Cancer Epidemiology and Cancer Epidemiology and Cancer PreventionCancer Prevention

Epidemiology 242Epidemiology 242

December 2, 2009December 2, 2009

Age Standardized Incidence Rates (/100,000)Age Standardized Incidence Rates (/100,000)

  US China World

Site Males Females Males Females Males Females

Stomach 7.2 3.3 41.4 19.2 22.0 10.3

Lung 61.9 36.1 42.4 19.0 35.5 12.1

Liver 5.5 2.0 37.9 14.2 15.7 5.8

Esophagus 4.9 1.3 27.4 12.0 11.5 4.7

Colon/Rectum 44.6 33.1 13.6 9.2 20.1 14.6

Breast ─ 101.1 ─ 18.7 ─ 37.5

Leukemia 11.2 7.4 5.7 4.1 5.9 4.1

Pancreas 8.3 6.3 3.9 2.6 4.6 3.3

Cervix 0 7.7 0 6.8 0 16.2

Brain 6.5 4.5 3.9 2.8 3.7 2.6

Prostate 124.8 0 1.6 0 25.3 0

Source: GLOBOCAN 2002

The Major CancersThe Major Cancers

Lung (ICD-10 C33 and C34)Lung (ICD-10 C33 and C34) Breast (female, C50)Breast (female, C50) Colon/rectum (C18-C20)Colon/rectum (C18-C20) Stomach (C16)Stomach (C16) Prostate (C61)Prostate (C61) Liver (C22)Liver (C22) Cervix uteri (C53)Cervix uteri (C53) Esophagus (C15)Esophagus (C15)

2009 Estimated US Cancer Cases*2009 Estimated US Cancer Cases*

*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2009.Source: American Cancer Society, 2009.

MenMen766,130766,130

WomenWomen713,220713,220

27%27% BreastBreast

14%14% Lung & bronchusLung & bronchus

10%10% Colon & rectumColon & rectum

6%6% Uterine corpus Uterine corpus

4%4% Non-HodgkinNon-Hodgkin lymphoma lymphoma

4%4% Melanoma of skinMelanoma of skin

4% Thyroid4% Thyroid

3%3% Kidney & renal pelvisKidney & renal pelvis

3%3% OvaryOvary

3%3% PancreasPancreas

22%22% All Other SitesAll Other Sites

ProstateProstate 25%25%

Lung & bronchusLung & bronchus 15%15%

Colon & rectumColon & rectum 10%10%

Urinary bladderUrinary bladder 7%7%

Melanoma of skinMelanoma of skin 5%5%

Non-HodgkinNon-Hodgkin5% 5% lymphoma lymphoma

Kidney & renal pelvisKidney & renal pelvis 5%5%

Leukemia Leukemia 3%3%

Oral cavityOral cavity 3%3%

PancreasPancreas 3%3%

All Other SitesAll Other Sites 19%19%

2009 Estimated US Cancer Deaths*2009 Estimated US Cancer Deaths*

ONS=Other nervous system.ONS=Other nervous system.Source: American Cancer Society, 2009.Source: American Cancer Society, 2009.

MenMen292,540292,540

WomenWomen269,800269,800

26%26% Lung & bronchusLung & bronchus

15%15% BreastBreast

9%9% Colon & rectumColon & rectum

6%6% PancreasPancreas

5%5% OvaryOvary

4%4% Non-HodgkinNon-Hodgkin lymphoma lymphoma

3%3% LeukemiaLeukemia

3%3% Uterine corpusUterine corpus

2%2% Liver & intrahepatic Liver & intrahepaticbile ductbile duct

2%2% Brain/ONSBrain/ONS

25% All other sites25% All other sites

Lung & bronchusLung & bronchus 30%30%

ProstateProstate 9%9%

Colon & rectum Colon & rectum 9%9%

PancreasPancreas 6%6%

LeukemiaLeukemia 4%4%

Liver & intrahepaticLiver & intrahepatic 4%4%bile ductbile duct

EsophagusEsophagus 4%4%

Urinary bladderUrinary bladder 3% 3%

Non-Hodgkin 3% Non-Hodgkin 3% lymphoma lymphoma

Kidney & renal pelvisKidney & renal pelvis 3%3%

All other sites 25%All other sites 25%

Cigarette Smoking Cigarette Smoking and Cancer Riskand Cancer Risk

Adult Per Capita Cigarette Consumption and Adult Per Capita Cigarette Consumption and Major Smoking and Health Events – United States, Major Smoking and Health Events – United States,

1900-20011900-2001

0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000YEAR

Nu

mb

er o

f C

igar

ette

s

Source: United States Department of Agriculture

End of WW II

1st Smoking-Cancer Concern

Fairness Doctrine Messages on TV

and Radio

Non-Smokers Rights Movement

Begins

Federal Cigarette Tax Doubles

Surgeon General’s Report on ETS

1st Surgeon General’s

Report

1st World Conference on Smoking and Health

Broadcast Ad Ban

1st Great American Smoke-out

OTC Nicotine Medications

Master Settlement Agreement

Great Depression

Tobacco Use in the US, 1900-2005Tobacco Use in the US, 1900-2005

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

1900

1905

1910

1915

1920

1925

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

Year

Per

Cap

ita

Cig

aret

te C

on

sum

pti

on

0

10

20

30

40

50

60

70

80

90

100

Ag

e-A

dju

sted

Lu

ng

Can

cer

Dea

th

Rat

es*

*Age-adjusted to 2000 US standard population. *Age-adjusted to 2000 US standard population.

Source: Death rates: US Mortality Data, 1960-2005, US Mortality Volumes, 1930-1959, National Center for 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 Health Statistics, Centers for Disease Control and Prevention, 2006. Cigarette consumption: US Department of Agriculture, 1900-2007.Agriculture, 1900-2007.

Per capita cigarette Per capita cigarette consumptionconsumption

Male lung cancer Male lung cancer death ratedeath rate

Female lung Female lung cancer death ratecancer death rate

MenMen

Women

0

10

20

30

40

50

60

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

YEAR

% C

UR

RE

NT

SM

OK

ER

STrends in cigarette smoking* among adults aged

>18 years, by sex - United States, 1955-2002

Source: 1955 Current Population Survey; 1965-2002 National Health Interview Survey; 2002 estimates for first quarter only

*Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day day or some days.

24.5%

18.8%

Smoking and Other CancersSmoking and Other Cancers

Head and neck cancers (oral, laryngeal Head and neck cancers (oral, laryngeal and pharyngeal cancers)and pharyngeal cancers)

Esophageal cancerEsophageal cancer Stomach cancerStomach cancer Pancreatic CancerPancreatic Cancer Bladder cancerBladder cancer Cervical cancerCervical cancer Liver cancerLiver cancer

Environmental Tobacco SmokeEnvironmental Tobacco Smoke

3,000 nonsmoking Americans die of 3,000 nonsmoking Americans die of lung cancerlung cancer

300,000 children suffer from lower 300,000 children suffer from lower respiratory tract infections.respiratory tract infections.

Major Infection-Associated Major Infection-Associated MalignanciesMalignancies

In 2002, 17.8% of the global cancer burden (1.9 In 2002, 17.8% of the global cancer burden (1.9 million cases) were infection-attributablemillion cases) were infection-attributable

Malignancy (infection)Malignancy (infection) Stomach cancer (Stomach cancer (Helicobactor pyloriHelicobactor pylori)) Cervical cancer (human papillomavirus)Cervical cancer (human papillomavirus) Liver cancer (hepatitis B and C viruses)Liver cancer (hepatitis B and C viruses) Burkitt’s lymphoma and nasopharyngeal cancer Burkitt’s lymphoma and nasopharyngeal cancer

(Epstein-Barr virus)(Epstein-Barr virus) Kaposi sarcoma and Non-Hodgkin lymphoma Kaposi sarcoma and Non-Hodgkin lymphoma

(HIV/HHV-8)(HIV/HHV-8) Bladder and colon cancer (schistosomiasis)Bladder and colon cancer (schistosomiasis) Adult T-cell leukemia/lymphoma (human T-cell Adult T-cell leukemia/lymphoma (human T-cell

lymphotropic virus type I)lymphotropic virus type I)

Mechanisms of Infection-Induced Mechanisms of Infection-Induced MalignancyMalignancy

Chronic Inflammation and CarcinogenesisChronic Inflammation and Carcinogenesis Chronic host-pathogen interactionChronic host-pathogen interaction

ImmunosuppressionImmunosuppression Chronic inflammationChronic inflammation

Oxidative StressOxidative StressDNA damage and mutationsDNA damage and mutationsCell injuryCell injuryCell divisionCell division

Infection inducing Cell proliferationInfection inducing Cell proliferation

Production of Oncogenic ProteinsProduction of Oncogenic Proteins

Genomic Instability from Viral Genomic IntegrationGenomic Instability from Viral Genomic Integration

Cancers attributable to infections Cancers attributable to infections worldwide, 2002worldwide, 2002

Source: Parkin, Source: Parkin, 20062006

3131

9 Possible Mechanisms How Alcohol Intake Increase Cancer Risk9 Possible Mechanisms How Alcohol Intake Increase Cancer Risk

According to Blot et al (1992)According to Blot et al (1992)

1. Contain congeners and other contaminants that 1. Contain congeners and other contaminants that may be carcinogenic may be carcinogenic

2. Generated metabolites that are carcinogenic to 2. Generated metabolites that are carcinogenic to humans humans

3. Act as solvent, increasing penetration of other 3. Act as solvent, increasing penetration of other carcinogens into target tissue carcinogens into target tissue

4. Reduce intake and bioavailability of nutrition 4. Reduce intake and bioavailability of nutrition 5. Inhibit the detoxification of carcinogenic 5. Inhibit the detoxification of carcinogenic

compoundscompounds6. Catalyze the metabolic activation of some 6. Catalyze the metabolic activation of some

compounds into carcinogens compounds into carcinogens 7. Affect hormonal status 7. Affect hormonal status 8. Increase cellular exposure to oxidants 8. Increase cellular exposure to oxidants 9. Suppress immune function 9. Suppress immune function

3232

What is What is ““a Drinka Drink””??

Despite the differences in concentration, the Despite the differences in concentration, the average intake of ethanol per drink is average intake of ethanol per drink is approximately constant across beverage types.approximately constant across beverage types.

A standard drink is:A standard drink is:• One 12-ounce bottle of beer* or wine cooler One 12-ounce bottle of beer* or wine cooler • One 5-ounce glass of wine One 5-ounce glass of wine • 1.5 ounces of 80-proof1.5 ounces of 80-proof++ distilled spirits. distilled spirits.

* Different beers have different alcohol content. Malt liquor has a higher alcohol content than most * Different beers have different alcohol content. Malt liquor has a higher alcohol content than most other brewed beverages.other brewed beverages.

++ 80-proof== 40% ABV (alcohol by volume) 80-proof== 40% ABV (alcohol by volume)

Cancer PreventionCancer Prevention

S Lippman, Cancer Res. 2009 Jul 1;69(13):5269-84S Lippman, Cancer Res. 2009 Jul 1;69(13):5269-84

Known risk factorsKnown risk factors

Smoking causes most cancers in Smoking causes most cancers in smokers.smokers.

Among non-smokers, most cancers Among non-smokers, most cancers are of unknown cause.are of unknown cause.

Infection causes most cancers in the Infection causes most cancers in the lowest-income countries.lowest-income countries.

Avoidable Known Cancer Risks USAAvoidable Known Cancer Risks USA

Proven Cancer Prevention StrategiesProven Cancer Prevention StrategiesCompelling non-RCT EvidenceCompelling non-RCT Evidence

Risk Factor AvoidanceRisk Factor AvoidanceSmoking prevention/cessation counselingSmoking prevention/cessation counselingWorker exposure reduction (asbestos, etc.)Worker exposure reduction (asbestos, etc.)

ImmunizationImmunizationHepatitis BHepatitis B

HPVHPV ScreeningScreening

Cervical PAP testingCervical PAP testing

Proven Cancer Prevention StrategiesProven Cancer Prevention StrategiesRCT EvidenceRCT Evidence

Screening Screening

Mammography with Clinical Breast Mammography with Clinical Breast ExamExam

Fecal Occult Blood Test (colorectal Fecal Occult Blood Test (colorectal cancer)cancer)

BRIDGING THE GAP BETWEEN CANCER TREATMENT AND PREVENTIONBRIDGING THE GAP BETWEEN CANCER TREATMENT AND PREVENTION(William WN, et al, Nat Rev Drug Discov. 2009 Mar;8(3):213-25.)(William WN, et al, Nat Rev Drug Discov. 2009 Mar;8(3):213-25.)

Widely-Accepted Prevention StrategiesWidely-Accepted Prevention StrategiesInsufficient or Negative EvidenceInsufficient or Negative Evidence

Oral cancer screening examinationOral cancer screening examination PSA testing for prostate cancerPSA testing for prostate cancer Lung cancer screening with CT or Lung cancer screening with CT or

XrayXray Dietary change: More vegetables Dietary change: More vegetables

and fruitsand fruits Dietary change: Less fatDietary change: Less fat Dietary antioxidant supplementsDietary antioxidant supplements Weight loss and exerciseWeight loss and exercise Sun avoidance: skin cancerSun avoidance: skin cancer

How Many Cancer Deaths/YrHow Many Cancer Deaths/Yr Could we Prevent Now? Could we Prevent Now?

Tobacco ControlTobacco Control

ScreeningScreening

Infection ControlInfection Control

How Many Cancer Deaths/YrHow Many Cancer Deaths/Yr Could we Prevent Now? Could we Prevent Now?

Tobacco-Caused Cancers – 1.15 million Tobacco-Caused Cancers – 1.15 million deathsdeaths

LungLung 75% of 1,300,000 deaths75% of 1,300,000 deaths

OropharynxOropharynx 40% of 320,000 deaths40% of 320,000 deaths

Other sitesOther sites 15% of 350,000 deaths15% of 350,000 deaths

How Many Cancer Deaths/YrHow Many Cancer Deaths/Yr Could we Prevent Now? Could we Prevent Now?

Screen-detectable cancers – 660,000 Screen-detectable cancers – 660,000 deathsdeaths

ColorectalColorectal 50% of 620,000 deaths50% of 620,000 deaths

CervixCervix 90% of 230,000 deaths90% of 230,000 deaths

BreastBreast 30% of 475,000 deaths30% of 475,000 deaths

How Many Cancer Deaths/YrHow Many Cancer Deaths/Yr Could we Prevent Now? Could we Prevent Now?

Infection-related Cancers – 750,000 deathsInfection-related Cancers – 750,000 deaths

Liver (immunization)Liver (immunization) 40% of 600,000 40% of 600,000 deathsdeaths

Stomach (antibiotics)Stomach (antibiotics) 60%? of 850,000 60%? of 850,000 deathsdeaths

[Cervix (immunization)][Cervix (immunization)] 50% of 230,000 50% of 230,000 deaths]deaths]

How Many Cancer Deaths/YearHow Many Cancer Deaths/Year Could we Prevent Now? Could we Prevent Now?

Tobacco programs 1,115,000 at low costTobacco programs 1,115,000 at low cost

Infection ControlInfection Control 750,000 at low/moderate 750,000 at low/moderate costcost

Screening Screening 660,000 at low/very high 660,000 at low/very high costcost

Total deaths preventable: about 2.5 Total deaths preventable: about 2.5 Million of the 7.5 million deaths/year from Million of the 7.5 million deaths/year from cancer worldwidecancer worldwide