When it comes to reducing cancer mortality in America, there is no question the nation has seen steady improvement with the death rate down 23 percent in just over two decades. Yet, it is also abundantly clear more work remains with cancer supplanting heart disease as the number one cause of death in 21 states. Drilling deeper, it’s also apparent not all cancer care is created equal.
Otis Brawley, MD, MACP, chief medical officer for the American Cancer Society (ACS), shared insights from Cancer Statistics 2016. Released in January, the new report analyzes information through 2012, the most recent year for which data is available.
“I think the takeaway is that we’ve had a 23 percent decline in the cancer mortality rate from 1991 through 2012,” he said. “That translates into 1.7 million cancer deaths averted from 1991 onward.”
Projecting out to 2016, Brawley said the drop in the mortality rate was expected to be about 25 percent. The ACS projects a total of 1,685,210 new cancer cases and 595,690 deaths from cancer this year.
Looking at the four most recent years of data (2009-2012), men have enjoyed a 3.1 percent decrease in new cancer diagnoses, while the rate for women has stayed steady over the same time period. Some of the decline in male diagnoses is believed to be linked to changes in screening recommendations for prostate cancer (see below).
Brawley noted cancer mortality rates rose for most of the 20th century, peaking in the early 1990s. Since 1991, however, mortality rates have declined every year. While the 23 percent overall decline is good news, some types of cancer have enjoyed even greater progress over the past 21 years.
The Big Four
In 2016, the ACS expects 44 percent of all newly diagnosed cancer cases in men to be attributable to lung, prostate or colon cancer with prostate cancer accounting for about 1 in 5 cases. For women, the most common new cancer diagnoses will be lung, breast or colon cancer with breast cancer accounting for 29 percent of those new cancer cases.
Lung, colon, breast and prostate cancers also continue to be the most common causes of cancer death with lung cancer leading the way. However, the big four have also have seen significant decreases in death rates as resources, research, and education have been applied to prevention, early detection and treatment.
“The death rate in lung cancer dropped 38 percent from 1991-2012 in men, and 13 percent from 2002-2012 among females,” Brawley said. He explained lung cancer death rates for women actually continued to rise until 2002, which aligns with historical smoking patterns where women did not begin to widely use tobacco products until much later than men. “The decline for men started in 1955, and it’s gone from a 55 percent prevalence of cigarette smoking to 20 percent today. Women went from a 35 percent prevalence in 1965 to about a 16 percent prevalence today,” Brawley said.
“The death rate in colorectal cancer and breast cancer declined by nearly 40 percent,” he continued. Brawley added colorectal screening has significantly impacted prevention by allowing for the removal of pre-cancerous polyps. Among adults ages 50 to 75, colonoscopy use has increased from 19 percent in 2000 to 55 percent in 2013. Colon cancer incidence and mortality rates have declined about 3 percent a year for both sexes over the last decade.
However, not all screening is created equal. Prostate cancer, Brawley added, is a bit trickier to judge. “We’ve had a decline in prostate cancer … and we hope that’s a good thing,” he said. “On paper, our prostate cancer mortality rate has declined by nearly 50 percent.”
As for why mortality rates are down so much, Brawley said there are multiple theories. Some of the decline could be linked to accounting issues. Some could be due to improved treatments in regional and metastatic prostate cancer. Some researchers have published data suggesting certain treatments might have led to an increase in cardiac deaths. And, Brawley added, another theory is that screening might actually work.
In addition to the United States, the prostate cancer death rate has gone down in 20 other countries. It should be noted, Brawley stated, that 17 of those 21 countries do not screen for prostate cancer. Furthermore, he continued, “The prostate cancer rate went down in the United States before we started screening.”
Calling mass screenings a ‘mistake,’ he noted, “We had an epidemic of prostate cancer screening before any research showed any efficacy.” In fact, the latest edition of the ACS report states about half of the overall decline in new cancer cases for men is because of the recent rapid decline in prostate cancer over-diagnoses since routine screening with the PSA test is no longer recommended.
Brawley continued, “Currently, no professional organization in the United States, Canada or Europe says men should be screened for prostate cancer.” He added there are several organizations, including the ACS, that say men should be told about the potential risks and benefits and should be allowed to make an informed decision about screening in concert with their healthcare provider.
Some Cancers on the Rise
Unfortunately, not all forms of cancer have shown decreases in incidence and mortality rates. Incidence rates increased from 2003 to 2012 among both men and women for tongue, tonsil, small intestine, liver, pancreas, kidney, and thyroid cancers and some types of leukemia. Additionally, men saw increased incidence rates for melanoma, multiple myeloma, male breast cancer, testicular cancer and throat cancer. For women, incidence rates increased for anal, vulvar, and endometrial cancers.
Brawley said some pancreatic, uterine, endometrial and liver cancers are linked to the increase in obesity. In the case of throat cancer, he noted there have been huge decreases in cases linked to smoking and drinking but big increases in throat cancer tied to HPV.
“The leading cause of cancer in the United States is still tobacco smoking,” Brawley said. “About 30 percent of all cancers are correlated to obesity, lack of physical activity and high caloric intake,” he added. “It’s fair to say 40-50 percent of all cancers are preventable due to lifestyle change.”
Unequal Opportunity
Brawley said another issue of key concern is care disparity. “It correlates with socioeconomic status more than anything else and then with geographical status.”
He added the uninsured, underinsured, and those without financial means receive less than optimal care. “We’ve got data to show in the United States, as a whole, you are better off having stage 2 colon cancer with insurance as opposed to stage 1 colon cancer without insurance.” Brawley added the data showed a 10 percent difference in five-year survival in favor of the group with more advanced cancer and insurance.
Similarly, there are regional disparities in care. “There is a huge geographical disparity,” Brawley stated. “While you’ve had a 40 percent decline in colorectal and breast cancer death rates, there are some states with less than a 10 percent decline.” Alabama, Arkansas, Louisiana, Mississippi, and Missouri are among the 14 states that have seen the much smaller decrease in mortality rates.
Brawley added the findings supersede race. “There is this fallacy that race defines biology,” he said. “I don’t think anyone thinks the biology is different for a white woman living in Mississippi or Alabama versus a white woman living in Ohio or Indiana, yet we see drastic difference in breast cancer rates.”
He also noted the racial disparities in breast cancer deaths have become more pronounced in the wake of major treatment improvements that occurred in the 1970s. “The disparities have increased every year since 1980 … and they are more in 2012 than in 2000,” he said, adding the gap has continued to widen as newer, more expensive treatments have become available. “Socioeconomics and education are a far greater driver of this than anything else.”
The Bottom Line
Brawley said he thinks one of the most important byproducts of the American Cancer Society’s annual statistical analysis is that it helps define the problems, which opens the door to meaningful dialogue.
“If access to appropriate care is a problem in the United States, then we need to figure out how to overcome that problem,” he stated. Brawley added the detailed data also highlights gaps in care to help guide decisions about allocation of resources.
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