Cancer Prevention in the United States

Workshop on Non-Communicable Diseases

May 5, 2012

Jo Ivey Boufford, M. D.

Communicable, maternal, perinatal and nutritional conditions NCDs Injuries

Males

0

2M

4M

6M

8M

AFR AMR EMR EUR SEAR WPR AFR AMR EMR EUR SEAR WPR

Females

Mill

ion

s o

f d

eath

s (i

n 2

00

8)

Global burden of NCDs: 36 million deaths

Premature NCD deaths before the age of 60 (2008 estimates)

0 M

5 M

10 M

15 M

20 M

25 M

30 M

35 M

Low-income

Countries

Lower-

Middle-income

Countries

Upper-

Middle-income

Countries

High-income

Countries

Communicable conditions NCDs < 60 Injuries NCDs > 60

NCD Risk Factors

Dahlgren G, Whitehead M. 1991. Policies and Strategies to Promote Social Equity in Health. Stockholm, Sweden: Institute for

Futures Studies.

Context: How Health Improvement is Produced

5

The Public Health System

Community Health care

delivery system

Employers &

Business

Governmental Public

Health Infrastructure

Academics The Media

Assuring the Conditions

for Population Health

INSTITUTE OF MEDICINE

Millennium Development Goals

Goal 1: Eradicate extreme poverty and hunger

Goal 2: Achieve universal primary education

Goal 3: Promote gender equality and empower women

Goal 4: Reduce child mortality

Goal 5: Improve maternal health

Goal 6: Combat HIV/AIDS, malaria and other diseases

Goal 7: Ensure environmental sustainability

Goal 8: Develop a Global Partnership for Development

What about NCDs?

Behavioral

Factors

50%

Inadequate

Access to

Medical Care

10%

Genetic Factors

20%

Environmental

Factors

20%

Causes of Premature Mortality

The Core Function Project: U.S. Public Health Service, 1993

Public Health as Percentage of Health Expenditures

(Institute of Medicine)

Public Health Expenditures

3%

Total Health Expenditures

97%

Prevention for a Healthier America:

Financial Return on Investment?

INVESTMENT: $10 per person per year

HEATH CARE

COST NET

SAVINGS:

$16 Billion annually

within 5 years

RETURN ON

INVESTMENT

(ROI):

$5.60 for every $1

With a Strategic Investment in Proven Community-Based Prevention Programs to Increase Physical Activity and Good Nutrition and Prevent Smoking and Other Tobacco Use

Cancer in the United States

• 1.5 million cases diagnosed each year

• Second leading cause of death behind CVD

Age-adjusted death rate by race/ethnicity per 100,000

for all types of cancer, combined (2007):

African Americans 216

Whites 177

American Indians/Alaska Natives 119

Hispanics 117

Asians/Pacific Islanders 108

Tobacco use and cancer risk

• There is solid evidence that smoking causes cancers of the long, oral cavity, pharynx, larynx, esophagus, bladder, kidney, pancreas, stomach, uterine cervix, and acute myeloid leukemia.

• Cigarette smoking causes an estimated 30% of all cancer deaths in the United States

Benefits of smoking cessation compared to continuing smokers

• Cessation by age 50 reduces the risk of dying within 15 years by up to 50%

• The risk of lung cancer is 30-50% lower after 10 years of abstinence

• Risk of oral and esophageal cancer is reduced by 50% within 5 years of cessation

Systematic reviews of epidemiologic evidence

Obesity and Cancer Risk

• Obesity is convincingly linked to postmenopausal

breast cancer, cancers of the esophagus, pancreas, colorectum, endometrium, and kidney

• Body fat is a probable risk factor for gallbladder cancer

• Weight loss has yet to be shown to reduce the risk of obesity-associated malignancies

Alcohol and Cancer Risk

• There is convincing evidence that drinking alcohol increases the risk of cancers of the mouth, esophagus, breast, and colorectum

• There is probable evidence that drinking alcohol increases the risk of liver cancer and, in women, colorectal cancer

• Daily consumption of around 50g of alcohol doubles or triples the risk for mouth, larynx, throat cancer compared to nondrinkers

Diet and Cancer Risk

• Both fruits and non-starchy vegetables are associated with probable decreased risk for cancers of the mouth, esophagus, and stomach

• Fruits but not not-starchy vegetables are associated with probable decreased risk of lung cancer

• Vitamin and dietary supplement use have no proven benefit

Physical Activity and Cancer Risk

• There is convincing evidence that increased physical activity protects against colorectal cancer

• There is probable evidence that physical activity is associated with lower risk of postmenopausal breast cancer and endometrial cancer

Patient Protection and Affordable Care Act

Enacted into law on March 23, 2010

ACA - Clinical Preventive Services include:

•Expanded support for primary care, including immunizations and screening

•Full coverage for age-appropriate preventive services

•Free annual wellness visits for Medicare beneficiaries

ACA and Community Based Prevention

• Community Transformation Grants and Place Based Initiatives across government

• Prevention and Public Health Trust

• Restaurant Menu Calorie Labelling

• National Prevention, Health Promotion and Public Health Council

• National Prevention Strategy

• National Health Disparities Strategy

New York City

• Population: 8.4 million

• Size: 305 square miles (790 km2)

• Diversity

– 800 languages

– 46% speak a language other than English at home

• Disparities

Leading Causes of Death New York City, 2009

Source: NYC DOHMH Bureau of Vital Statistics 2009

Implementing Take Care New York 2012

New York City aims to: 1. Promote Quality Health Care for All 2. Be Tobacco Free 3. Promote Physical Activity and Healthy Eating 4. Be Heart Healthy 5. Stop the Spread of HIV and Other Sexually Transmitted

Infections 6. Recognize and Treat Depression 7. Reduce Risky Alcohol Use and Drug Dependence 8. Prevent and Detect Cancer 9. Raise Healthy Children 10. Make All Neighborhoods Healthy Places

Take Care New York 2012 Objective 8: Prevent and detect cancer

Smoking Mass Media Campaign: Suffering Every Minute

• Shows how smoking can cause long-term suffering

• Focuses on emphysema and stroke, which can require family members to care for loved ones

Pe

rce

nt

of

adu

lts

NYC and NYS tax increases

Smoke-free workplaces

Free patch programs start

3-yr average 3-yr average 3-yr average

Hard-hitting media campaigns

NYS tax increase

Federal tax increase

NYS tax increase

Source: New York City Community Health Survey

Effect of Environmental Approaches to Smoking Prevention

NYC, 2002-2010

New York City Health Department Campaign Against Trans Fat

• Regulations since 2006 to eliminate artificial trans fat from all restaurants

• Legal requirement to post calorie counts on menus and menu boards

NYC Green Carts: Promoting Access to Fresh Fruits and Vegetables

Media Messages About Sugary Drinks

Decline in Sugary Drink Consumption in NYC 2005-2009

*Youth Risk Behavior Survey data refers to soda only **Take Care New York baseline ***Includes adults who can be reached by cell phone Sources: NYC Community Health Survey 2002-2009. NYC Youth Risk Behavior Survey 2005, 2007, 2009.

Community Health Survey

Promoting Physical Activity

Improving Air Quality in Times Square

SOCIETY AND

INSTITUTIONS

COMMUNITY

INDIVIDUALS ILLNESS

TARGET OF

INTERVENTION

TYPE OF INTERVENTION

Hospital

Care

Intersectoral Working: Jobs/Housing/

Education

Public Advocacy Health

Promotion/

Prevention

HEALTH

Primary

Care