Professor of Hematology, Oncology, Medicine and Epidemiology Otis W. Brawley, M.D. Chief Medical Officer Executive Vice President American Cancer Society Professor of Hematology, Oncology, Medicine and Epidemiology Emory University 2

2009 Estimated US Cancer Deaths* Men 292,540 Lung & bronchus 30% Prostate 9% Colon & rectum 9% Pancreas 6% Leukemia 4% Liver & intrahepatic 4% bile duct Esophagus 4% Urinary bladder 3% Non-Hodgkin 3% lymphoma Kidney & renal pelvis 3% All other sites 25% Women 269,800 26% Lung & bronchus 15% Breast 9% Colon & rectum 6% Pancreas 5% Ovary 4% Non-Hodgkin lymphoma 3% Leukemia 3% Uterine corpus 2% Liver & intrahepatic bile duct 2% Brain/ONS 25% All other sites ONS=Other nervous system. Source: American Cancer Society, 2009. 3

US Mortality, 2006 1. Heart Diseases 631,636 26.0 No. of deaths % of all deaths Rank Cause of Death 1. Heart Diseases 631,636 26.0 2. Cancer 559,888 23.1 3. Cerebrovascular diseases 137,119 5.7 4. Chronic lower respiratory diseases 124,583 5.1 5. Accidents (unintentional injuries) 121,599 5.0 6. Diabetes mellitus 72,449 3.0 7. Alzheimer disease 72,432 3.0 8. Influenza & pneumonia 56,326 2.3 9. Nephritis* 45,344 1.9 10. Septicemia 34,234 1.4 *Includes nephrotic syndrome and nephrosis. Source: US Mortality Data 2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009. 4

Change in US Death Rates* from 1991 to 2006 Rate Per 100,000 1991 2006 * Age-adjusted to 2000 US standard population. Sources: 1950 Mortality Data - CDC/NCHS, NVSS, Mortality Revised. 2006 Mortality Data: US Mortality Data 2006, NCHS, Centers for Disease Control and Prevention, 2009. 5

Cancer Death Rates* by Sex US 1975-2005 Rate Per 100,000 Men Both Sexes Women *Age-adjusted to the 2000 US standard population. Source: US Mortality Data 1960-2005, National Center for Health Statistics, Centers for Disease Control and Prevention, 2008. 6

Cancer Death Rates* Among Men, US 1930-2005 Rate Per 100,000 Lung & bronchus Stomach Prostate Colon & rectum Pancreas Leukemia Liver *Age-adjusted to the 2000 US standard population. Source: US Mortality Data 1960-2005, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2008. 7

Cancer Death Rates* Among Women, US 1930-2005 Rate Per 100,000 Lung & bronchus Uterus Breast Colon & rectum Stomach Ovary Pancreas *Age-adjusted to the 2000 US standard population. Source: US Mortality Data 1960-2005, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2008. 8

2009 Estimated US Cancer Cases* Men 766,130 Women 713,220 27% Breast 14% Lung & bronchus 10% Colon & rectum 6% Uterine corpus 4% Non-Hodgkin lymphoma 4% Melanoma of skin 4% Thyroid 3% Kidney & renal pelvis 3% Ovary 3% Pancreas 22% All Other Sites Prostate 25% Lung & bronchus 15% Colon & rectum 10% Urinary bladder 7% Melanoma of skin 5% Non-Hodgkin 5% lymphoma Kidney & renal pelvis 5% Leukemia 3% Oral cavity 3% Pancreas 3% All Other Sites 19% *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2009. 9

Cancer Incidence Rates* by Sex US 1975-2005 Rate Per 100,000 Men Both Sexes Women *Age-adjusted to the 2000 US standard population and adjusted for delays in reporting. Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database: SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008. 10

Cancer Incidence Rates* Among Men, US 1975-2005 Rate Per 100,000 Prostate Lung & bronchus Colon and rectum Urinary bladder Non-Hodgkin lymphoma Melanoma of the skin *Age-adjusted to the 2000 US standard population and adjusted for delays in reporting. Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database: SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008. 11

Cancer Incidence Rates* Among Women, US 1975-2005 Rate Per 100,000 Breast Colon and rectum Lung & bronchus Uterine Corpus Ovary Non-Hodgkin lymphoma *Age-adjusted to the 2000 US standard population and adjusted for delays in reporting. Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database: SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008. 12

Cancer Incidence & Death Rates* in Children 0-14 Years, 1975-2005 Rate Per 100,000 Incidence Mortality *Age-adjusted to the 2000 Standard population. Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008. 13

Cancer Incidence Rates* in Children 0-14 Years by Sex, 2001-2005 Site Male Female Total All sites 16.1 14.1 15.1 Leukemia 5.4 4.5 5.0 Acute Lymphocytic 4.3 3.6 3.9 Brain/ONS 3.4 3.1 3.2 Soft tissue 1.1 1.0 1.1 Non-Hodgkin lymphoma 1.2 0.6 0.9 Kidney and renal pelvis 0.8 0.8 0.8 Bone and Joint 0.7 0.7 0.7 Hodgkin lymphoma 0.7 0.4 0.5 Leukemia is the most common cancer among children ages 0-14 years and comprises approximately 30% of all childhood cancers. Acute lymphocytic leukemia is the most common form of leukemia in children. Cancer of the brain/other nervous system is the second most common incident cancer in both boys and girls. *Per 100,000, age-adjusted to the 2000 US standard population. ONS = Other nervous system Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008. 14

Cancer Death Rates* in Children 0-14 Years by Sex, US 2001-2005 Site Male Female Total All sites 2.7 2.3 2.5 Leukemia 0.8 0.7 0.8 Acute Lymphocytic 0.4 0.3 0.4 Brain/ONS 0.8 0.7 0.7 Non-Hodgkin lymphoma 0.1 0.1 0.1 Soft tissue 0.1 0.1 0.1 Bone and Joint 0.1 0.1 0.1 Kidney and Renal pelvis 0.1 0.1 0.1 *Per 100,000, age-adjusted to the 2000 US standard population. ONS = Other nervous system Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008. 15

Tobacco Use in the US, 1900-2005 Per capita cigarette consumption Male lung cancer death rate Female lung cancer death rate *Age-adjusted to 2000 US standard population. 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 Agriculture, 1900-2007. 16

Current* Cigarette Smoking Prevalence (%) Among High School Students by Sex and Race/Ethnicity - US 1991-2007 *Smoked cigarettes on one or more of the 30 days preceding the survey. Source: Youth Risk Behavior Surveillance System, 1991, 1995, 1997, 1999, 2001, 2003, 2005, 2007 National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2008. 17

Trends in Consumption of Five or More Recommended Vegetable and Fruit Servings for Cancer Prevention, Adults 18 and Older, US, 1994-2007 Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000, 2003, 2005, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2004, 2006, 2008. 18

Trends in Prevalence (%) of No Leisure-Time Physical Activity, by Educational Attainment Adults 18 and Older - US 1992-2007 Adults with less than a high school education All adults Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Educational attainment is for adults 25 and older. Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000, 2002, 2004, 2005, 2006, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2003, 2005, 2006, 2007, 2008. 19

Trends in Obesity* Prevalence (%) Children and Adolescents, by Age Group US 1971-2006 *Body mass index (BMI) at or above the sex-and age-specific 95th percentile BMI cutoff points from the 2000 sex-specific BMI-for-age CDC Growth Charts. Note: Previous editions of Cancer Statistics used the term “overweight” to describe youth in this BMI category. Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2006: Ogden CL, et al. High Body Mass Index for Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05. 20

Trends in Obesity* Prevalence (%), By Gender Adults Aged 20 to 74, US, 1960-2006† *Obesity is defined as a body mass index of 30 kg/m2 or greater. † Age adjusted to the 2000 US standard population. Source: National Health Examination Survey 1960-1962, National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2004, 2005-2006: National Health and Nutrition Examination Survey Public Use Data Files, 2003-2004, 2005-2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006, 2007. 21

Mammogram Prevalence (%), by Educational Attainment and Health Insurance Status Women 40 and Older, US, 1991-2006 All women 40 and older Women with less than a high school education Women with no health insurance *A mammogram within the past year. Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data Tape (2000, 2002, 2004, 2006), National Centers for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2000, 2001, 2003, 2005, 2007. 22

Disparities in Health The concept that some populations (however defined) do worse than others Populations can be defined or categorized by race, culture, area of geographic origin, socioeconomic status

Disparities in Health The concept that some populations (however defined) do worse than others The measure can be incidence, mortality, survival, quality of life

All Sites – Cancer Mortality Rates 1973-2004 By Race, Males and Females African American Caucasian AI/AN Hispanic API Incidence and mortality rates per 100,000 and age-adjusted to 2000 US standard population SEER Cancer Statistics Review 1975-2004.

Disparities in Health We need to approach this issue logically and rationally We must focus on what we can change and not on what we cannot change We must define social and logistical issues versus scientific issues.

My Concern “Equal treatment yields equal outcome among equal patients” There is not equal treatment There is not enough concern about nor emphasis on the fact that there is not equal treatment

How can we provide adequate, high-quality care (to include preventive care) to a population that has so often not received it?

Female Breast Cancer Death Rates by Race and Ethnicity, US, 1975-2004 29

Adjusted Breast Cancer Survival by Stages and Insurance Status, among Patients Diagnosed in 1999-2000 and Reported to the NCDB 30

Breast Cancer It is estimated that 57,000 breast cancer deaths were averted between 1990 and 2005 due to screening, early detection, and aggressive treatment. Breast cancer screening rates have actually gone down during the period 2000 to 2005

Breast Cancer Imagine a world in which… Mammography rates were greater than 80% All women with an abnormal screen got it evaluated All women with breast cancer got optimal therapy

Screening Guidelines for the Early Detection of Colorectal Cancer and Adenomas, American Cancer Society 2008 Beginning at age 50, men and women should follow one of the following examination schedules: A flexible sigmoidoscopy (FSIG) every five years A colonoscopy every ten years A double-contrast barium enema every five years A Computerized Tomographic (CT) colonography every five years A guaiac-based fecal occult blood test (FOBT) or a fecal immunochemical test (FIT) every year A stool DNA test (interval uncertain) Tests that detect adenomatous polyps and cancer Tests that primarily detect cancer People who are at moderate or high risk for colorectal cancer should talk with a doctor about a different testing schedule

Trends in Recent* Fecal Occult Blood Test Prevalence (%) by Educational Attainment and Health Insurance Status Adults 50 Years and Older, US 1997-2006 *A fecal occult blood test within the past year. Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001, 2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007. 34

Trends in Recent* Flexible Sigmoidoscopy or Colonoscopy Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50 Years and Older, US 1997-2006 *A flexible sigmoidoscopy or colonoscopy within the past ten years. Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001, 2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007. 35

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Adjusted Colorectal Cancer Survival by Stages and Insurance Status, among Patients Diagnosed in 1999-2000 and Reported to the NCDB 37

Colorectal Cancer It is estimated that 77,000 colorectal cancer deaths were averted between 1990 and 2005 due to screening, early detection, and aggressive treatment. Colorectal cancer screening rates have actually gone down during the period 2000 to 2005

Colorectal Cancer Imagine a world in which… Colorectal screening rates were greater than 80% All men and women with an abnormal screen got it evaluated All with colorectal cancer got optimal therapy

Sunburn* Prevalence (%) in the Past Year, Adults 18 and Older, US 2004 *Reddening of any part of the skin for more than 12 hours. Note: The overall prevalence of sunburn among adult males is 46.4% and among females is 36.3%. Source: Behavioral Risk Factor Surveillance System Public Use Data Tape , 2004. National Center for Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2005. 40

Ultraviolet Radiation Exposure Behaviors Ultraviolet Radiation Exposure Behaviors* Prevalence (%), Adults 18 and Older, US, 2005 *Proportion of respondents reporting always or often practicing the particular sun protection behavior on any warm sunny day. †Used an indoor tanning device, including a sunbed, sunlamp, or tanning booth at least once, in the past 12 months. Source: National Health Interview Survey Public Use Data File 2005, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006. 41

Cancer Survival and Deprivation in Scotland 42

Survival Rates RMS Titanic Concept of Dr. Lisa Newman First Class 60% Second Class 43% Third Class 20%

How can we provide adequate, high-quality care (to include preventive care) to a population that has so often not received it?

Per Capita Spending in USD Higher Per Capita Spending in the U.S. Does Not Translate into Longer Life Expectancy The Cost of a Long Life Average Life Expectancy (years) United States Per Capita Spending in USD Life Expectancy – Per Capita Spending 2006 CIA FACTBOOK 45

The Economics of Healthcare Healthcare is 17% of the nation’s Gross Domestic Product and growing The country with the second greatest is Israel with 9.5% of its GDP devoted to healthcare The U.S. spends more on healthcare than it spends on food and clothing

The Economics of Healthcare The average Medicare costs per beneficiary nationwide in 2006 was $8,304 New York City $9,564 Honolulu $5,311 Miami $16,351 San Francisco $8,331 NY Times June 11, 2009

Disparities in Health Some consume too much (unnecessary care given) Some consume too little (necessary care not given) We could decrease the waste and improve overall health!!

Disparities in Health There are dramatic geographical differences in use of a number of expensive screening technologies and therapies without evidence of difference in outcomes. Prostate cancer screening and overtreatment Lung cancer screening Third and fourth-time chemotherapy of metastatic disease Intensity Modulated Radiation Therapy in some cancers Overuse of radiologic imaging

Faith-based versus Evidence-based Medicine We in medicine have a tendency to adopt things before fully accessing their benefit or harm. We also criticize those who question the benefit and some even praise/worship advocates with a monetary interest. Bone marrow transplant for breast cancer Lung cancer screening with chest X-ray Neuroblastoma screening with urine VMA The Halsted Mastectomy Postmenopausal hormone replacement Prostate cancer screening

The rational use of medicine not the rationing of medicine Disparities in Health A call for the use of “Evidence-Based Care” That is: The rational use of medicine not the rationing of medicine

We know WHAT to do, We just need to DO it!!