otis w. brawley, m.d. chief medical officer executive vice president american cancer society
DESCRIPTION
Otis W. Brawley, M.D. Chief Medical Officer Executive Vice President American Cancer Society. Professor of Hematology, Oncology, Medicine and Epidemiology Emory University. 2009 Estimated US Cancer Deaths*. Men 292,540. Women 269,800. Lung & bronchus30% Prostate9% Colon & rectum 9% - PowerPoint PPT PresentationTRANSCRIPT
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June 18-19, 2009 | Hyatt Regency Chicago
Sponsored by
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Otis W. Brawley, M.D. Otis W. Brawley, M.D. Chief Medical Officer
Executive Vice PresidentAmerican Cancer SocietyAmerican Cancer Society
Professor of Hematology, Oncology, Medicine and Epidemiology
Emory University
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2009 Estimated US Cancer Deaths*
ONS=Other nervous system.Source: American Cancer Society, 2009.
Men292,540
Women269,800
26% Lung & bronchus
15% Breast
9% Colon & rectum
6% Pancreas
5% Ovary
4% Non-Hodgkin lymphoma
3% Leukemia
3% Uterine corpus
2% Liver & intrahepaticbile duct
2% Brain/ONS
25% All other sites
Lung & bronchus 30%
Prostate 9%
Colon & rectum 9%
Pancreas 6%
Leukemia 4%
Liver & intrahepatic 4%bile duct
Esophagus 4%
Urinary bladder 3%
Non-Hodgkin 3% lymphoma
Kidney & renal pelvis 3%
All other sites 25%
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US Mortality, 2006
*Includes nephrotic syndrome and nephrosis.Source: US Mortality Data 2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.
1. Heart Diseases 631,636 26.0 2. Cancer 559,888 23.13. Cerebrovascular diseases 137,119 5.7 4. Chronic lower respiratory diseases 124,583 5.1 5. Accidents (unintentional injuries) 121,599 5.0 6. Diabetes mellitus 72,449 3.0 7. Alzheimer disease 72,432 3.0 8. Influenza & pneumonia 56,326 2.3 9. Nephritis* 45,344 1.910. Septicemia 34,234 1.4
Rank Cause of DeathNo. of deaths
% of all deaths
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Change in US Death Rates* from 1991 to 2006
* Age-adjusted to 2000 US standard population.Sources: 1950 Mortality Data - CDC/NCHS, NVSS, Mortality Revised.2006 Mortality Data: US Mortality Data 2006, NCHS, Centers for Disease Control and Prevention, 2009.
17.8
63.334.8
313.0
215.1
43.6
180.7200.2
0
100
200
300
400
Heart diseases Cerebrovasculardiseases
Influenza &pneumonia
Cancer
19912006
Rate Per 100,000
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Cancer Death Rates* by SexUS 1975-2005
*Age-adjusted to the 2000 US standard population.Source: US Mortality Data 1960-2005, National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.
0
50
100
150
200
250
300
1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005
Men
Both Sexes
Rate Per 100,000
Women
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Cancer Death Rates* Among Men, US 1930-2005
*Age-adjusted to the 2000 US standard population.Source: US Mortality Data 1960-2005, US Mortality Volumes 1930-1959,National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.
0
20
40
60
80
10019
30
1935
1940
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
Lung & bronchus
Colon & rectum
Stomach
Rate Per 100,000
Prostate
Pancreas
LiverLeukemia
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Cancer Death Rates* Among Women, US 1930-2005
*Age-adjusted to the 2000 US standard population.Source: US Mortality Data 1960-2005, US Mortality Volumes 1930-1959,National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.
0
20
40
60
80
10019
30
1935
1940
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
Lung & bronchus
Colon & rectum
Uterus
Stomach
Breast
Ovary
Pancreas
Rate Per 100,000
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2009 Estimated US Cancer Cases*
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2009.
Men766,130
Women713,220
27% Breast
14% Lung & bronchus
10% Colon & rectum
6% Uterine corpus
4% Non-Hodgkin lymphoma
4% Melanoma of skin
4% Thyroid
3% Kidney & renal pelvis
3% Ovary
3% Pancreas
22% All Other Sites
Prostate 25%
Lung & bronchus 15%
Colon & rectum 10%
Urinary bladder 7%
Melanoma of skin 5%
Non-Hodgkin5% lymphoma
Kidney & renal pelvis 5%
Leukemia 3%
Oral cavity 3%
Pancreas 3%
All Other Sites 19%
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Cancer Incidence Rates* by Sex US 1975-2005
*Age-adjusted to the 2000 US standard population and adjusted for delays in reporting.Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database: SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008.
0
100
200
300
400
500
600
700
1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005
Both Sexes
Men
Women
Rate Per 100,000
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Cancer Incidence Rates* Among Men, US 1975-2005
0
50
100
150
200
250
1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005
Prostate
Lung & bronchus
Colon and rectum
Urinary bladder
Non-Hodgkin lymphoma
Rate Per 100,000
Melanoma of the skin
*Age-adjusted to the 2000 US standard population and adjusted for delays in reporting.Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database: SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008.
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Cancer Incidence Rates* Among Women, US 1975-2005
*Age-adjusted to the 2000 US standard population and adjusted for delays in reporting.Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database: SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008.
0
50
100
150
200
250
1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005
Colon and rectum
Rate Per 100,000
Breast
Lung & bronchus
Uterine CorpusOvary
Non-Hodgkin lymphoma
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Cancer Incidence & Death Rates* in Children 0-14 Years, 1975-2005
0
2
4
6
8
10
12
14
16
18
1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005
Incidence
Mortality
Rate Per 100,000
*Age-adjusted to the 2000 Standard population.Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.
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Cancer Incidence Rates* in Children 0-14 Years by Sex, 2001-2005
*Per 100,000, age-adjusted to the 2000 US standard population.ONS = Other nervous systemSource: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.
Site Male Female Total
All sites 16.1 14.1 15.1
Leukemia 5.4 4.5 5.0
Acute Lymphocytic 4.3 3.6 3.9
Brain/ONS 3.4 3.1 3.2
Soft tissue 1.1 1.0 1.1
Non-Hodgkin lymphoma 1.2 0.6 0.9
Kidney and renal pelvis 0.8 0.8 0.8
Bone and Joint 0.7 0.7 0.7
Hodgkin lymphoma 0.7 0.4 0.5
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Cancer Death Rates* in Children 0-14 Years by Sex, US 2001-2005
*Per 100,000, age-adjusted to the 2000 US standard population.ONS = Other nervous systemSource: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.
Site Male Female Total
All sites 2.7 2.3 2.5
Leukemia 0.8 0.7 0.8
Acute Lymphocytic 0.4 0.3 0.4
Brain/ONS 0.8 0.7 0.7
Non-Hodgkin lymphoma 0.1 0.1 0.1
Soft tissue 0.1 0.1 0.1
Bone and Joint 0.1 0.1 0.1
Kidney and Renal pelvis 0.1 0.1 0.1
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Tobacco Use in the US, 1900-2005
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
1900
1905
1910
1915
1920
1925
1930
1935
1940
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
Year
Per C
apita
Cig
aret
te C
onsu
mpt
ion
0
10
20
30
40
50
60
70
80
90
100
Age-
Adju
sted
Lun
g Ca
ncer
Dea
th R
ates
*
*Age-adjusted to 2000 US standard population.
Source: Death rates: US Mortality Data, 1960-2005, US Mortality Volumes, 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006. Cigarette consumption: US Department of Agriculture, 1900-2007.
Per capita cigarette consumption
Male lung cancer death rate
Female lung cancer death rate
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Current* Cigarette Smoking Prevalence (%) Among High School Students by Sex and
Race/Ethnicity - US 1991-2007
*Smoked cigarettes on one or more of the 30 days preceding the survey.Source: Youth Risk Behavior Surveillance System, 1991, 1995, 1997, 1999, 2001, 2003, 2005, 2007 National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2008.
28
35
31
1316
27
23
11
19 18 19
2725
1214
19
2523 24
8
15 15
19
3230
1114
23
4037
12
28
33
40 40
17
32
36
28
34
39 38
22
32
18
33
2726
0
10
20
30
40
50
White, non-HispanicFemale
White, non-Hispanic Male
AfricanAmerican, non-
HispanicFemale
AfricanAmerican, non-Hispanic Male
HispanicFemale
Hispanic Male
Prev
alen
ce (%
)
1991 1995 1997 1999 2001 20032005 2007
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Note: Data from participating states and the District of Columbia were aggregated to represent the United States.Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000, 2003, 2005, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2004, 2006, 2008.
24.2 24.4 24.1 24.4 23.6 24.3 24.7
0
5
10
15
20
25
30
35
1994 1996 1998 2000 2003 2005 2007
Year
Prev
alen
ce (%
)Trends in Consumption of Five or More
Recommended Vegetable and Fruit Servings for Cancer Prevention, Adults 18 and Older, US, 1994-2007
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Trends in Prevalence (%) of No Leisure-Time Physical Activity, by Educational Attainment
Adults 18 and Older - US 1992-2007
Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Educational attainment is for adults 25 and older.Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000, 2002, 2004, 2005, 2006, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2003, 2005, 2006, 2007, 2008.
05
1015202530354045505560
1992
1994
1996
1998
2000
2002
2003
2004
2005
2006
2007
Year
Prev
alen
ce (%
)
Adults with less than a high school education
All adults
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Trends in Obesity* Prevalence (%)Children and Adolescents, by Age Group
US 1971-2006
*Body mass index (BMI) at or above the sex-and age-specific 95th percentile BMI cutoff points from the 2000 sex-specific BMI-for-age CDC Growth Charts. Note: Previous editions of Cancer Statistics used the term “overweight” to describe youth in this BMI category.Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2006: Ogden CL, et al. High Body Mass Index for Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05.
54
65
75
7
11 1110
16 16
12
1718
0
5
10
15
20
2 to 5 years 6 to 11 years 12 to 19 years
Prev
alen
ce (%
)
NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94)NHANES 1999-2002 NHANES 2003-2006
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Trends in Obesity* Prevalence (%), By GenderAdults Aged 20 to 74, US, 1960-2006†
*Obesity is defined as a body mass index of 30 kg/m2 or greater. † Age adjusted to the 2000 US standard population. Source: National Health Examination Survey 1960-1962, National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2004, 2005-2006: National Health and Nutrition Examination Survey Public Use Data Files, 2003-2004, 2005-2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006, 2007.
1311
161512
1715
13
17
2321
26
3128
3433 323535 34
36
0
5
10
15
20
25
30
35
40
45
Both sexes Men Women
Prev
alen
ce (%
)
NHES I (1960-62) NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94)NHANES 1999-2002 NHANES 2003-2004 NHANES 2005-2006
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Mammogram Prevalence (%), by Educational Attainment and Health Insurance StatusWomen 40 and Older, US, 1991-2006
*A mammogram within the past year. Note: Data from participating states and the District of Columbia were aggregated to represent the United States.Source: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data Tape (2000, 2002, 2004, 2006), National Centers for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2000, 2001, 2003, 2005, 2007.
0
10
20
30
40
50
60
70
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2004 2006Year
Prev
alen
ce (%
)
Women with less than a high school education
Women with no health insurance
All women 40 and older
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Disparities in Health
• The concept that some populations (however defined) do worse than others
• Populations can be defined or categorized by race, culture, area of geographic origin, socioeconomic status
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Disparities in Health
• The concept that some populations (however defined) do worse than others
• The measure can be incidence, mortality, survival, quality of life
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All Sites – Cancer Mortality Rates1973-2004 By Race, Males and Females
100
150
200
250
300
'75 '78 '81 '84 '87 '90 '93 '96 '99 '02Year
Rat
e
Incidence and mortality rates per 100,000 and age-adjusted to 2000 US standard populationSEER Cancer Statistics Review 1975-2004.
African American
Caucasian
AI/ANHispanic
API
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Disparities in Health
• We need to approach this issue logically and rationally
• We must focus on what we can change and not on what we cannot change
• We must define social and logistical issues versus scientific issues.
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My Concern
• “Equal treatment yields equal outcome among equal patients”
• There is not equal treatment• There is not enough concern about nor
emphasis on the fact that there is not equal treatment
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How can we provide adequate, high-quality care (to include
preventive care) to a population that has so often
not received it?
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0
5
10
15
20
25
30
35
40
45
1975 1978 1981 1984 1987 1990 1993 1996 1999 2002
Year
Rat
e pe
r 100
,000
African Americans
Whites
Hispanic/Latina
American Indian/Alaska Native
Asian American/Pacific Islander
American Cancer Society, Surveillance Research, 2007
2004
Female Breast Cancer Death Ratesby Race and Ethnicity, US, 1975-2004
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Adjusted Breast Cancer Survival by Stages and Insurance Status, among Patients Diagnosedin 1999-2000 and Reported to the NCDB
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Breast Cancer
• It is estimated that 57,000 breast cancer deaths were averted between 1990 and 2005 due to screening, early detection, and aggressive treatment.
• Breast cancer screening rates have actually gone down during the period 2000 to 2005
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Breast Cancer
Imagine a world in which…• Mammography rates were greater than 80%• All women with an abnormal screen got it evaluated• All women with breast cancer got optimal therapy
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Screening Guidelines for the Early Detection of Colorectal Cancer and Adenomas, American Cancer Society 2008
• Beginning at age 50, men and women should follow one of the following examination schedules:
A flexible sigmoidoscopy (FSIG) every five years A colonoscopy every ten years A double-contrast barium enema every five years A Computerized Tomographic (CT) colonography every five years A guaiac-based fecal occult blood test (FOBT) or a fecal immunochemical test
(FIT) every year A stool DNA test (interval uncertain) Tests that detect adenomatous polyps and cancer Tests that primarily detect cancer
People who are at moderate or high risk for colorectal cancer should talk with a doctor about a different testing schedule
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20
16
8
21
16
9
18
12
22
16
9
19
14
9
16
12
8
24
0
5
10
15
20
25
30
Total Less than a high schooleducation
No health insurance
Prev
alen
ce (%
)
1997 1999 2001 20022004 2006
Trends in Recent* Fecal Occult Blood Test Prevalence (%) by Educational Attainment and Health Insurance Status Adults 50 Years and Older, US 1997-2006
*A fecal occult blood test within the past year. Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001, 2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007.
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44
37
22
44
36
21
45
36
21
50
41
22
56
43
25
0
10
20
30
40
50
60
Total Less than a high schooleducation
No health insurance
Pre
vale
nce
(%)
1999 2001 2002 2004 2006
Trends in Recent* Flexible Sigmoidoscopy or Colonoscopy Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50 Years and Older, US 1997-2006
*A flexible sigmoidoscopy or colonoscopy within the past ten years. Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001, 2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007.
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U.S. Colorectal Cancer Mortality 1975-2005
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.019
75
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
Rate
per
100
,000 Blalck Male
WhiteMale
Black Female
White Female
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Adjusted Colorectal Cancer Survival by Stages and Insurance Status, among Patients Diagnosed in 1999-2000 and Reported to the NCDB
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Colorectal Cancer• It is estimated that 77,000 colorectal cancer deaths were
averted between 1990 and 2005 due to screening, early detection, and aggressive treatment.
• Colorectal cancer screening rates have actually gone down during the period 2000 to 2005
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Colorectal Cancer
Imagine a world in which…• Colorectal screening rates were greater than 80%• All men and women with an abnormal screen got it
evaluated• All with colorectal cancer got optimal therapy
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Sunburn* Prevalence (%) in the Past Year, Adults 18 and Older, US, 2004
46.4
36.3
22.524.0
18.4
5.7 5.8
26.3
0
5
10
15
20
25
30
35
40
45
50
Male Female
Age-
Adju
sted
Pre
vale
nce
(%)
White non-Hispanic
Other
Hispanic
Black non-Hispanic
*Reddening of any part of the skin for more than 12 hours. Note: The overall prevalence of sunburn among adult males is 46.4% and among females is 36.3%.
Source: Behavioral Risk Factor Surveillance System Public Use Data Tape , 2004. National Center for Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2005.
Sunburn* Prevalence (%) in the Past Year, Adults 18 and Older, US 2004
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Ultraviolet Radiation Exposure Behaviors* Prevalence (%), Adults 18 and Older, US, 2005
30
33
1210
30
14
19
26
1311
37
11
40
1210
24
17
40
0
5
10
15
20
25
30
35
40
45
Applysunscreen
Seek the shade Wear a hat Wear long-sleeved shirt
Wear longpants
Used indoortanningdevice†
Prev
alen
ce (%
)
Total Male Female
*Proportion of respondents reporting always or often practicing the particular sun protection behavior on any warm sunny day. †Used an indoor tanning device, including a sunbed, sunlamp, or tanning booth at least once, in the past 12 months.
Source: National Health Interview Survey Public Use Data File 2005, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.
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Cancer Survival and Deprivation in Scotland
5yr survival Affluent Deprived
Breast 58% 48% Colon 40% 34%
Lymphoma 58% 42% Prostate 45% 36% Bladder 70% 58%
Melanoma 84% 69%
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Survival Rates RMS TitanicConcept of Dr. Lisa Newman
First Class 60%
Second Class 43%
Third Class 20%
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How can we provide adequate, high-quality care (to include preventive care) to a population that has so
often not received it?
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Higher Per Capita Spending in the U.S. Does NotTranslate into Longer Life Expectancy
The Cost of a Long Life
Life Expectancy – Per Capita Spending
2006 CIA FACTBOOK
Ave
rage
Life
Exp
ecta
ncy
(yea
rs)
Per C
apita
Spe
ndin
g in
USD
74
75
76
77
78
79
80
81
82
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
United States
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The Economics of Healthcare• Healthcare is 17% of the nation’s Gross Domestic Product
and growing• The country with the second greatest is Israel with 9.5%
of its GDP devoted to healthcare• The U.S. spends more on healthcare than it spends on
food and clothing
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The Economics of Healthcare• The average Medicare costs per beneficiary
nationwide in 2006 was $8,304• New York City $9,564• Honolulu $5,311• Miami $16,351• San Francisco $8,331
NY Times June 11, 2009
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Disparities in Health• Some consume too much (unnecessary care given)• Some consume too little (necessary care not given)• We could decrease the waste and improve overall
health!!
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Disparities in Health
There are dramatic geographical differences in use of a number of expensive screening technologies and therapies without evidence of difference in outcomes.
•Prostate cancer screening and overtreatment•Lung cancer screening•Third and fourth-time chemotherapy of metastatic disease•Intensity Modulated Radiation Therapy in some cancers•Overuse of radiologic imaging
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Faith-based versus Evidence-based Medicine
• We in medicine have a tendency to adopt things before fully accessing their benefit or harm.
• We also criticize those who question the benefit and some even praise/worship advocates with a monetary interest.
• Bone marrow transplant for breast cancer• Lung cancer screening with chest X-ray• Neuroblastoma screening with urine VMA• The Halsted Mastectomy• Postmenopausal hormone replacement• Prostate cancer screening
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Disparities in Health
• A call for the use of “Evidence-Based Care” That is:
The rational use of medicinenot the rationing of medicine
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We know WHAT to do,
We just need to DO it!!
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