Cancer summitt 2020 buffalo aug 2011


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Presentation by our Keynote Speaker, Leslie J. Kohman, MD at our Cancer Mission 2020 28th Congressional District Summit in Buffalo, NY. Dr. Kohman is the Professor of Surgery Medical Director at Upstate Cancer Center in Syracuse, NY.

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  • The next four slides look at the lifetime probability of developing cancer and relative survival rates of cancer.   Presently, the risk of an American man developing cancer over his lifetime is one in two.
  • The risk of an American woman developing cancer over her lifetime is one in three.
  • Infections 20% in developing countries Hepatitis B, HIV, HPV, H. pylori
  • Lack of health insurance and other barriers prevents many Americans from receiving optimal health care. According to the US Census Bureau, almost 51 million Americans were uninsured in 2009; almost one­third of Hispanics (32%) and one in 10 chil­ dren (17 years and younger) had no health insurance coverage. Uninsured patients and those from ethnic minorities are sub­ stantially more likely to be diagnosed with cancer at a later stage, when treatment can be more extensive and more costly
  • The death rate for all cancers combined decreased by 1.9% per year from 2001 to 2007 in men and 1.5% per year from 2002 to 2007 in women. Compared to the peak rates -- in 1990 for men and 1991 for women -- the cancer death rate for all sites combined in 2007 was 22.2% lower in men and 13.9% lower in women.
  • About 898,000 cancer deaths were averted from 1991 through 2007 as a result of the continued decline in cancer deaths rates.
  • The 5-year relative survival rate for cancer is 67% among whites and 58% among African Americans (taking normal life expectancy into consideration). For many sites, survival rates in African Americans are 10% to more than 20% lower than in whites. This is due, in part, to African Americans being less likely to receive a cancer diagnosis at an early, localized stage, when treatment can improve chances of survival. Additional factors that contribute to the survival differential include unequal access to medical care and tumor characteristics not related to early detection.
  • Cancer Survival by Insurance Status*. *Patients aged 18 to 64 years diagnosed from 1999 to 2000; excluded from the analysis: unknown stage; race/ethnicity other than White, African American, or Hispanic; missing information on stage, age, race/ethnicity, or zip code. Covariates included in the model are age, race, sex, and zip code‐based income. Data Source: National Cancer Data Base. © This slide is made available for non-commercial use only. Please note that permission may be required for re-use of images in which the copyright is owned by a third party.
  • Level of education is often used as a marker for socioeconomic status. If the death rates of the most educated non-Hispanic whites are applied to all individuals ages 25 to 64 – i.e., if everyone had the cancer burden of the most educated -- the number of cancer deaths in this age group could be reduced by 37%.
  • The next series of slides look at the burden of cancer among our nation's children. Cancer incidence among children ages 0-14 years has been increasing slightly, by about 0.6% per year, since 1975. Cancer-related mortality in children ages 0-14 decreased 2.9% per year from 1975 to 1997, and since has been decreasing by 1.0% per year.
  •   Tobacco use is a major preventable cause of death, particularly from lung cancer. The year 2004 marks the anniversary of the release of the first Surgeon General’s report on Tobacco and Health, which initiated a decline in per capita cigarette consumption in the United States. As a result of the cigarette smoking epidemic, lung cancer death rates showed a steady increase through 1990, then began to decline among men. The lung cancer death rate among US women, who began regular cigarette smoking later than men, has begun to plateau after increasing for many decades.
  • The American Cancer Society recommends that individuals eat five or more servings of vegetables and fruits a day for cancer prevention. Fruit and vegetable consumption may protect against cancers of the mouth and pharynx, esophagus, lung, stomach, and colon and rectum. However, there has been little improvement in consumption since the mid-1990s. About one in four adults was eating the recommended servings in 2009.
  • The American Cancer Society recommends that adults engage in at least 30 minutes of moderate to vigorous physical activity, above usual activities, on 5 or more days of the week; 45 to 60 minutes of intentional physical activity is preferable. However, similar to trends in nutrition, there has been little change in leisure-time physical activity during the 1990s. About one-fourth of adults do not engage in any leisure-time physical activity. Even more striking is that almost half of adults with less than a high school education do not participate in any leisure-time physical activity. It should be noted that leisure-time physical activity, as presented in this graph, does not reflect job-related physical activity for the currently employed population. While there has been little change in leisure-time physical activity since the early 1990s, data from other sources illustrates long-term social changes have contributed to reduced total physical activity in US adults, including reduced leisure time for physical activity, shifts from using walking as a mode of transportation to increased reliance on automobiles, and shifts to more sedentary or mechanized work.
  • This slide highlights the obesity epidemic as mentioned in the previous slide. In 2009, over 55% of adults in all states, except District of Columbia, were overweight or obese, compared to none in 1992.
  • We also know that
  • NO BENEFIT to screening for lung, prostate, ovarian, pancreatic or skin cancer. The reduction in mortality is far less than the incidence of early detection.
  • USPSTF – different from American Cancer Society a little
  • The prevalence of women reporting a mammogram within the past year increased from 50% in 1991 to 64% in 2000, and has since remained relatively stable (2008: 62%). During this time, mammogram utilization varied considerably by educational attainment. The prevalence of women with less than a high school education reporting a recent mammogram was approximately 8 percentage points lower than the prevalence for all women. Even more striking is that the prevalence for women with no health insurance is approximately 26 percentage points lower than the prevalence for all women.
  • This graph shows that the prevalence of women who have had a Pap test within the past three years has remained high, and has increased during the late 1990s. Throughout the decade, the prevalence among women with less than a high school education as well as the prevalence among women with no health insurance was approximately 10 percent lower than the percentage for all women.
  • In 2008, approximately 15% of US adults 50 and older had a fecal occult blood test (FOBT) in the previous year. Adults with less than a high school education are less likely to report a recent FOBT. The prevalence for adults with no health insurance is about 8 percentage points lower than the prevalence for all adults.
  • While there has been a downward trend during recent years in the use of FOBT, the prevalence of flexible sigmoidoscopy (FSIG) or colonoscopy has continuously increased from 1997 to 2008. Adults with less than a high school education were less likely to report FSIG or colonoscopy than all adults. Even more striking is that the prevalence for adults with no health insurance is less than half of that for all adults. Continuing efforts are needed to address health system barriers to colon cancer screening, to encourage health care practitioners to promote screening to their patients, and to raise awareness among eligible adults about the importance of getting screened for CRC.
  • Bill Medicare and insurance companies
  • (eg, in the ICU, intubated, with resuscitation, or as a result of adverse effects of treatment). 
  • only 3% of radiology residents would like to spend substantial time interpreting mammograms in clinical practice In a survey conducted by the Society of Breast Imaging in 2003 and 2004, 29% of breast imaging practices reported a vacancy for one or more radiologists to interpret mammography studies. A higher proportion of facilities reporting vacancies also reported longer wait times for screening mammography than facilities without vacancies [19]. Almost one third (30%) of practices responding to the survey also reported unfilled positions for radiologic technologists certified in mammography [19].
  • At current rates of  cancer  screening, the United States will need an additional 1,050 gastroenterologists by 2020, according to the study by The Lewin Group. If colorectal cancer screening rates were to increase by 10 percent, the nation would need as many as 1,550 additional gastroenterologists by that time, the firm found.  Colon cancer  is the nation’s second leading cancer killer. There are currently 10,390 practicing gastroenterologists in the United States, according to the report.
  • NIH funding is the very lifeblood of our nation’s biomedical research enterprise, accounting for nearly 80 percent of all funding for non-profit medical research in the US. This research: • Leads to US patents that fuel the biotechnology industry, promoting our competitiveness in the global biomedical market and spurring economic growth. • Supports training of our biomedical research workforce, the very foundation of sustaining our knowledgebased economy. • Is the engine for innovation that is critical to driving down healthcare costs and improving productivity and quality of life in the US.
  • FY 2009 would have to be $5.35 M just to be equal to 2003
  • Research (improving care) Education (creating care providers) Funding (accessing care)
  • left significant voids in:  Payment coverage for the cost of pharmacy facilities (drug procurement, storage, inventory, and waste disposal),  The cost of developing, managing, and changing the treatment plan, the foundation of quality cancer care.
  • increase political commitment for cancer prevention and control; generate new knowledge, and disseminate existing knowledge develop standards and tools for prevention, early detection, treatment and care facilitate broad networks of cancer control partners at global, regional and national levels; strengthen health systems at national and local levels; provide for rapid, effective transfer of best practice interventions to developing countries coordinate and conduct research and develop scientific strategies for cancer prevention and control.
  • Cancer summitt 2020 buffalo aug 2011

    1. 1. Stop Cancer Now! Leslie J. Kohman, MD Professor of Surgery Medical Director, Upstate Cancer Center Syracuse, NY August 18, 2011
    3. 3. <ul><li>Cancer accounted for 7.6 million deaths (around 13% of all deaths) in 2008.  </li></ul><ul><li>Deaths from cancer worldwide will rise to over 11 million in 2030. </li></ul><ul><li>More than 70% of all cancer deaths occur in low- and middle-income countries. </li></ul>
    4. 6. Why so much cancer? <ul><li>Awareness </li></ul><ul><li>Accounting </li></ul><ul><li>Improved detection </li></ul><ul><li>AGING POPULATION </li></ul>
    5. 7. Causes of Cancer
    6. 8. USA 2011 <ul><li>1,596,670 new cancer cases </li></ul><ul><ul><li>1 in 4 deaths </li></ul></ul><ul><ul><li>2 nd only to cardiovascular disease </li></ul></ul><ul><li>571,950 deaths (1,500 / day) </li></ul><ul><ul><li>30% caused by tobacco use </li></ul></ul><ul><ul><li>33% related to overweight or obesity, physical inactivity, and poor nutrition </li></ul></ul><ul><ul><li>9% caused by infection </li></ul></ul><ul><ul><li>Sun exposure, environmental factors </li></ul></ul>
    7. 9. Costs of Cancer in 2010 <ul><li>$263.8 billion: </li></ul><ul><ul><li>$102.8 billion for direct medical costs </li></ul></ul><ul><ul><li>$20.9 billion for lost productivity due to illness </li></ul></ul><ul><ul><li>$140.1 billion for lost productivity due to premature death </li></ul></ul>
    8. 10. Most cancer is preventable
    9. 14. Association of Insurance with Cancer Care Utilization and Outcomes CA: A Cancer Journal for Clinicians Volume 58, Issue 1, pages 9-31, 24 FEB 2009 DOI: 10.3322/CA.2007.0011
    10. 17. We need to improve <ul><li>Prevention! </li></ul><ul><li>Early Detection </li></ul><ul><li>Treatment and Access </li></ul><ul><li>Palliative Care Services </li></ul><ul><li>Healthcare Workforce </li></ul><ul><li>Policy </li></ul>
    11. 18. How to Improve Cancer Care <ul><li>Awareness </li></ul><ul><li>Advocacy </li></ul><ul><li>Policy </li></ul><ul><li>Research (improving care) </li></ul><ul><li>Education (creating care providers) </li></ul><ul><li>Funding (accessing care) </li></ul>
    12. 19. Prevention <ul><li>How are we doing? </li></ul><ul><li>Can we do better? </li></ul>
    13. 24. More preventable causes and how to avoid them: <ul><li>Sun exposure and tanning (65-90% melanomas; most non-melanoma skin cancers) </li></ul><ul><ul><li>Use sunscreen </li></ul></ul><ul><ul><li>Don’t tan! </li></ul></ul><ul><li>Infections </li></ul><ul><ul><li>HPV vaccination (90% cervical cancer; penile, anal and head and neck) </li></ul></ul><ul><ul><li>Hepatitis B vaccination (90% liver cancer) </li></ul></ul>
    14. 25. Colonoscopy <ul><li>41.8 million average-risk people aged 50 years or older have not been screened for colorectal cancer </li></ul><ul><li>40% of colonoscopies on Medicare patients unnecessary: </li></ul><ul><ul><li>Normal < 10 years ago </li></ul></ul><ul><ul><li>Older than 75 </li></ul></ul><ul><li>Total cost $100 million </li></ul>
    15. 27. Early Detection (Screening) <ul><li>How are we doing? </li></ul><ul><li>Can we do better? </li></ul>
    16. 28. Screening ≠ Prevention
    17. 30. Cancer Screening Prevention Early Detection Cervical Colorectal Breast
    18. 31. Evidence-based screening tests: <ul><ul><li>Mammograms women age 50-74 </li></ul></ul><ul><ul><ul><li>Q 2 years </li></ul></ul></ul><ul><ul><li>Colonoscopy women and men age 50-74 </li></ul></ul><ul><ul><ul><li>Q 10 years </li></ul></ul></ul><ul><ul><li>Pap smears women with a cervix age 25-60 </li></ul></ul><ul><ul><ul><li>Q 3 years </li></ul></ul></ul>
    19. 36. Awareness
    20. 37. Treatment 5-year survival 1975-1977 50% Now 68%
    21. 38. Cancer Drug Shortages: the real rationing <ul><li>34 generic cancer drugs </li></ul><ul><li>14 in short supply </li></ul><ul><li>Many new drugs cost up to $90,000 per patient, extend life by only a few months </li></ul><ul><li>Older curative cancer drugs, $3 per dose, unavailable </li></ul>
    22. 39. Why? <ul><li>Oncologists, not patients, buy the drugs </li></ul><ul><li>Generics drop prices by 90% </li></ul><ul><li>Medicare Prescription Act of 2003 limits drug price increases </li></ul><ul><li>Low profit margins </li></ul><ul><li>No quick fix </li></ul>
    23. 40. Palliative Care and Hospice
    24. 41. <ul><li>Many cancer patients receive chemotherapy in the last few months of life </li></ul><ul><li>Receiving chemotherapy is correlated with a delay in referral to hospice.  </li></ul><ul><li>Why do doctors provide treatments that are medically futile? </li></ul><ul><ul><li>expectations for treatment by patients and families </li></ul></ul><ul><ul><li>uncertainty about a patient's prognosis </li></ul></ul><ul><ul><li>legal pressure </li></ul></ul>
    25. 42. <ul><li>patients who overestimate their likelihood of long-term survival are more likely to experience a “bad” death </li></ul>
    26. 43. <ul><li>improved quality of life </li></ul><ul><li>Improved mood </li></ul><ul><li>Less aggressive care at the end of life </li></ul><ul><li>longer survival. </li></ul>N Engl J Med 2010;363:733-42.
    27. 44. <ul><li>According to a  Duke University  study, hospice care saves Medicare on average $2,300 per patient. </li></ul>
    28. 45. Healthcare Workforce
    29. 46. Projected Numbers of Women 40 Years and Older and Radiologists per 100,000 Population by Year <ul><li>Note—Data are from the U.S. Census Bureau and the 2003 survey of radiologists conducted by the American College of Radiology. Column totals may not be exact due to rounding errors. </li></ul>Year Baseline 2003 2005 2010 2015 2020 2025 No. of women ≥ 40 y 68,357,000 70,197,000 75,265,000 79,633,000 83,888,000 88,583,000 No. of radiologists per 100,000 women 21.1 20.6 19.4 18.5 17.9 17.5 % Change -2.3 -5.9 -4.4 -3.5 -2.3 Cumulative % change -2.3 -8.0 -12.1 -15.2 -17.1
    30. 47. Why? <ul><li>lack of interest in the field </li></ul><ul><li>fear of lawsuits </li></ul><ul><li>stress of interpretation </li></ul>
    31. 48. Colonoscopy <ul><li>since 1994, screening-aged population increased 50% </li></ul><ul><li>Capacity exists to screen within 1 year using fecal occult blood testing </li></ul><ul><li>Up to 10 years to screen using flexible sigmoidoscopy or colonoscopy. </li></ul><ul><li>Might need as many as 32,700 more gastroenterologists in the US to meet demand. </li></ul>
    32. 49. Research <ul><li>11 million cancer survivors are alive today, due to the lifesaving benefits of cancer research. </li></ul><ul><ul><li>Basic science research </li></ul></ul><ul><ul><li>Translational research </li></ul></ul><ul><ul><li>Clinical Trials </li></ul></ul>
    33. 50. “ Cancer is more willful and calculating than previously imagined” AACR, 2011 <ul><li>We have focused on only 2% of the genome </li></ul><ul><li>90% of protein-encoding cells in our bodies are microbes </li></ul><ul><li>Their signaling is dramatically complex </li></ul>
    34. 51. Hallmarks of Cancer 2000
    35. 53. Hallmarks of Cancer 2011
    36. 55. NIH (NCI) Funding <ul><li>Funds 80% of non-profit medical research </li></ul><ul><li>Leads to US patents, spurring economic growth </li></ul><ul><li>Supports training biomedical research workforce, the foundation of our knowledge-based economy </li></ul><ul><li>Engine for innovation to reduce health care costs and improve productivity </li></ul>
    37. 56. Economic Impact <ul><li>$2.21 return for every NIH dollar spent. </li></ul><ul><ul><li>$50.5 billion in new state business </li></ul></ul><ul><li>more than 350,000 jobs </li></ul><ul><li>wages in excess of $18 billion in the 50 states </li></ul><ul><li>another 800,000 supporting jobs in the private sector </li></ul>
    38. 59. NCI Grant Funding <ul><li>Fiscal 2011 paylines for RO1s: </li></ul><ul><ul><li>New investigators 10% </li></ul></ul><ul><ul><li>Established investigators 7% </li></ul></ul><ul><li>Career Development (K) Awards: </li></ul><ul><ul><li>Falling number of awards </li></ul></ul><ul><ul><li>Pay line 22% </li></ul></ul>
    39. 60. Clinical Trials <ul><li>> 50% children < 5% adults </li></ul><ul><li>Barriers: </li></ul><ul><ul><li>Time </li></ul></ul><ul><ul><li>Eligibility criteria </li></ul></ul><ul><ul><li>Insurance issues </li></ul></ul><ul><ul><li>Shortage of older drugs </li></ul></ul>
    40. 61. Policy Issues
    41. 62. Research Funding
    42. 63. Unintended Consequences….. Medicare Modernization Act of 2003 (MMA)
    43. 64. <ul><li>Cuts to Medicare reimbursement for cancer care $14.7 billion from 2004-2013 </li></ul><ul><li>Community cancer clinics, which treat 84% of Americans with cancer, have experienced a more than 25% decrease in the payment of drug administration services from 2004 through 2009. </li></ul><ul><li>Costs of pharmacy facilities and providing quality treatment planning are not reimbursed. </li></ul><ul><li>Oftentimes, Medicare reimbursement does </li></ul><ul><li>not even cover the actual acquisition costs of cancer drugs. </li></ul>
    44. 65. Patient Protection and Affordable Care Act <ul><li>Mandates that insurers cover certain cancer screenings </li></ul><ul><li>Does NOT require insurers to cover follow-up tests if an abnormality is found. </li></ul><ul><li>Does NOT address many workforce challenges </li></ul><ul><li>Does NOT establish loan forgiveness programs in specialties facing workforce shortages </li></ul><ul><li>Does NOT repeal SGR </li></ul>
    45. 66. Policy Joint Committee on Deficit Reduction $1.2 Trillion in cuts <ul><li>AT RISK : </li></ul><ul><li>Medicare payments to physicians (>50% cancer pts) </li></ul><ul><li>Graduate medical education funding </li></ul><ul><li>Medicare payment for oncology and other drugs administered by physicians </li></ul><ul><li>Medicare imaging payments </li></ul><ul><li>Medical research programs at NIH and AHRQ </li></ul><ul><li>Public health initiatives </li></ul><ul><li>Discretionary portions of the Affordable Care Act </li></ul>
    46. 67. What’s the Solution?
    47. 68. Action Plan <ul><li>Increase political commitment </li></ul><ul><li>Research and education </li></ul><ul><li>Develop standards and tools </li></ul><ul><li>Facilitate networks at global, regional and national levels </li></ul><ul><li>Strengthen health systems </li></ul><ul><li>Transfer best practices to developing countries </li></ul><ul><li>Strategies for cancer prevention and control </li></ul>
    48. 69. Bending the Cost Curve in Cancer Care NEJM | May 25, 2011 | Topics: Cost of Health Care Thomas J. Smith, M.D., and Bruce E. Hillner, M.D.
    49. 70. Bending the Cost Curve in Cancer Care NEJM | May 25, 2011 | Topics: Cost of Health Care Thomas J. Smith, M.D., and Bruce E. Hillner, M.D.
    51. 72. Speak up! Advocate Donate