Health Promotion and Disease Prevention-focus on

Cancer

Edward Anselm, MDAssistant Professor of Medicine

Icahn School of Medicine at Mount Sinai

Medical Director

Health Republic Insurance of New Jersey

Outline: learning objectives

• Know the most common causes of preventable cancer • Describe the epidemiology of cancer nationally, state wide and locally • Understand the primary and secondary prevention measures for each

cancer • Understand the evidence for the effectiveness of screening procedures

utilizing USPSTF guidelines • Understand the risks of screening procedures • Understand the role of genetics and environment in cancer • Discuss some of the Public Health measures to address cancer

prevention

Common Cancers

http://apps.nccd.cdc.gov/uscs/toptencancers.aspx

Difference between incidence rates and death ratesMale v FemaleDifferences among the races

Common Cancers in Men

Common Cancers in Women

Cancer Causation

• Spontaneous mutations• Exposure to chemicals, radiation, or toxins• Inflammation, certain infections• Populations with higher genetic risk• Conditions with higher risk• Effects of hormones

Cancer Prevention

• Don’t smoke/stop smoking• Diet/weight• Avoid solar radiation• Immunize• Hepatitis B• Human Papilloma Virus

• Prevention in high risk groups• Hormones• Surgery

Early Detection and Treatment of Cancer• Screening of populations at risk• Age and gender• Genetic markers• Specific medical conditions

• Breast• Colorectal cancer and polyps• Lung Cancer• Prostate• http://www.uspreventiveservicestaskforce.org/adultrec.htm#cancer

Risks of screening and subsequent investigations• Anxiety• Inconvenience• Pain• Complications of radiation and other procedures• Cost • Finding a cancer may not improve health or help a patient live longer.• False-negative test results can occur.• False-positive test results can occur.

Risk for Breast Cancer

• Gender and Age• Genetics

• BRACA 1/2 • Family History• Race

• Non-cancerous breast conditions/dense breasts• Radiation treatment• Hormonal effects

• Early menarche, late menopause• Child-bearing, breast feeding• Use of oral contraceptives, hormone replacement therapy

Mammography: Number needed to screen to prevent one deathAge band NNS NNI40 and 49 746 1904 50 and 59 351 1339 60 and 69 233 377

Annual screening of women between 40 and 84 years yields an NNS of 84 Biennial screening of women ages 50-74 yields an NNS of 144

• AJR Am J Roentgenol. 2012 Mar;198(3):723-8. doi: 10.2214/AJR.11.7146. Mammography screening: a new estimate of number needed to screen to prevent one breast cancer death. Hendrick RE1, Helvie MA.

Estimated Benefits and Harms of Mammography Screening for 10,000 Women Who Undergo Annual Screening Mammography Over a 10-Year Periodhttp://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/Table2

Age, y No. of Breast Cancer Deaths Averted With

Mammography Screening Over Next

15 yb

No. (95% CI) With ≥1 False-Positive Result

During the 10 yc

No. (95% CI) With ≥1 False Positive

Resulting in a Biopsy During the 10 yc

No. of Breast Cancers or DCIS

Diagnosed During the 10 y That Would

Never Become Clinically Important

(Overdiagnosis)d

40 1–16 6,130 (5,940–6,310) 700 (610–780) ?–104e

50 3–32 6,130 (5,800–6,470) 940 (740–1,150) 30–13760 5–49 4,970 (4,780–5,150) 980 (840–1,130) 64–194

Table 2. Estimated Benefits and Harms of Mammography Screening for 10,000 Women Who Undergo Annual Screening Mammography Over a 10-Year Period a

Persuading doctors to screen

• Overcoming cultural bias• Overcoming controversy• Overcoming expediency/Electronic reminders• Performance measurement• Performance incentives• Reimbursement rates

Persuading patients to screen

• De-stigmatization of cancer• Explain advantages of early detection• Lowering barriers to access• Insurance/Insurance copayment• Referral requirements• Appointment access• Workplace programs

• Increasing public awareness