Determing the Future Course of Cancer in the World

Determing the Future Course of Cancer in the World

Richard C. Wender, MDChief Cancer Control Officer

American Cancer Society

• Eight key challenges and trends will determine the future of cancer in Denmark and around the world

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

Joannie Lortet-Tieulent

I would make the economic transition of low and middle income countries (double burden of cancers specific to poor countries and increasing cancers of rich countries) a special challenge, or change the title of the first challenge

Trend #1: The changing epidemiology of cancer deaths

The Global Burden of Cancer Continues to Increase

In 2012:14.1 million cancer cases8.2 million cancer deathsare estimated to have occurred

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

In 2012, 57% of cases and 65% of deaths occurred in the economically developed world

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

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

In general, lower income countries are disproportionately impacted by cancers caused by infectious agents

As we develop a global economy and relative affluence reaches more people in more countries, we can expect the transition of cancer epidemiology

Colorectal Cancer Incidence

Sedentary life-styles, increase in red meat consumption and obesity increase risk for colorectal cancer

Cervical Cancer Incidence

Yet infection-related cancer burden is still high

The Other Side of the Cancer Epidemiology Story

High resource nations are making dramatic progress in the war on cancer

All Cancers Mortality Rates in Denmark

143

113

Estimated annual change latest 10 years: -1.5%

Cancer Mortality Rates in Denmark, by Major Cancer, Men

Cancer Mortality Rates in Denmark, by Major Cancer, Women

We are making great progress in cancer amenable to prevention or early detection … and very little progress in all other solid tumors

Trend #2: The relentless spread of tobacco use

• 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)

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)

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


refer to the FCTCOverviewThe WHO Framework Convention on Tobacco Control (WHO FCTC) is the first treaty negotiated under the auspices of the World Health Organization. The WHO FCTC is an evidence-based treaty that reaffirms the right of all people to the highest standard of health. The WHO FCTC represents a paradigm shift in developing a regulatory strategy to address addictive substances; in contrast to previous drug control treaties, the WHO FCTC asserts the importance of demand reduction strategies as well as supply issues.The WHO FCTC was developed in response to the globalization of the tobacco epidemic. The spread of the tobacco epidemic is facilitated through a variety of complex factors with cross-border effects, including trade liberalization and direct foreign investment. Other factors such as global marketing, transnational tobacco advertising, promotion and sponsorship, and the international movement of contraband and counterfeit cigarettes have also contributed to the explosive increase in tobacco use.The core demand reduction provisions in the WHO FCTC are contained in articles 6-14:• Price and tax measures to reduce the demand for tobacco, and• Non-price measures to reduce the demand for tobacco, namely: Protection from exposure to tobacco smoke; Regulation of the contents of tobacco products; Regulation of tobacco product disclosures; Packaging and labelling of tobacco products; Education, communication, training and public awareness; Tobacco advertising, promotion and sponsorship; and, Demand reduction measures concerning tobacco dependence and cessation.The core supply reduction provisions in the WHO FCTC are contained in articles 15-17: Illicit trade in tobacco products; Sales to and by minors; and, Provision of support for economically viable alternative activities.The WHO FCTC opened for signature on 16 June to 22 June 2003 in Geneva, and thereafter at the United Nations Headquarters in New York, the Depositary of the treaty, from 30 June 2003 to 29 June 2004. The treaty, which is now closed for signature, has 168 Signatories, including the European Community, which makes it one of the most widely embraced treaties in UN history. Member States that have signed the Convention indicate that they will strive in good faith to ratify, accept, or approve it, and show political commitment not to undermine the objectives set out in it. Countries wishing to become a Party, but that did not sign the Convention by 29 June 2004, may do so by means of accession, which is a one-step process equivalent to ratification.The Convention entered into force on 27 February 2005 - 90 days after it had been acceded to, ratified, accepted, or approved by 40 States.

Trend #3: The worldwide obesity epidemic

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

Select Countries’ Obesity Rates

Obesity and the economics of prevention – Fit not fat. OECD 2010

Denmark: Men 11% of adultsand Women 12% of adults are obese

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

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.


I have not found data for Denmark yet

Continuation of the current obesity trend will lead to about 500,000 additional cancer cases in the US by 2030

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

http://www.cancer.gov/cancertopics/factsheet/risk/obesity

Does weight loss reduce cancer risk?

Bariatric surgery offers the most provocative data linking weight loss and reduction in cancer risk

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.

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.

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

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

http://www.cancer.gov/cancertopics/factsheet/risk/obesity


is it per year, or overall? what are the timelines (by 2025 for example)?

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

http://www.oecd.org/dataoecd/1/61/497/6427.pdf

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

Trend #4: The inversion of the age pyramid

US population

2008


is this for the USA?

Population Pyramids, USA

Population Pyramids, China

Population Pyramids, Denmark

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

Our aging population will lead to a tsunami of cancer

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

Challenge #5: Determine the true value of the early detection of cancer

• 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

“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


Is it a quote from the past? (please add year). Ahmedin and I think this is a strong assumption that does not hold true given current treatment options. Maybe in the future...


add year.And what about non-solid tumors?Not all brain tumors can be removed. Some even kill the patient when still relatively small.

Why are we moving away from screening?

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

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

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

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

European Prostate Screening Trial

Data suggest that peak benefit will not be seen till 15-20 years of follow-up

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

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”

Cancer Mortality in U.S. Men

http://www.jefferson.edu/

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

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.


2014?


http://www-dep.iarc.fr/NORDCAN/english/animated-maps.asp?cancer=251&sex=1&submit=%A0%A0%A0Execute%A0%A0%A0there's a video of the increae, with one map every 5-year period.Available on NORDCANONLINE ANALYSIS Incidence/moralityCancer MapTestis

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

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

NLST – Initial Results

20% fewer lung cancer deaths in spiral CT group

Results were highly statistically significant … 7% reduction in all-cause mortality!

Deaths Associated with Diagnostic Workup

LDC T CXRTotal Deaths: 16 10• With cancer 10 10

• Without cancer 6

A Fundamental Challenge With Cancer Screening

The people who stand to benefit are different than the people who may experience harm

I believe that research directed at the early detection of solid tumors offers our best opportunity to convert survivorship into cure

Trend #6: The emergence of personalized therapy

• 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

We Need Personalized Treatment Not Just Personalized Therapy

Treat the right patients with the right therapies at the right stage

Are there any models that make it acceptable and safe to choose less treatment?

Can we subject treatment decisions to the same type of risk-benefit analysis that we apply to screening decisions?

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

Trend #7: The growing number of cancer survivors

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

Cancer Survivors

In the Danish population of 5.4 million people, more than 300 000 are cancer survivors.

USA

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

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.

Challenge #8: The urgent need to reduce the cost of care

The Urgent Need to Reduce the Cost of Care

Our current rate of health care spending is unsustainable

Health expenditure in Denmark

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

http://www.healthleadersmedia.com/

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

~~

Palliative care involvement at the time of diagnosis is critical…but not adequate

The Redefinition of Hope

Hope is not another round of chemo or another day in an ICU

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

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.

http://www.jefferson.edu/

Documents

Determing the Future Course of Cancer in the World