAP testing
Proven Cancer Prevention StrategiesProven Cancer Prevention StrategiesRCT EvidenceRCT Evidence
Screening Screening
Mammography with Clinical Breast Mammography with Clinical Breast ExamExam
Fecal Occult Blood Test (colorectal Fecal Occult Blood Test (colorectal cancer)cancer)
BRIDGING THE GAP BETWEEN CANCER TREATMENT AND PREVENTIONBRIDGING THE GAP BETWEEN CANCER TREATMENT AND PREVENTION(William WN, et al, Nat Rev Drug Discov. 2009 Mar;8(3):213-25.)(William WN, et al, Nat Rev Drug Discov. 2009 Mar;8(3):213-25.)
Widely-Accepted Prevention StrategiesWidely-Accepted Prevention StrategiesInsufficient or Negative EvidenceInsufficient or Negative Evidence
Oral cancer screening examinationOral cancer screening examination PSA testing for prostate cancerPSA testing for prostate cancer Lung cancer screening with CT or Lung cancer screening with CT or
XrayXray Dietary change: More vegetables Dietary change: More vegetables
and fruitsand fruits Dietary change: Less fatDietary change: Less fat Dietary antioxidant supplementsDietary antioxidant supplements Weight loss and exerciseWeight loss and exercise Sun avoidance: skin cancerSun avoidance: skin cancer
How Many Cancer Deaths/YrHow Many Cancer Deaths/Yr Could we Prevent Now? Could we Prevent Now?
Tobacco ControlTobacco Control
ScreeningScreening
Infection ControlInfection Control
How Many Cancer Deaths/YrHow Many Cancer Deaths/Yr Could we Prevent Now? Could we Prevent Now?
Tobacco-Caused Cancers – 1.15 million Tobacco-Caused Cancers – 1.15 million deathsdeaths
LungLung 75% of 1,300,000 deaths75% of 1,300,000 deaths
OropharynxOropharynx 40% of 320,000 deaths40% of 320,000 deaths
Other sitesOther sites 15% of 350,000 deaths15% of 350,000 deaths
How Many Cancer Deaths/YrHow Many Cancer Deaths/Yr Could we Prevent Now? Could we Prevent Now?
Screen-detectable cancers – 660,000 Screen-detectable cancers – 660,000 deathsdeaths
ColorectalColorectal 50% of 620,000 deaths50% of 620,000 deaths
CervixCervix 90% of 230,000 deaths90% of 230,000 deaths
BreastBreast 30% of 475,000 deaths30% of 475,000 deaths
How Many Cancer Deaths/YrHow Many Cancer Deaths/Yr Could we Prevent Now? Could we Prevent Now?
Infection-related Cancers – 750,000 deathsInfection-related Cancers – 750,000 deaths
Liver (immunization)Liver (immunization) 40% of 600,000 40% of 600,000 deathsdeaths
Stomach (antibiotics)Stomach (antibiotics) 60%? of 850,000 60%? of 850,000 deathsdeaths
[Cervix (immunization)][Cervix (immunization)] 50% of 230,000 50% of 230,000 deaths]deaths]
How Many Cancer Deaths/YearHow Many Cancer Deaths/Year Could we Prevent Now? Could we Prevent Now?
Tobacco programs 1,115,000 at low costTobacco programs 1,115,000 at low cost
Infection ControlInfection Control 750,000 at low/moderate 750,000 at low/moderate costcost
Screening Screening 660,000 at low/very high 660,000 at low/very high costcost
Total deaths preventable: about 2.5 Total deaths preventable: about 2.5 Million of the 7.5 million deaths/year from Million of the 7.5 million deaths/year from cancer worldwidecancer worldwide
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