A Strategic Approach to

the Control of Cancer

Otis W. Brawley, M.D.

Chief Medical and Scientific Officer
American Cancer Society
Professor of Hematology, Medical
Oncology, Medicine and Epidemiology
Emory University
 Disclosures
• Dr. Brawley has nothing to disclose.
 Global Deaths (millions per annum)

8
7
6
5
4
3
2
1
0
TB A ID S M alaria A ll 3 C an cer

WHO (2003)
CANCER – WORLDWIDE BURDEN (2005)

11 million New Cases

7 million Deaths
25 million Living with Cancer
CANCER – WORLDWIDE BURDEN (2030)

27 million New Cases

17 million Deaths
75 million Living with Cancer
 Outline

• Observations on the US Economy

• The need to redefine cancer for the 21st
century
• Trends in cancer epidemiology
• Interventions that can save lives
 U.S. Health Care Spending

In 2009, the U.S. spent

$2.53 TRILLION
on Health Care
U.S. Health Care Spending

How Big is a Trillion?

1 million seconds Last week

1 billion seconds Richard Nixon’s

resignation

1 trillion seconds 30,000 BCE

Spending in Context

200
6

* Excludes alcoholic beverages ($150 billion) and tobacco products ($92 billion)
Source: Bureau of Economic Analysis; National Bureau of Statistics of China, MGI analysis
 Spending: US vs. Other
Countries
Per capita health care
spending, 2006
$ at PPP*

Per capita GDP

($)
* Purchasing power parity.
** Estimated Spending According to Wealth.
Source: Organization for Economic Co-operation and Development (OECD)
 American Healthcare

• 16.2% of GDP in 2008

• 17.3% of GDP in 2009
• 19.3% of GDP by 2019 (projected)
• 25% of GDP by 2025 (projected)
Overall Quality: Life
Expectancy at 65
The US is ranked 12th for Males and 16th for
Females

Source: OECD, 2006 data

 Toward an Efficient
Healthcare System
• Some consume too much
(Unnecessary care given)
• Some consume too little
(Necessary care not given)
• We could decrease the waste and
improve overall health!
• Evidence Based Medicine
Rudolph Ludwig Karl Virchow
Virchow’s Accomplishment
One of the first cellular pathologists

Virchow’s node

Defined conditions that cause thrombosis

One of the initial description of leukemia

Defined cancer as a disease involving

uncontrolled cell growth

Defined cancer using a light microscope on

specimens obtained by autopsy
Virchow’s Accomplishments
The definition of cancer used in 2010 is
largely that of Virchow with minor
modifications

More than 160 years later, we still use his

definitions using a light microscope.

There is clear evidence that some early

detected cancers do not poise a threat and
do not need to be treated.
Overdiagnosis
Cure is Possible but not Necessary

Prostate Cancer

Breast Cancer

Lung Cancer (NSCLC)

Cervical Disease

Renal Cancer

Melanoma

Colon Cancer
 Overdiagnosis
Cure is Possible but not Necessary

In the US, it is estimated:

More than half of all screen diagnosed prostate
cancers
At least fifteen percent of screen detected frank
breast cancers. A larger proportion of Ductal
carcinoma in situ (DCIS)
Perhaps ten percent or more of lung cancers
diagnosed through CT screening
A large proportion of cervical dysplasia
A Genomic Definition of Cancer
Genetics vs Genomics
Genetics is the study of heredity or inherited
traits (such as eye color) and alterations in
specific genes that may impact the individual
potential for a given health condition.

Genomics is the study of complex sets of genes,

how they are expressed in cells (what their
level of activity is), and the role they play in
biology.
 The Growth in Cancer Incidence
and Mortality is due to:
The increasing size of and the aging of
the population

Industrialization and adaptation of

Western habits (smoking, diet, etc.)
This is especially a problem in South
America, Africa and Asia

Growing biotechnology and

development of diagnostic tests and
screening technologies.
 Cancer Incidence Rates* Among Men, US, 1975-2006

Rate Per 100,000

250

Prostate
200

150

100
Lung & bronchus

50
Colon and rectum
Urinary bladder

0 Non-Hodgkin lymphoma
1975 1978 1981 1984 1987 1990 1993 1996of the
Melanoma 1999
skin 2002 2005

*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, 1975-2006, National Cancer Institute, 2009.
 Cancer Death Rates* Among Men, US,1930-2006

100
Rate Per 100,000
Lung & bronchus
80

60

40 Stomach
Prostate
Colon & rectum

20

Pancreas
0
1930

1940

1950

1955

1965

1975

1985

1990

2000
1935

1945

1960

1970

1980

1995

2005
Leukemia Liver

*Age-adjusted to the 2000 US standard population.

Source: US Mortality Data 1960-2006, US Mortality Volumes 1930-1959,
National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.
 Cancer Incidence Rates* Among Women, US, 1975-2006

Rate Per 100,000

150
Breast

100

50 Colon and rectum Lung & bronchus

Uterine corpus

0 Non-Hodgkin lymphoma
1975 1978 1981 1984 1987 1990 1993 1996 Melanoma
1999 2002 2005

*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, 1975-2006, National Cancer Institute, 2009.
 Cancer Death Rates* Among Women, US,1930-2006

100
Rate Per 100,000

80

60

40 Lung & bronchus

Uterus
Breast
20
Colon & rectum
Stomach

0 Ovary
1930

1940

1950

1955

1965

1975

1985

1990

2000
1935

1945

1960

1970

1980

1995

2005
Pancreas

*Age-adjusted to the 2000 US standard population.

Source: US Mortality Data 1960-2006, US Mortality Volumes 1930-1959,
National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.
 Cancer Death Rates* by Sex, US, 1975-2006

300 Rate Per 100,000

Men

250

Both Sexes
200

Women
150

100

50

0
1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

*Age-adjusted to the 2000 US standard population.

Source: US Mortality Data 1960-2006, National Center for Health Statistics, Centers for Disease Control and
Prevention, 2009.
 Cancer Death Rates* by Sex and Race, US, 1975-2006

500
Rate Per 100,000
450

400 African American men

350

300
White men
250

200
African American women
150
White women
100

50

0
1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

*Age-adjusted to the 2000 US standard population.

Source: Surveillance, Epidemiology, and End Results Program, 1975-2006, Division of Cancer Control and
Population Sciences, National Cancer Institute, 2009.
Cancer Incidence & Death Rates* in Children 0-14 Years, 1975-2006

18 Rate Per 100,000

16
Incidence
14

12

10

4
Mortality
2

0
1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

*Age-adjusted to the 2000 Standard population.

Source: Surveillance, Epidemiology, and End Results Program, 1975-2006, Division of Cancer Control and
Population Sciences, National Cancer Institute, 2009.
 Trends in Five-year Relative Survival (%)* Rates, US,
1975-2005

Site 1975-1977 1984-1986 1999-2005

All sites 5054 68
Breast (female) 7579 90
Colon 5259 66
Leukemia 3542 54
Lung and bronchus 1313 16
Melanoma 8287 93
Non-Hodgkin lymphoma 4853 69
Ovary 3740 46
Pancreas 33 6
Prostate 6976 100
Rectum 4957 69
Urinary bladder 7478 82

*5-year relative survival rates based on follow up of patients through 2006.

Source: Surveillance, Epidemiology, and End Results Program, 1975-2006, Division of Cancer Control and
Population Sciences, National Cancer Institute, 2009.
 Trends in the Number of Cancer Deaths Among Men and
Women, US, 1930-2007

3 0 0 ,0 0 0 295,000

290,000 Men
Men
285,000
2 5 0 ,0 0 0
280,000
Number of Cancer Deaths

275,000
2 0 0 ,0 0 0 Women
270,000
Women
265,000

1 5 0 ,0 0 0

00

03
04
01
02

05
06
07
20
20
20
20
20
20
20
20
1 0 0 ,0 0 0

5 0 ,0 0 0

0
1930 1940 1950 1960 1970 1980 1990 2000

Source: US Mortality Data, 1930-2007, National Center for Health Statistics, Centers for Disease
Control and Prevention, 2010.
Deaths averted from 1991-2020 in males and
1992-2020 in females based on current rate of
decline

The blue line represents the actual number of cancer deaths recorded (solid) and projected
(dashed) based on decreasing trends during 2003-2007. The red line represents the expected
number of cancer deaths if cancer mortality rates had remained the same since 1990 (males)
and 1991(females).
 Trends in Cigarette Smoking Prevalence* (%), by Sex, Adults 18
and Older, US, 1965-2008

60

50

40
Prevalence (%)

30
Men
20

Women
10

0
1965

1979
1983
1985
1990
1992
1994
1995

1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
1974

1997

Ye ar

*Redesign of survey in 1997 may affect trends. Estimates are age adjusted to the 2000 US standard population using five
age groups: 18-24, 25-34 years, 35-44 years, 45-64 years, and 65 years and over.
Source: National Health Interview Survey, 1965-2008, National Center for Health Statistics, Centers for Disease Control and
Prevention, 2009.
 Current* Cigarette Smoking Prevalence (%) Among High School
Students by Sex and Race/Ethnicity, US, 1991-2007

50
1991 1995 1997 1999 2001 2003
2005 2007
40
40 40
40 39 38
37
3536 34
33 33 32
32 31 32
30
Prevalence (%)

30 2727 2828 28
27
26
25 25
23 23 24 23
22
19 1819 19 19
20 18
17 16
1415 15
13 14
12
1112 11
10 8

0
White, non- White, non- African African Hispanic Hispanic Male
Hispanic Hispanic Male American, non- American, non- Female
Female Hispanic Hispanic Male
Female

*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.
Lung Cancer

Mortality down by 14.3% since 1992

Adult tobacco prevalence of 20.6% in 2008 (NHIS)

Youth Tobacco prevalence of 20.0% in 2007 (YRBS)

Prostate Cancer Screening

An issue that must be approached ethically, logically and rationally

We must realize:
What we know.
What we do not know.
What we believe.
 American Urological Association

Given the uncertainty that PSA testing results in more

benefit than harm, a thoughtful and broad approach to
PSA is critical.

Patients need to be informed of the risks and benefits of

testing before it is undertaken. The risks of overdetection
and overtreatment should be included in this discussion.

PSA Best Practice Statement 2009

European Association of Urology

Recommends for informed decision making within

the physician-patient relationship.

Recommends against mass screening.

“Men should obtain information on the risks

and potential benefits of screening and make
an individual decision”

European Urology 56(2), 2009

National Comprehensive Cancer Network

There are advantages and

disadvantages to having a PSA test, and
there is no ‘right’ answer about PSA
testing for everyone. Each man should
make an informed decision about
whether the PSA test is right for him.”
 The American Cancer Society
2010 Prostate Cancer Screening Guideline

“Men should have an opportunity to make

an informed decision with their health care
provider about whether to be screened for
prostate cancer, after receiving information
about the uncertainties, risks, and potential
benefits associated with prostate cancer
screening.”
 Needs in Prostate Cancer Medicine

We need:

a better screening test

a better way to determine the cancers that need to be watched and
those that need to be treated.

Then we can actually figure out how good our current treatments are!!!
 Mammogram Prevalence (%), by Educational Attainment and
Health Insurance Status, Women 40 and Older, US, 1991-2008
70

62
60 All women 40 and older
54
50
Prevalence (%)

40 Women with less than a high school education

36

30

Women with no health insurance

20

10

0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2004 2006 2008
Year

*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 to 2008), National Centers for Chronic Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, 1997, 1999, 2000, 2001-2009.
 Breast Cancer as of 2008

Mortality down by 30.1% since 1992

Early Detection: Of women aged 40 and older

who have breast screening :

 53% (NHIS),

 62.1% (BRFSS)
Breast Cancer
Odds that Mammography will save a
woman’s
life over a ten year period

Age 40-49 0.05%

Age 50-59 0.07%

Age 60-69 2.7%

Breast Cancer
765,870 cancer deaths were averted between
1991 and 2006 in women

It is estimated that 57,000 humans did not die of

breast cancer

This was due to screening, early detection, and

aggressive treatment.

It is estimated screening prevalence was 45% to

50% during the period
Breast Cancer Screening in the U.S.
The Ten Year Potential 64,673 deaths
averted
Number in USPSTF Avertabl Lives Lost
Age Population Estimate of e Deaths due to Non-
Number Compliance
Needed to
Screen
40's 22,327,592 1,900 11,751 4,113

20,542,363 1,340 15,330 5,366

50's

60's 13,909,277 370 37,592

13,157
Breast Cancer (Taskforce
Estimates)
One year of screening women aged 40 to 49

22,327,000 women screened

156,300 women called back for

evaluation

78,700 breast biopsies

32,000 Women diagnosed with breast

cancer

7800 deaths

1200 lives saved by mammography

Breast Cancer (Taskforce
Estimates)
One year of screening women aged 40 to 49

22,327,000 women screened

32,000 diagnosed

24,200 survive

7800 deaths

1200 lives saved by mamography

Breast Cancer (Swedish
Study)
One year of screening women aged 40 to 49

22,327,000 women screened

32,000 diagnosed

25,000 women survive

7000 deaths

2000 lives saved by mammography

Breast Cancer
Taskforce vs Swedish Study (estimates)

22,327,000 women screened per year

32,000 diagnosed

24,200 to 25,000 women survive

7000 to 7800 deaths

1200 lives saved vs 2000 lives saves

Difference of about 800 Lives per year

Colorectal Cancer as of 2008
Colorectal Cancer Mortality has
decreased by 29.3% since 1992

Colorectal Cancer Screening rates:

•53.2% by NHIS and

•63.1% by BRFSS
 Trends in Recent* Fecal Occult Blood Test Prevalence (%), by
Educational Attainment and Health Insurance Status, Adults 50
Years and Older, US, 1997-2008

30
1997 1999 2001 2002
2004 2006 2008
25 24
22
21
20
20 19 18
Prevalence (%)

16 16 16 16
15 14
15
12 13 12
9 9 9
10 8 8 7

0
Total Less than a high school No health insurance
education

*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: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data
Tape (2000 to 2008), National Centers for Chronic Disease Prevention and Health Promotion, Centers for Disease
Control and Prevention, 1997, 1999, 2000, 2001-2009.
 Trends in Recent* Flexible Sigmoidoscopy or Colonoscopy
Prevalence (%), by Educational Attainment and Health Insurance
Status, Adults 50 Years and Older, US, 1997-2008

70 1999 2001 2002 2004

60 2006 2008
60 56
50
50
44 44 45 43 42
Prevalence (%)

41
40 37 36 36

30 25 26
22 21 21 22
20

10

0
Total Less than a high school No health insurance
education

*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: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data
Tape (2000 to 2008), National Centers for Chronic Disease Prevention and Health Promotion, Centers for Disease
Control and Prevention, 1997, 1999, 2000, 2001-2009.
Nutrition and Physical Activity

Obesity, high caloric intake, and lack of

physical activity has the potential of
being a greater cause of cancer in the
U.S. than tobacco by 2030

We are currently not able to model this

in an acceptable fashion

It is causing a rise in cancer incidence

 Trends in Consumption of Five or More Recommended Vegetable
and Fruit Servings for Cancer Prevention, Adults 18 and Older, US
1994-2007

35

30
2 4 .2 2 4 .4 2 4 .1 2 4 .4 2 3 .6 2 4 .3 2 4 .7
25
Prevalence (%)

20

15

10

0
1994 1996 1998 2000 2003 2005 2007
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 (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.
 Trends in Prevalence (%) of No Leisure-Time Physical Activity, by
Educational Attainment, Adults 18 and Older, US, 1992-2008

60
Adults with less than a high school education
55
50
45
40
Prevalence (%)

35
30
25
20
15 All adults
10
5
0

2007
1992

1994

1996

1998

2000

2002

2003

2004

2005

2006

2008
Year

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 to 2008), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease
Control and Prevention, 1997-2009.
 Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20
to 74, US, 1960-2008†
45

40
35 35 36
33 33 33 34
35
31
30 28
26
Prevalence (%)

25 23
21
20 17
16 17
15 15
13
15 12 13
11
10

0
Both sexes Men Women

NHES I (1960-62) N HANES I (1971-74) N HANES II (1976-80) NHANES III (1988-94)

NHANES 1999-2002 N HANES 2003-06 N HANES 2007-08

*Obesity is defined as a body mass index of 30 kg/m2 or greater. † Age adjusted to the 2000 US standard population.
Source: 1976-2006: National Health and Nutrition Examination Survey, Hispanic Health and Nutrition Examination Survey
(1982–84). Centers for Disease Control and Prevention, National Center for Health Statistics, Health, United States, 2008,
With Special Feature on the Health of Young Adults. Hyattsville, Maryland: 2009. 2007-2008: National Health and Nutrition
Examination Survey Public Use Data File, 2007-2008 National Center for Health Statistics, Centers for Disease Control and
Prevention, 2009.
 Trends in Obesity* Prevalence (%), Children and Adolescents, by
Age Group, US, 1971-2008
25

20
20
18 18
17
16 16
Prevalence (%)

15
12
11 11
10 10
10
7
7 6
5 5 5
5 4

0
2 to 5 years 6 to 11 years 12 to 19 years

NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94)

NHANES 1999-2002 NHANES 2003-06 NHANES 2007-08

*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. 2003-06: Ogden CL, et al. High Body Mass Index for
Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05. 2007-08: Ogden CL, et al. Prevalence of
High Body Mass Index in US Children and Adolescents, 2007-2008. JAMA 2010; 303 (3): 242-249.
 Sunburn* Prevalence (%) in the Past Year, Adults 18 and
Older, US, 2005

50
44
45
41 Total
40 38
36
34
Age-Adjusted Prevalence (%)

35 32 White non-
Hispanic
30

25 Other
22 22 22 22
20
20 19
Hispanic
15
10
10 8
6 Black non-
5 Hispanic

0
Total Male Female

*Report of at least one sunburn in the past year.

Source: National Health Interview Survey Public Use Data File 2005, National Center for Health Statistics,
Centers for Disease Control and Prevention, 2006.
A Strategic Approach to
the Control of Cancer

Otis W. Brawley, M.D.

Chief Medical and Scientific Officer
American Cancer Society
Professor of Hematology, Medical
Oncology, Medicine and Epidemiology
Emory University