If you hear good news often enough, does it become “no news?”
That’s my concern with today’s release of the 2009 version of the Annual Report to the Nation on the status of cancer incidence and deaths in the United States from 1975 to 2006. The “news” is still good—with some caveats—but will people still pay attention to the message? I certainly hope so.
If someone had told me years ago about the successes we could achieve in reducing cancer incidence and deaths I would have had serious reservations about our ability to accomplish that task. Here we are 35 years later, and we have done just that.
This report—which was published in the journal Cancer and is a collaborative effort between the American Cancer Society, the National Cancer Institute, the Centers for Disease Control and Prevention and North American Association of Central Cancer Registries--brings us the same message as last year: overall the rates of cancer incidence and death continue to decline in men and women. At the same time, some types of cancer are increasing in frequency, and while death rates from lung cancer are dropping in men, the same cannot be said for women.
The report also highlights the incredible decline in cancer deaths from colorectal cancer in the United States, and emphasizes the opportunity for this country to reduce cancer deaths from this disease by half by 2020 if we did everything we could to get people screened and properly treated. But there may be warning signs of things to come: there is a disturbing trend of increasing deaths from colorectal cancer in people younger than age 50, which is the age when everyone recommends starting routine screening for people at average risk of getting colorectal cancer.
The report is full of complicated data and information. Let me offer some of the statistical highlights:
1) From 1999 through 2006, incidence rates for all cancers in both sexes combined declined 0.7% per year. For men, the decline was 1.3% per year, and for women the decrease was 0.5% per year.
2) From 2001 to 2006, the annual decline in cancer death rates in both sexes combined was 1.6% per year. For men from 2001-2006, the decline was 2% per year, and for women from 2002-2006 the decrease was 1.5% per year.
3) In men, the decline in incidence and death rates was primarily due to decreases in three major cancers: lung, prostate, and colorectal. In women, the declines were primarily due to decreases in breast and colorectal cancers.
4) There is a glimmer of hope that lung cancer deaths may be declining in women (they have been going down in men for a number of years), but unfortunately the actual number (0.9% decrease per year from 2003-2006) is not significant. And, the number year of new lung cancer cases in women measured from year to year has been increasing 0.4% per year from 2002-2006.
5) There are still cancers that are increasing in frequency. For men, among the top 15 cancers, from 2002-2006 the researchers report significant average annual increases each year in melanoma (3.1%), kidney (1.8%), liver (2.6%), esophagus (0.7%) and myeloma (0.7%).
For women, the leading increases in cancer incidence include lung cancer (as noted above), melanoma (3.0%), non-Hodgkin lymphoma (1.1%), thyroid (6.3%), pancreas (1.7%), leukemia (0.3%), kidney (2.4%), and bladder (0.2%).
The researchers continue to highlight the critical fact that there continues to be substantial disparities in cancer incidence and deaths in this country.
For example, black men have the highest incidence of cancer in the country. Black men also have had a significant decline in the incidence of prostate cancer from 1997-2006. When looking at death rates, black men and women had the highest rates from 2002-2006 and they were lowest for Asian and Pacific Islanders.
As has been the custom in these annual reports, the researchers concentrate on a specific area of interest for further, in-depth analysis. In this year’s report, the topic was colorectal cancer, its declining mortality, and the opportunities over the next decade to reduce deaths even further.
The good news here is that the death rates for colorectal cancer are declining dramatically in the United States among all ethnic groups except for American Indian/Alaskan Natives. The decline is most dramatic for people age 65 and over, possibly due to the fact that they have access to Medicare to cover screening and treatment costs.
However—and this is one of the most concerning aspects of this report—the researchers also report that there is a short term increase in the incidence of colorectal cancer in people less than 50, possibly due to a long term impact of changing risk factors including smoking, overweight/obesity and eating a diet high in red meat consumption all of which are known to be associated with increasing colorectal cancer rates (as recently reported in several recent studies, including one from the American Cancer Society).
The report notes that from 1975 to 2000, the incidence of colorectal cancer has declined 22%. Based on a computer model, screening has accounted for 50% of that decline. Treatment and changing risk factors (for the better, during that time period) accounted for the rest of the benefit that was observed.
To me, this is the “kicker” statement of the paper, one that we should all pay close attention to:
“If we can accelerate the projected trends, then an overall mortality reduction of 50% by 2020 is possible….Risk factor modifications, although they require the longest time to produce an impact, will have a sizable effect by 2020. Increases in the proportion of adults screened and in the use of endoscopic CRC screening will provide the largest reduction in future death rates with application of current state-of-screening technologies, risk factor modification, and use of current treatment practices.”
Of course, if you are a regular reader of this blog, you know that I am a strong proponent of colorectal cancer screening and treatment. And, you also know that the comment above—although important and relevant—really isn’t new. That’s because colorectal cancer is one of the cancers that can frequently be prevented or caught early and treated effectively, if we only applied the basic knowledge that we already have.
To give you an idea of the impact of our capabilities to reduce the burden and suffering from this cancer, consider the above in light of the following statistic:
· In 2009, the American Cancer Society estimates there will be 49,920 deaths from colorectal cancer in the United States.
· If you reduce that by half—as the paper suggests could be done if we did everything right—then by the year 2020 we would have about 25,000 (or more) fewer deaths from colorectal cancer.
Can you imagine saving 25,000 lives from colorectal cancer every year? Talk about impact! I hope you agree that would be dramatic.
But then we have to look at the context of the current situation, especially when it comes to getting effective screening tests into more widespread use.
As this current report highlights, there are new ways to screen for colorectal cancer such as CT colonography. But, even though the burden of this disease is greatest in the Medicare population, the Centers for Medicare and Medicaid Services has declined to cover the test because they claim their analysis shows it isn’t cost effective and because it hasn’t been carefully studied in the 65-and-over population (which is also true for many other things we do in medicine).
I am not going to go into detail on that issue here, and you can read my previous blog posts on the topic—especially the one from June 17, 2009 where the staff from CMS that made the decision to deny coverage talked about how proud they were of their decision in holding down costs and standing up against “special interests.”
When you look at the total picture, it would seem that we should be doing everything we can for all of our people to reduce the risk of death from this disease (which can frequently be prevented in the first place).
That would mean emphasizing the need to “stick to the program” of eating well, avoiding tobacco, maintaining a healthy body weight, and getting screened. And we should be emphasizing getting screened with the best available methods, which the American Cancer Society believes should include CT colonography.
If we don’t do what we need to do, we certainly will not meet a goal of a 50% reduction in colorectal cancer deaths by 2020. At the same time, we run the risk of seeing an actually increase in the disease if we don’t get our arms around reducing the risk factors noted above.
In the end, I suspect the most important message of the day is that we have made true, measureable progress in reducing the incidence and deaths from many cancers (some of the recent and continuing comments in a leading newspaper notwithstanding). This is due to a combination of many factors, including better screening, better treatment, and more awareness and communication.
But we should not fail to recognize that there are some cancers where we could do much better, and some cancers where the rates of incidence and deaths are actually increasing.
Our research has brought us a long way, and we have much further to go. These annual reports offer us the opportunity to take a true measure of our successes and our failures.
So, here is to the hope of more successes, our opportunity to do even better, and the willingness to squarely address issues which prevent us from becoming all that we can be when it comes to reducing the burden and suffering of the many diseases we call cancer.