www.worldcancercongress.org

Session code:

The 2nd Edition of The Cancer Atlas

Cancer Interventions and Potential for Impact

Ahmedin Jemal, DVM, PhD American Cancer Society

CTS.4.230

PRIMARY PREVENTION

EARLY DETECTION

TREATMENT

SURVIVORSHIP & QUALITY OF

LIFE

END-OF-LIFE CARE

e.g.,

Tobacco control

Vaccination

e.g.,

Pap test/VIA

Mammography

Colonoscopy

e.g.,

Radiotherapy

Surgery

Chemotherapy

e.g.,

Psychosocial care

e.g.,

Pain control

Interventions Across the Cancer Continuum

05 December, 2014

Tobacco

•  1.3 billion smokers worldwide (most in LMIC)

•  1 in 2 regular smokers die of smoking-related diseases, about 6 million deaths each year (Doll et al. BMJ 1994)

•  Compared to never smokers, smokers shortened their life expectancy by:

•  ≥10 years (all smokers) •  ~ 20 years (die from smoking-related diseases in middle age) (Doll et al. BMJ 2004, Jha et al NEJM 2013)

Effect of Smoking Cessation on Survival to 80 Years of Age, According to Four Age Groups at the Time of Quitting

Jha and Peto. N Engl J Med 2013;368:341-350.

Age 45-54

Age 35-44

Age 55-64

Age 25-34

10 years gained

9 years gained

6 years gained

4 years gained

Tools to Promote Cessation & Discourage Initiation

MPOWER In 2008, WHO introduced the MPOWER measures to assist in country-level implementation of the WHO FCTC provisions.

MPOWER MEASURES M

MONITOR tobacco use and prevention policies P

PROTECT people from tobacco smoke O

OFFER help to quit tobacco use W

WARN about the dangers of tobacco E

ENFORCE bans on tobacco advertising, promotion, and sponsorship R

RAISE taxes on tobacco

48%

14% 6%

14%

8% 10%

Tax contribution Ad bans Anti-smoking campaigns Smoke-free laws Warning labels Cessation programs

•  Aggressively implemented tobacco control measures since 1989 •  Smoking prevalence decreased by 46% by 2010

Effects of Tobacco Control Policies in Brazil

Levy D, et al. PLoS Med. 2012; 9(11): e1001336.

Estimated contributions of tobacco control measures to declines in tobacco use:

ü  420,000 deaths (1989-2010) ü  6.6 million deaths in 40 years

Averted Deaths

Cigarette price ↑ 230%

Share of Total Taxes in the Retail Price of the Most Widely Sold Brand of Cigarettes, 2012

WHO Report on the Global Tobacco Epidemic, 2013

Note: Tobacco sales were banned in Bhutan in 2012.

In only 32 countries does the share of cigarette tax exceed 75% of retail price

Vaccinations

Hepatitis B virus (HBV) infection

Human papillomavirus (HPV) infection

Infections cause 16% of cancers worldwide, 2 million cases/year

HBV Infection & Vaccine (Background) HBV Infection Vaccine

•  2 billion total population infected

•  360 million chronically infected (sub-Saharan Africa, Asia)

•  340,000 liver cancer cases (500,000-700,000 deaths from liver cancer & cirrhosis) each year

•  Available since 1982

•  3 doses, 1st dose within 24 hrs after birth

•  Taiwan, 1st country to introduce nationwide infant vaccination program in 1984

The Effect of Taiwan’s 30-Year National Hepatitis B Immunization Program on Liver Cancer Incidence Rates

Chiang et al. JAMA. 2013;310(9):974-976.

80% lower

Rate

per 1

00,00

0

Age-specific incidence rate by sex in cohorts born before and after the implementation of the program, 1984

*Countries with no data may represent countries where hepatitis B is not endemic (e.g. Scandinavian countries) and national hepatitis B vaccination programs have not been introduced.

WHO, 2013.

Percentage of One-year-olds Given the Three-series Hepatitis B Vaccination,* 2012 183 countries introduced

national HBV vaccination program as of 2012

HPV Vaccination (Background) •  12 high-risk oncogenic HPV types are responsible for

•  Nearly all cervical cancers (530,000 cancer cases/year) •  40-90% of vaginal, vulvar, penile, anal cancers •  26% of oropharyngeal cancers

•  HPV 16/18 infections account for •  70% of cervical cancers •  90% of remaining HPV-related cancers

•  HPV 6/11 (low risk) cause 90% of genital warts

Two Prophylactic Vaccines Against HPV infections •  Quadrivalent vaccine (16/18/6/11): available since 2006 •  Bivalent vaccine (16/18): available since 2007

•  WHO recommends 2-dose series for girls aged 9-13 years, prior to initiation of sexual activity (Weekly epidemiological record, No. 43, 24 October 2014)

•  Indicated for prevention of cervical, anal, vaginal, vulvar, and penile

pre-cancerous lesions and genital warts

Real World Evidence for the Effectiveness of the HPV Vaccine

<18 years 18-20 years

21-25 years 26-30 years

≥30 years

Australia introduced 3-dose HPV vaccine in 2007

Figure: Trends in incidence of high-grade cervical abnormalities before and after the implementation of the program in Victoria, Australia, in four age groups (Brotherton et al. Lancet. 2011; 377:2085-92)

HPV Vaccine Introduction 45 countries have introduced the vaccine nationally as of 2013 Cost of vaccine (US$100 per dose): major barrier to the introduction of vaccine in LMIC GAVI: low price (US$4.50 per dose) for low-income countries

WHO, 2013

Since 2013, GAVI has funded HPV vaccine demonstration projects in 20 countries (yellow dots), and funds the national HPV vaccine program in Rwanda

Rwanda: 93% coverage

US: 37% coverage

9-Valent Vaccine, Under FDA Regulatory Assessment

Luxembourg, Sanjose et al. Lancet Oncol. 2010; 11:1048-56.

Contribution of 9-valent vaccine to cervical cancer worldwide

Early Detection

Cervical cancer Colorectal cancer Breast cancer Lung cancer

0  

10  

20  

30  

40  

50  

60  

1980   1985   1990   1995   2000   2005  

Limited Progress in Reducing Cervical Cancer in LMIC

High-Income Countries Low- and Middle-Income Countries R

ate

per 1

00,0

00

CI5 Plus

Uganda (Kyadondo County)

0  

10  

20  

30  

40  

50  

60  

1980   1985   1990   1995   2000   2005  

Denmark  

UK  (Scotland)  

Australian  Capital  Territory  

USA  (SEER  9,  White)  Brazil (Goiania) Colombia

(Cali)

Philippines (Manilla)

Most of the countries without HPV vaccine introduction also lack screening programs

IARC, 2014.

Countries without Large-scale Cervical Cancer Screening

Note: Countries without large-scale screening may have subnational programs or limited availability of screening

0.65

0.34 0.55

0.99

0.0

0.5

1.0

1.5

2.0

0 1 2 3 4

Visual Inspection With Acetic Acid & HPV DNA Test

Cumulative prevalence of high-grade cervical abnormalities at 12 months, South Africa (Denny et al, JAMA 2005)

1.42

2.91

5.41

0.0

2.0

4.0

6.0

8.0

0 1 2 3 HPV DNA Group

N=2,163

VIA Group

N=2,227

Delayed Evaluation

(Control) Group N=2,165

Overall 30-59 years

30-39 years

50-59 years

40-49 years

Pre

vale

nce

(%)

Haz

ard

ratio

Hazard ratio for cervical cancer deaths by age, India- VIA Screening (Sankaranarayanan et al. Lancet 2007)

Integration of cervical cancer screening programs into health systems of LMICs

•  Rwanda, national cervical cancer screening program using Care HPV DNA Test and VIA with support from Merck (Binagwaho et al., Bull World Health Organ 2013)

•  HIV care services, Zambia, Zimbabwe, Kenya, Botswana

Inequalities in Availability of Cancer Treatment

Surgery Radiation Chemotherapy

International Atomic Energy Agency, 2014.

Availability of Radiotherapy for Percentage of Cancer Patients by Country

*Disparities in access to radiotherapy may still exist in those countries with 100% coverage

•  1 radiotherapy machine treats 500 patients per year •  60% of cancer patients benefit from radiotherapy

5,000 additional radiotherapy machines are required to meet patient needs in LMIC

%= #  𝑚𝑎𝑐ℎ𝑖𝑛𝑒𝑠  ∗500  𝑐𝑎𝑠𝑒𝑠/0.6  ∗𝑛𝑒𝑤  𝑐𝑎𝑠𝑒𝑠/𝑦𝑒𝑎𝑟  * 100  

Conclusions

•  Many proven interventions for primary prevention, early detection, and treatment—but large geographic inequalities in the availability of services remain

•  Expansion of known interventions to low- and middle- income countries requires innovative solutions, commitment and collaboration

Thank You!