Download Ahmedin Jemal, DVM, PhD American Cancer Society

The 2nd Edition of The Cancer Atlas
Cancer Interventions and Potential for Impact
Ahmedin Jemal, DVM, PhD
American Cancer Society
Session code: CTS.4.230
www.worldcancercongress.org
Interventions Across
the Cancer Continuum
PRIMARY
PREVENTION
EARLY
DETECTION
TREATMENT
SURVIVORSHIP
& QUALITY OF
LIFE
END-OF-LIFE
CARE
e.g.,
e.g.,
e.g.,
e.g.,
e.g.,
Tobacco control
Pap test/VIA
Radiotherapy
Psychosocial care
Pain control
Vaccination
Mammography
Surgery
Colonoscopy
Chemotherapy
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
Age 25-34
10 years
gained
Age 45-54
6 years
gained
Jha and Peto. N Engl J Med 2013;368:341-350.
Age 35-44
9 years
gained
Age 55-64
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
Effects of Tobacco Control Policies in Brazil
•  Aggressively implemented tobacco control measures since 1989
•  Smoking prevalence decreased by 46% by 2010
Cigarette price
↑ 230%
Estimated contributions of tobacco control
measures to declines in tobacco use:
8%
10%
14%
Averted Deaths
ü  420,000 deaths (1989-2010)
ü  6.6 million deaths in 40 years
48%
6%
14%
Tax contribution
Anti-smoking campaigns
Warning labels
Ad bans
Smoke-free laws
Cessation programs
Levy D, et al. PLoS Med. 2012; 9(11): e1001336.
Share of Total Taxes in the Retail Price of the Most Widely
Sold Brand of Cigarettes, 2012
In only 32 countries does the share of cigarette tax exceed 75% of retail price
Note: Tobacco sales were banned in
Bhutan in 2012.
WHO Report on the Global Tobacco Epidemic, 2013
Vaccinations
Infections cause 16% of cancers worldwide, 2 million cases/year
Hepatitis B virus (HBV)
infection
Human papillomavirus (HPV)
infection
HBV Infection & Vaccine (Background)
HBV Infection
Vaccine
•  2 billion total population infected
•  Available since 1982
•  360 million chronically infected
(sub-Saharan Africa, Asia)
•  3 doses, 1st dose within 24 hrs
after birth
•  340,000 liver cancer cases
(500,000-700,000 deaths from
liver cancer & cirrhosis) each year
•  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
Rate per 100,000
Age-specific incidence rate by sex in cohorts born
before and after the implementation of the program, 1984
Chiang et al. JAMA. 2013;310(9):974-976.
80%
lower
Percentage of One-year-olds Given the Three-series Hepatitis B
Vaccination,* 2012
183 countries introduced
national HBV vaccination
program as of 2012
*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.
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
Australia introduced 3-dose
HPV vaccine in 2007
Figure: Trends in incidence of highgrade 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)
<18 years
18-20 years
21-25 years
26-30 years
≥30 years
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
Since 2013, GAVI has
funded HPV vaccine
demonstration
projects in 20
countries (yellow
dots), and funds the
national HPV vaccine
program in Rwanda
US: 37%
coverage
Rwanda:
93% coverage
WHO, 2013
9-Valent Vaccine, Under FDA Regulatory Assessment
Contribution of 9-valent vaccine to cervical cancer worldwide
Luxembourg, Sanjose et al. Lancet Oncol. 2010; 11:1048-56.
Early Detection
Cervical cancer
Colorectal cancer
Breast cancer
Lung cancer
Limited Progress in Reducing Cervical Cancer in LMIC
Low- and Middle-Income Countries
60 Uganda
(Kyadondo
County)
Rate per 100,000
50 40 30 Colombia
(Cali)
Brazil (Goiania)
High-Income Countries
60 Denmark 50 UK (Scotland) 40 Australian Capital Territory 30 USA (SEER 9, White) 20 20 Philippines (Manilla)
10 0 1980 1985 1990 1995 2000 2005 CI5 Plus
10 0 1980 1985 1990 1995 2000 2005 Countries without Large-scale Cervical Cancer Screening
Most of the countries without HPV vaccine introduction also lack screening programs
Note: Countries without
large-scale screening may
have subnational programs
or limited availability of
screening
IARC, 2014.
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)
Hazard ratio for cervical cancer deaths by age,
India- VIA Screening
(Sankaranarayanan et al. Lancet 2007)
2.0
6.0
5.41
4.0
2.91
2.0
0.0
1.42
0
1
HPV DNA
Group
N=2,163
2
3
Delayed
VIA
Evaluation
Group
N=2,227 (Control) Group
N=2,165
Hazard ratio
Prevalence (%)
8.0
1.5
1.0
0.99
0.65
0.5
0.0
0.55
0.34
0
1
Overall
30-59
years
2
30-39
years
3
40-49
years
4
50-59
years
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
Availability of Radiotherapy for Percentage of Cancer Patients by Country
•  1 radiotherapy machine treats 500 patients per year
•  60% of cancer patients benefit from radiotherapy
%=​# 𝑚𝑎𝑐ℎ𝑖𝑛𝑒𝑠 ∗500 𝑐𝑎𝑠𝑒𝑠/0.6 ∗𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠/
𝑦𝑒𝑎𝑟 * 100 5,000 additional radiotherapy
machines are required to meet
patient needs in LMIC
*Disparities in access to radiotherapy may still exist in those countries with 100% coverage
International Atomic Energy Agency, 2014.
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 middleincome countries requires innovative solutions,
commitment and collaboration
Thank You!