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Determing the Future Course of Cancer in the World Richard C. Wender, MD Chief Cancer Control Officer American Cancer Society.

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Presentation on theme: "Determing the Future Course of Cancer in the World Richard C. Wender, MD Chief Cancer Control Officer American Cancer Society."— Presentation transcript:

1 Determing the Future Course of Cancer in the World Richard C. Wender, MD Chief Cancer Control Officer American Cancer Society

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

3 1.The changing epidemiology of cancer deaths 2.The relentless spread of tobacco use 3.The obesity epidemic 4.The inversion of the age pyramid 5.Determining the true value of the early detection of cancer 6.The emergence of personalized treatment 7.The growing number of cancer survivors 8.The urgent need to reduce the cost of care

4 Trend #1: The changing epidemiology of cancer deaths

5 The Global Burden of Cancer Continues to Increase In 2012: 14.1 million cancer cases 8.2 million cancer deaths are estimated to have occurred

6 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

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

8 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

9 Countries With The Top 10 Cancer Rates RankCountryAge-standardized rate (W) per 100,000 both sexes 1Denmark338.1 2France324.6 3Australia323.0 4Belgium321.1 5Norway318.3 6United States of America318.0 7Ireland307.9 8Republic of Korea307.8 9The Netherlands304.8 10New Caledonia297.9

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

11 Tobacco related cancers are on the rise

12 Estimated new cases

13 Developed Counties Estimated deaths

14 Estimated new cases

15 Developing Counties Estimated deaths

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

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

18 Cervical Cancer Incidence Yet infection- related cancer burden is still high

19 The Other Side of the Cancer Epidemiology Story High resource nations are making dramatic progress in the war on cancer

20 Denmark: 2011 Cancer Statistics 52% of all deaths were due to cancer of the lung, breast, colorectum and prostate Lung cancer was the leading cancer death in men and in women, representing 23% of cancer deaths From 2001-2011, mortality rates for all cancers have fallen by 1.5% annually

21 All Cancers Mortality Rates in Denmark 143 113 Estimated annual change latest 10 years: -1.5%

22 Cancer Mortality Rates in Denmark, by Major Cancer, Men

23 Cancer Mortality Rates in Denmark, by Major Cancer, Women

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

25 Trend #2: The relentless spread of tobacco use

26 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)


28 Smoking Prevalence and Lung Cancer Incidence in Denmark Lortet-Tieulent et al. European Journal of Cancer. 2013 40 years

29 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)

30 National Cancer Institute (NCI) has called for Transdisciplinary Tobacco Research Centers to study: – Initiation of tobacco use – Prevention of tobacco use – Addiction to tobacco – Treatment of tobacco addiction – Treatment of tobacco related cancers

31 Is the NCI tobacco research plan in sync with anti-tobacco alternatives that are proven to work?

32 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

33 Are therapeutic efforts to promote cessation cost-effective compared to policy changes? Are there new medications in the pipeline?

34 What is the impact of FDA regulation on tobacco use?

35 Trend #3: The worldwide obesity epidemic

36 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

37 Select Countries’ Obesity Rates

38 Obesity and the economics of prevention – Fit not fat. OECD 2010 Denmark: Men 11% of adults and Women 12% of adults are obese

39 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

40 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.

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

42 Obesity is Associated With Increased Risk of These Cancers … and Probably Others: Esophogus Gallbladder Colon and rectum Breast (after menopause) Endometrium Kidney Thyroid Pancreas

43 How Does Body Weight Affect Cancer Risk? Immune system function and inflammation Hormones – insulin and estrogen Factors regulating cell division: e.g. insulin like growth factor (IGF-1) Protein influencing hormone binding and metabolism: e.g. sex hormone binding globulin

44 Does weight loss reduce cancer risk?

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

46 McGill University 1,000 surgery patients and 5,700 matched controls followed for 5 years Cancer diagnosis Surgery group2% Controls8.5% Christov NV, Surg Obes Relat Dis. 2008 4(6) 691-5.

47 The Swedish Obese Subjects (SOS) Study Surgery Group:2,010 Contemporaneously Matched controls:2,037 Sjostrom L, Lancet Oncology 2006. Vol. 10(7) 653-662.

48 S.O.S. (cont’d) Surgery GroupControls Weight loss19.9 kg1.3 kg Number of new cancers117169 CI 0.53-0.85 p=0.0009 Entire beneficial effect seen in women Eliminating cancers found in the first 3 years did not change results

49 NCI Best Estimate If every adult reduced their BMI by 1 percent, this could actually result in the avoidance of 100,000 new cases

50 We have an urgent need for research designed to tackle the obesity epidemic

51 Obesity Research 1.Biological – What are the physiologic links between over-eating, under-exercising, overweight, obesity, initiation of cancer, response to treatment, and risk of metastasis? 2.Benefits of treatment – Does weight loss alter cancer risk? – How much weight loss is enough?

52 Obesity and Policy Research Are Taxes An Answer To The Obesity Epidemic? Denmark 2011 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 drinks

53 Are Taxes An Answer To The Obesity Epidemic? Hungary 2011: Tax on high sugar, salt, and caffeine foods Finland 2011: Tax on confectionary products, biscuit buns, and pastries France 2012: Tax on soft drinks

54 Here’s What We Don’t Know About Losing Weight (... the short list) Can community and family-focused interventions enhance one by one approach? Will losing weight lower cancer risk? – By how much? – For which cancers? What primary-care based interventions are effective and at what cost?

55 Trend #4: The inversion of the age pyramid

56 US population 2008

57 Population Pyramids, USA

58 Population Pyramids, China

59 Population Pyramids, Denmark

60 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


62 Our aging population will lead to a tsunami of cancer

63 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

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

65 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

66 “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



69 Why are we moving away from screening?

70 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

71 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

72 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

73 Comparing 9- to 11-Year Follow-up 9-year11-year Reduction in risk of death from prostate cancer0.71 per 1000 men1.07 per 1000 men Number needed to invite to prevent 1 death 1410936 Number needed to diagnose to prevent 1 death 4833

74 European Prostate Screening Trial

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

76 Estimate of overdiagnosis: 50% of screen-detected cancers

77 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

78 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”

79 Cancer Mortality Rates in Denmark, by Major Cancer, Men

80 Cancer Mortality in U.S. Men

81 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

82 Testicular cancer rising in Nordic countries

83 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.

84 Cancers With Increasing Incidence: Plausible Contributing Factors Obesity Esophagus Pancreas Liver Increased diagnosis and aging Thyroid Kidney

85 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

86 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

87 NLST – Initial Results 20% fewer lung cancer deaths in spiral CT group Results were highly statistically significant … 7% reduction in all-cause mortality!

88 Major Complication Associated With Invasive Diagnostic Procedure Following Positive Low-Dose CT Screen Category % with major complications Did not result in cancer diagnosis 0.06 Did result in cancer diagnosis 11.2

89 Deaths Associated with Diagnostic Workup LDC TCXR Total Deaths:1610 With cancer1010 Without cancer6

90 A Fundamental Challenge With Cancer Screening The people who stand to benefit are different than the people who may experience harm

91 Defining a Cancer Screening Research Agenda? 1.Develop a richer understanding of how to assess efficacy. – Are randomized trials sufficient, or even preferred? – Can high quality observational studies inform policy?

92 Defining A Cancer Screening Research Agenda? (cont’d) 2.Implementation research – Is shared decision making feasible and effective? – Is risk-based screening a better strategy? – Navigation works … but is not needed by all

93 Defining A Cancer Screening Research Agenda? (cont’d) 3.Biomedical domain – Can we develop newer or better approaches to screening? Biomarkers New imaging modalities – Can we identify those individuals most likely to benefit (and individuals who are unlikely to benefit)

94 Defining A Cancer Screening Research Agenda? (cont’d) 4.Cost-effectiveness – As treatments for advanced disease become more extensive, the value proposition for prevention and screening will improve

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

96 Trend #6: The emergence of personalized therapy

97 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

98 We Need Personalized Treatment Not Just Personalized Therapy Treat the right patients with the right therapies at the right stage







105 Was I right to offer this option? The patient is satisfied, … does that mean it was an appropriate choice?

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

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

108 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

109 Trend #7: The growing number of cancer survivors

110 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

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


113 Cancer Care Trajectory Wender R, Snyderman D. Cancer: What the Primary Care Practitioner Needs to Know, Part 2. Prim Care. 2009 Dec;36(4), 726

114 The IOM Report on Cancer Survivorship 1.Recognize the distinct needs of survivors 2.Comprehensive care summaries and follow-up plans 3.Clinical practice guideline 4.Quality measures 5.Research to test models of care

115 The IOM Report (cont’d) 6.Comprehensive state and national cancer control plans 7.Educate health care providers 8.Eliminate discrimination in employment 9.Ensure access to care 10.Increase survivorship research Ganz P. Prim Care Clin Office Pract 36(2009), 721-741.

116 Survivorship Research Questions Biomedical: Second cancers – Prevention – Surveillance Late effects of the disease and treatment – Symptom management – Psychological issues – Sexuality – Fertility

117 Survivorship Research Questions (cont’d) Implementation/health care delivery Care plans – Do they improve care? – Defining responsibilities Policy issues – Payment for team care and coordination

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

119 The Urgent Need to Reduce the Cost of Care Our current rate of health care spending is unsustainable


121 Health expenditure in Denmark

122 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 1/12/2012

123 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 ~ ~

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

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

126 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

127 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.


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