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Cancer in Idaho:
Data Update &
Strategic Plan Objectives
Idaho Cancer Policy Agenda Meeting
April 25, 2014
Chris Johnson, Epidemiologist
Cancer Data Registry of Idaho
[email protected]
3 Handouts
2
Cancer
• 100+ different diseases
• Since 2008, #1 cause of death in Idaho
– About 22% of deaths are from cancer
• In 2011 in Idaho:
7,263 new invasive cases
849 new in situ cases
2,559 cancer deaths
30% of those diagnosed this year will die of cancer
within five years
3
Leading Cause of Death by Age
Idaho 2012
• Cancer is the leading cause of death among age
groups 45-54, 55-64 and 65-74
4
Trends in Crude Mortality Rates, Idaho
5
Why is Cancer the Leading Cause of
Death in Idaho?
• Competing risks
– Why are heart disease/stroke deaths down?
• “Statins and Smoking”
– Decreases in blood cholesterol levels and
uncontrolled hypertension (risk factors), mostly
through medication
– Improvements in medical treatments for blocked
arteries, stroke
– Lower smoking rates in Idaho
6
Cancer Risk Factors
7
Levels of Disease Prevention
• Primary Prevention
– Aims to prevent the disease from
occurring
– Reduces incidence
• Secondary Prevention
– After the disease has occurred but
before symptoms
– Aims to find and treat disease early
• Tertiary Prevention
– Goals are to improve treatment
outcomes, prevent complications
8
Lung Cancer,
Tobacco, other
Tobacco-related
Cancers
Measures
of cancer
burden:
incidence,
mortality,
YPLL
Melanoma
Colon &
Rectum Cancer
Breast Cancer
Behavior: smoking, physical activity,
9
diet, screening
Lung Cancer/Smoking Constellation
Lung Cancer
• Idaho 2011:
– 838 new cases
– 616 deaths
• By far the leading cause of cancer death
among both men and women
– Each year, more people die of lung cancer than
of colon, breast, and prostate cancers combined
– Lung cancer has a poor prognosis; nearly 90%
of persons with lung cancer die of the disease
11
Lung Cancer Risk Factors
• Smoking causes ~85% of lung cancer deaths
• Radon – 2nd leading cause of lung cancer
– About 10% of lung cancer deaths
– Leading cause of lung cancer among nonsmokers
• Secondhand smoke
• Asbestos, arsenic, chromium, nickel, other
substances in workplace
• Air pollution, including diesel exhaust
12
Smoking
• Accounts for at least 30% of all cancer deaths
• Population attributable risk varies by cancer site
for other smoking-related cancers:
– Larynx
– Oral Cavity
– Nose and
Sinuses
– Pharynx
– Esophagus
– Stomach
– Pancreas
– Cervix
– Kidney
– Bladder
– Ovary
– Colon & Rectum
– AML
13
Counseling & Interventions
• The USPSTF recommends that clinicians ask all
adults about tobacco use and provide tobacco
cessation interventions for those who use
tobacco products.
– Grade: A recommendation: there is high certainty
that the net benefit is substantial.
14
USPSTF Screening Recommendation
(Dec 2013)
• The USPSTF recommends annual screening for lung
cancer with low-dose computed tomography (LDCT) in
adults ages 55 to 80 years who have a 30 pack-year
smoking history and currently smoke or have quit within
the past 15 years.
– Screening should be discontinued once a person has
not smoked for 15 years or develops a health problem
that substantially limits life expectancy or the ability or
willingness to have curative lung surgery.
• Screening cannot prevent most lung cancer–related
deaths, and smoking cessation remains essential.
15
Drilling Down into CCAI Strategic Plan
Measures
2. Reduce the lung cancer death rate
6. Reduce the oropharyngeal cancer death rate
18. Decrease the proportion of adults aged 18+
who are current smokers
19. Reduce tobacco use by adolescents
23. Reduce the proportion of males who use
smokeless tobacco
16
Lung Cancer State Map
17
Lung Cancer Trends - Idaho
18
Lung Cancer Age-Specific Rates,
Idaho, 2007-2011
19
Variation and Disparities
in Lung Cancer in Idaho
• Geographic
• Race/ethnicity
• Area-based SES measures
20
County Maps of Smoking and Lung
Cancer Incidence & Mortality
Smoking 11-12
Inc 07-11
Mort 08-12
Boundary
Boundary
Boundary
Bonner
Bonner
Bonner
1
1
1
Kootenai
Kootenai
Kootenai
Benewah Shoshone
Benewah Shoshone
Benewah Shoshone
Latah
Latah
Latah
Clearwater
Nez PerceLewis
Clearwater
Clearwater
Nez PerceLewis
2
Idaho
Nez PerceLewis
2
Lemhi
7
4
Clark
Butte
Jefferson
Teton
Madison
Blaine
Elmore
Camas
Gooding
3
Owyhee
Fremont
Custer
Canyon
Bonneville
4
Washington
Payette
Gem
Bingham
Cassia
Oneida
Bear Lake
Franklin
Jefferson
Teton
Madison
Blaine
Elmore
Camas
Gooding
3
Owyhee
Fremont
Custer
Butte
6
LincolnMinidoka
Power Bannock Caribou
Jerome
Clark
Canyon
Bonneville
4
Washington
Payette
Gem
Bingham
Butte
Canyon
Cassia
Oneida
Elmore
Bear Lake
Franklin
Camas
Gooding
3
Owyhee
Fremont
Jefferson
Teton
Madison
Blaine
6
LincolnMinidoka
Power Bannock Caribou
Jerome
Clark
Custer
Boise
Ada
5
Twin Falls
7
Valley
Boise
Ada
5
Twin Falls
7
Valley
Boise
Ada
Adams
Adams
Washington
Payette
Gem
Lemhi
Lemhi
Adams
Valley
2
Idaho
Idaho
Bonneville
5
Bingham
6
LincolnMinidoka
Power Bannock Caribou
Jerome
Twin Falls
Cassia
Oneida
Bear Lake
Franklin
21
Smoking Prevalence, Idaho 2012
* In 2012, about 190,000 adult smokers in Idaho.
22
Smoking Prevalence, Idaho 2012
23
Smoking Prevalence, Idaho 2012
24
Area-Based Measures
• Used methods based on Harvard School of
Public Health Disparities Geocoding Project
– Geocoded cancer incidence data
– Used area-based socioeconomic measures
(ABSMs) to characterize both the cases and
population
– Computed rates stratified by the area-based
measure of socioeconomic status
– Ran multilevel models and will be showing the
effects that were statistically significant
25
Census Tract 2010
Poverty
American Community Survey 2007-2011
Boundary
Bonner
1
Census Tracts 2010
Kootenai
Census_Tract_Poverty_ACS_0711
Benewah Shoshone
0% - <5% poverty
05% - <10% poverty
Latah
Clearwater
Nez PerceLewis
10% - <20% poverty
20% + poverty
2
Idaho
Lemhi
Adams
7
Valley
4
Washington
Payette
Gem
Clark
Boise
Butte
Canyon
Jefferson
Teton
Madison
Blaine
Ada
Elmore
Camas
Gooding
3
Owyhee
Fremont
Custer
Bonneville
5
Bingham
6
LincolnMinidoka
Power Bannock Caribou
Jerome
Twin Falls
Cassia
Oneida
Bear Lake
Franklin
26
Census Tract 2010
Uninsured
American Community Survey 2008-2012
Boundary
Bonner
1
Census Tracts 2010
Kootenai
Census_Tract_Uninsured_ACS_0812
Benewah Shoshone
<15% uninsured
15% - <25% uninsured
Latah
Clearwater
Nez PerceLewis
25% - <35% uninsured
35%+ uninsured
2
Idaho
Lemhi
Adams
7
Valley
4
Washington
Payette
Gem
Clark
Boise
Butte
Canyon
Jefferson
Teton
Madison
Blaine
Ada
Elmore
Camas
Gooding
3
Owyhee
Fremont
Custer
Bonneville
5
Bingham
6
LincolnMinidoka
Power Bannock Caribou
Jerome
Twin Falls
Cassia
Oneida
Bear Lake
Franklin
27
Lung Cancer Incidence by Census
Tract % Uninsured
28
Potentially Averted Lung Cancer
Cases, 2007-2011
Uninsured Status-Related Population Attributable Fraction
Lung & Bronchus Cancer Incidence, Idaho, 2007-2011
Area Uninsured Status
<15% uninsured
15% - <25% uninsured
25% - <35% uninsured
35%+ uninsured
Total
Person-Years
1,588,827
2,961,564
2,123,378
1,074,624
7,748,393
Case Counts
Observed
Expected
606
606
1,499
1,293
1,320
1,022
708
490
4,133
3,412
Potentially Averted
Cases
Percent
0.0%
206
13.7%
298
22.5%
218
30.7%
721
17.4%
Expected counts = age-specific rates from low uninsured area applied to populations of other areas.
29
Lessening the Burden from Lung
Cancer
• Primary Prevention
– Don’t smoke!
– Test for radon
• Secondary Prevention
– LDCT among high risk population
• Tertiary Prevention
– Ensure quality treatment
• Access to care
• Concordant with guidelines (e.g. NCCN)
• Clinical trials
30
Using the Drill-Down Results
• Target geographic areas
• Disparities by:
–
–
–
–
Income
Education
Uninsured
LGBT
31
Colon & Rectum Cancer
Constellation
Colon & Rectum Cancer
• Idaho 2011:
– 639 new invasive cases
– 17 new in situ cases
– 222 deaths
• Of cancers affecting both men and women,
second leading cause of cancer death
33
Colon & Rectum Cancer Risk Factors
• UK (2011) study estimates 54% of colon & rectum
cancer cases are attributable to lifestyle factors:
Br J Cancer. 2011; 105(Suppl 2): S77–S81.
–
–
–
–
–
–
–
Red and preserved meat consumption (21%)
Overweight and obesity (13%)
Low fiber diet (12%)
Alcohol (12%)
Tobacco (8%)
Physical inactivity (3%)
Other [infections, radiation] (4%)
• The percentages reflect the effect of removing one cause of
cancer independently of other causes, and there is overlap,
so the total is less than the sum
34
USPSTF Recommendation (Oct 2008):
• The USPSTF recommends screening for
colorectal cancer using fecal occult blood
testing, sigmoidoscopy, or colonoscopy in adults
beginning at age 50 years and continuing until
age 75 years.
– Grade: A recommendation – there is high
certainty that the net benefit is substantial.
35
Colorectal Cancer Screening
• CDC: “If everyone aged 50 years or older had
regular screening tests, at least 60% of deaths
from this cancer could be avoided.”
• Colorectal cancer screening helps find
precancerous polyps so they can be removed
before they turn into cancer. In this way,
colorectal cancer is prevented.
• Screening tests also can find colorectal cancer
early, when the chance of cure is better.
36
CCAI Strategic Plan Objectives
Pertaining to Colon & Rectum Cancer
•
•
•
•
•
•
5 – Mortality
9 – Incidence
15 – Late stage CRC among persons aged 50+
16 – CRC Screening
21 – Overweight
22 – Physical activity
37
Colon & Rectum Cancer State Map
38
Colorectal Cancer Screening
Idaho 2012, Ages 50-75
39
Colorectal Cancer Screening
Idaho 2012, Ages 50-75
40
Colorectal Cancer Screening
Idaho 2012, Ages 50-75
41
Colon & Rectum Cancer Trends
42
Colon & Rectum Cancer Incidence by
Race/Ethnicity, 2007-2011
Race/Ethnicity
Count
Non-Hispanic White
2,872
Hispanic (any Race)
97
Black
9
American Indian/Alaska Native
38
Asian or Pacific Islander
26
Pop
6,623,464
848,174
74,451
144,202
126,108
Rate Rate Ratio Ratio P-Value
39.2
32.7
0.83
0.120
31.8
0.81
0.662
46.8
1.20
0.379
31.7
0.81
0.332
43
Colon & Rectum Cancer Incidence by
Census Tract % Poverty
44
Potentially Averted Colon & Rectum
Cancer Cases, 2007-2011
Poverty Status-Related Population Attributable Fraction
Colorectal Cancer Incidence, Idaho, 2007-2011
Area Uninsured Status
0% - <5% poverty
5% - <10% poverty
10% - <20% poverty
20% + poverty
Total
Person-Years
528,593
2,015,643
3,905,375
1,298,778
7,748,389
Case Counts
Observed
Expected
161
161
770
654
1,639
1,386
497
380
3,067
2,581
Potentially Averted
Cases
Percent
0.0%
116
15.0%
253
15.5%
117
23.5%
486
15.8%
Expected counts = age-specific rates from low poverty area applied to populations of other areas.
45
Lessening the Burden from
Colon & Rectum Cancer
• Primary Prevention
– Healthy diet, Healthy BMI, Physical activity
– Don’t smoke
• Secondary Prevention
– Colon & rectum cancer screening
• Tertiary Prevention
– Ensure quality treatment
• Access to care
• Concordant with guidelines (e.g. NCCN)
• Clinical trials
46
Using the Drill-Down Results
• Target geographic areas
• Disparities by:
– Income
– Education
– Area-based SES
47
Breast Cancer Constellation
Breast Cancer (Female)
• Idaho 2011:
– 1,006 new invasive cases
– 225 new in situ cases
– 194 deaths
• Among Idaho women, breast cancer is:
– the most common cancer (incidence)
– 2nd most common for mortality
49
Breast Cancer Risk Factors
• Risk Factors you Cannot Change
– Aging
– Race and ethnicity
– Genetic risk factors
• 5-10% of breast cancers are hereditary
• BRCA1 and BRCA2
– Family history
• 15% of women who get breast cancer have a
family history; 85% do not.
– Dense breast tissue
– Certain other breast conditions (LCIS, DCIS,
atypical ductal or lobular hyperplasia)
– Number of menstrual cycles
– Previous chest radiation
– Diethylstilbestrol exposure
50
Breast Cancer Risk Factors
• Lifestyle-related factors
–
–
–
–
–
Birth control
Hormone therapy after menopause
Drinking alcohol
Being overweight or obese after menopause
Lack of physical activity
• Unclear factors
– Chemicals in the environment
– Tobacco smoke
– Night work
51
Idaho Breast Cancer Trends
52
30% Reduction In Breast Cancer
Mortality Since 1980s
• How much due to screening?
– Goal is to treat cancer earlier, when a cure is
more likely
• How much due to treatment?
– Adjuvant tamoxifen lowers breast cancer
mortality by nearly a third in long term studies of
women with ER+ breast cancers (about 75
percent of those diagnosed)
• There were greater improvements in mortality
among women with ER+ than ER- tumors (SEER
1990-2003).
53
Mammography Screening
Recommendations
for Women at Average Risk
American Cancer
Society
National Cancer
Institute
National
Comprehensive
Cancer Network
United States
Preventive
Services Task
Force
Every year
starting at age 40
Every 1-2 years
starting at age 40
Every year
starting at age 40
Every 2 years
Ages 50-74
• Women at higher risk of breast cancer may
need to be screened earlier and more often
than other women.
54
JAMA Review – Pace & Keating
April 2014
• 450 articles from 1960 to 2014 reviewed for
evidence on the mortality benefit and chief harms
of mammography screening.
– Mortality benefit of mammography is “modest”
• 15% reduction of breast cancer mortality for women
in their 40s, and 32% for women in their 60s.
– Risks of harm from screening are “significant”
• Over 10 years of annual mammograms, 61% with
false-positive result.
• 19% of cancers represent overdiagnosis
– Clinicians must focus on informed screening
decisions based on individual risk of a breast
cancer diagnosis.
55
CCAI Strategic Plan Objectives
Pertaining to Breast Cancer
• 3 – Mortality
• 11 – Late stage incidence rate ages 40+
• 17A- Biennial mammogram 40+
• 17B- Biennial mammogram 50-74
56
Breast Cancer Mortality
57
Breast Cancer Incidence
58
Mammography Screening
Idaho 2012, Females 40+
59
Lessening the Burden from
Breast Cancer
• Primary Prevention
– Overweight and obesity, Physical activity
• Secondary Prevention
– USPSTF – recommends biennial screening
mammography for women aged 50 to 74 years
• Tertiary Prevention
– Ensure quality treatment
• Access to care
• Concordant with guidelines (e.g. NCCN)
• Clinical trials
60
Melanoma of the Skin Constellation
Melanoma of the Skin
• Idaho 2011:
– 443 new invasive cases
– 385 new in situ cases
– 57 deaths.
• Melanoma is the 5th most common cancer in
Idaho in terms of incidence and 14th most
common site for cancer deaths.
• Unreported cases from in-office labs continues
to be an issue for most states.
– Meaningful Use 2 may help improve melanoma
reporting.
62
USPSTF Recommendations:
• [2009] Not enough evidence to recommend for
or against routine screening (total body
examination by a doctor) to find skin cancers
early.
• [2012] Recommends counseling children,
adolescents, and young adults aged 10 to 24
years who have fair skin about minimizing their
exposure to ultraviolet radiation to reduce risk
for skin cancer.
– Insufficient evidence to assess the balance of
benefits and harms of counseling adults older
than age 24 years.
63
CCAI Strategic Plan Objectives
Pertaining to Skin Cancer
• 8 – Mortality
• 27 – Tanning appliances grades 9-12
• 28 – Sunburn adults
• 29 – Tanning appliances adults
64
Melanoma of the Skin Mortality
65
Melanoma of the Skin Incidence
66
Melanoma of the Skin Trends
67
Sunburn among Adults, Idaho 2012
68
Sunburn among Adults, Idaho 2012
69
Indoor Tanning among Adults
Idaho 2012
70
Indoor Tanning among Adults
Idaho 2012
71
Indoor Tanning among Children
Idaho 2013
72
Lessening the Burden from
Melanoma of the Skin
• Primary Prevention
–
–
–
–
Avoiding excessive sun exposure
Avoiding intense, intermittent, UV exposure
Preventing sunburns
Prompt self-referral to physician for changing nevi
• Secondary Prevention
– USPSTF – not enough evidence to recommend
for or against routine screening
• Tertiary Prevention
– Ensure quality treatment
• Access to care, guidelines, clinical trials
73
Using the Drill-Down Results
• Target geographic areas
• Focus on the young and the affluent for sunburn
– Young females for indoor tanning
74
Hospitals & Clinical Trials
75
American College of Surgeons
Commission on Cancer (CoC)
Cancer Programs in Idaho (n=7)
•
•
•
•
•
•
•
Eastern Idaho Regional Medical Center
Kootenai Medical Center
Portneuf Medical Center
Saint Alphonsus Regional Medical Center
St. Joseph Regional Medical Center
St. Luke's Magic Valley Medical Center
St. Luke’s Regional Medical Center/MSTI
– About 70% of Idaho resident cancer cases seen
at one of these facilities
76
Clinical Trial Enrollment
77
The Future of Cancer in Idaho
• As Idaho’s population
increases and we live
longer, we can expect
more cases of cancer
and cancer deaths in
the future
78
Lessening the Burden
• Primary Prevention – Decreases Incidence
–
–
–
–
Don’t smoke! Test for radon
Obesity & physical activity
Skin cancer prevention
Vaccinations for Hep B and HPV
• Secondary Prevention - Screening
– Breast
– Colorectal
– Lung
• Tertiary Prevention - Ensure Quality Treatment
– Access to care, Clinical trials
– Concordant with guidelines (e.g. NCCN)
79