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Cancer: Prevention and Control
Cancer: Prevention and Control
Billy U. Philips, Jr., Ph.D., FACE
Billy U. Philips, Jr., Ph.D., FACE
Professor, Division of Epidemiology
Professor, Division of Epidemiology
and Biostatistics
and Biostatistics
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 2
Burden of Cancer in the US.
Burden of Cancer in the US.
1998
1998
1,228,000 New Cases
1,228,000 New Cases
564,800 Deaths
564,800 Deaths
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 3
Burden of Cancer in Texas
Burden of Cancer in Texas
1998
1998
77,500 New Cases
77,500 New Cases
35,600 Deaths
35,600 Deaths
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 4
Terminology
Terminology
-
-
Cancer
Cancer

Prevention
Prevention
-
-
The prevention of disease by
The prevention of disease by
altering susceptibility or reducing
altering susceptibility or reducing
exposure for susceptible individuals.
exposure for susceptible individuals.

Screening
Screening
-
-
The application of tests to
The application of tests to
detect cancer in asymptomatic people.
detect cancer in asymptomatic people.

Early Detection
Early Detection
-
-
Physician evaluation of a
Physician evaluation of a
person who may or may not have
person who may or may not have
symptoms.
symptoms.
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 5
Most Common Cancers
Most Common Cancers
Men
Men
Incidence
Incidence
Mortality
Mortality
1. Prostate
1. Prostate
1. Lung
1. Lung
2. Lung 2. Prostate
2. Lung 2. Prostate
3. Colorectal
3. Colorectal
Women
Women
Incidence
Incidence
Mortality
Mortality
1. Breast
1. Breast
1. Lung
1. Lung
2. Lung 2. Breast
2. Lung 2. Breast
3. Colorectal
3. Colorectal
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 6
Leading Causes of Death
Leading Causes of Death
US. Men US. Men
Age 1. 2.
1-14 Accidents Cancer
15-34 Accidents Homicide
35-54 CHD Cancer
55-74 CHD Cancer
75+ CHD Cancer
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 7
Leading Causes of Death
Leading Causes of Death
US. Women
US. Women
Age 1. 2.
1-14 Accidents Cancer
15-34 Accidents Cancer
35-54 Cancer CHD
55-74 Cancer CHD
75+ CHD Cancer
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 8
Primary Cancer Prevention
Primary Cancer Prevention
Prevention of malignancy before it is
Prevention of malignancy before it is
established by:
established by:

controlling risk factors by modification or
controlling risk factors by modification or
elimination;
elimination;

protecting from the effects of environmental
protecting from the effects of environmental
carcinogens;
carcinogens;

interrupting neoplastic transformation.
interrupting neoplastic transformation.
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 9
Cancer Risk Reduction
Cancer Risk Reduction
Cigareet Smoking in the US
0
10
20
30
40
50
1970 1975 1980 1985 1990 1995 2000
Year
P
r
e
v
a
l
e
n
c
e

%
Men
Women
Broadcast
Ads Ban 1973
Cigarette Tax
Doubles 1983
Tobacco
Companies Law
Suits 1996
Tax Doubles
Again 1989
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 10
Prevention by Protection
Prevention by Protection
Malignant Melanoma
0
10
20
30
40
50
60
70
80
90
.75
or
l ess
.76 to
1.5
1.6
to2.5
2.6 to
4.0
4.1 +
Thickness of Lesion - mms
%

5

Y
e
a
r

S
u
r
v
i
v
a
l
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 11
Cancer Mortality Rates
Cancer Mortality Rates
100
150
200
250
69 73 77 81 85 89 93
Year of Deat h
R
a
t
e

p
e
r

1
0
0
,
0
0
0
Mal es
Bot h
Femal es
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 12
US Preventive Services Task Force:
US Preventive Services Task Force:
Principals of Patient Education
Principals of Patient Education
Counseling
Counseling
Develop a therapeutic Develop a therapeutic
alliance alliance
Counsel all patients Counsel all patients
Ensure patient Ensure patient
understands relationship understands relationship
of behavior and health of behavior and health
Assess barriers to Assess barriers to
behavior change behavior change
Gain commitment from Gain commitment from
patient to change patient to change
Involve patients in Involve patients in
selecting risk factor to selecting risk factor to
change change
Use a combination of Use a combination of
strategies strategies
Design behavior Design behavior
modification plans modification plans
Monitor progress through Monitor progress through
follow follow- -up contact up contact
Involve office staff Involve office staff
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 13
US Preventive Services Task
US Preventive Services Task
Force: Recommendations
Force: Recommendations

Target personal health practices
Target personal health practices

Share decision
Share decision
-
-
making
making

Order tests selectively
Order tests selectively

Render preventive services every encounter
Render preventive services every encounter

Support community
Support community
-
-
level interventions
level interventions
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 14
Time Savers
Time Savers
-
-
Patient
Patient
Education and Counseling
Education and Counseling

Tailor the office environment to prevention
Tailor the office environment to prevention

Use patient questionnaires
Use patient questionnaires

Assess readiness to change
Assess readiness to change

Use chart reminders
Use chart reminders

Be familiar with community resources
Be familiar with community resources

Value and promote patient education and
Value and promote patient education and
counseling as routine practices
counseling as routine practices
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 15
Secondary Prevention
Secondary Prevention
Early identification of malignancy
Early identification of malignancy
by the application of tests in
by the application of tests in
preclinical (screening) or clinical
preclinical (screening) or clinical
(detection) settings leading to a
(detection) settings leading to a
high probability of cure.
high probability of cure.
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 16
US Preventive Services Task
US Preventive Services Task
Force: Evidence
Force: Evidence
I
At least one randomized controlled trial
At least one randomized controlled trial
II-1
Controlled trials without randomization
Controlled trials without randomization
II-2
Cohort or case
Cohort or case
-
-
control studies, usually
control studies, usually
from multiple centers
from multiple centers
II-3
Multiple time series or cross
Multiple time series or cross
-
-
sectional
sectional
studies with dramatic results
studies with dramatic results
III
Expert opinion
Expert opinion
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 17
Breast Cancer
Breast Cancer
Routine Mammogram 1 Routine Mammogram 1- -2 yr, w/wo CBE 2 yr, w/wo CBE
Age 40 Age 40- -49 49 I I C C
Age 50 Age 50- -69 69 I, II I, II- -2 2 A A
Age 70 Age 70- -74 74 I, II I, II- -3 3 C C
Age 75 + Age 75 + III III C C
Annual CBE, w/wo Periodic Mammogram Annual CBE, w/wo Periodic Mammogram
Age 40 Age 40- -49 49 III III C C
Age 50 Age 50- -59 59 I I C C
Age 60+ Age 60+ III III C C
Routine BSE Routine BSE I,II I,II- -2,III 2,III C C
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 18
Prostate Cancer
Prostate Cancer
As Routine
As Routine
Digital rectal exam
Digital rectal exam
II
II
-
-
2
2
D
D
PSA
PSA
I, II
I, II
-
-
2, III
2, III
D
D
Ultrasound
Ultrasound
II
II
-
-
2, III
2, III
D
D
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 19
Colorectal Cancer
Colorectal Cancer
Annual FOB
Annual FOB
Age 50 + Age 50 + I, II I, II- -1, II 1, II- -2 2 B B
Routine Sigmoidoscopy
Routine Sigmoidoscopy
Age 50 + Age 50 + II II- -2, II 2, II- -3 3 B B
Routine
Routine
Digital Rectal Exam
Digital Rectal Exam
III
III
C
C
Barium Enema
Barium Enema
III
III
C
C
Colonoscopy
Colonoscopy
III
III
C
C
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 20
Lung Cancer
Lung Cancer
Routine
Routine
Chest X
Chest X
-
-
ray
ray
I, II
I, II
-
-
1, II
1, II
-
-
2
2
D
D
Sputum Cytology
Sputum Cytology
I, II
I, II
-
-
1, II
1, II
-
-
2
2
D
D
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 21
Cancer Screening: Benefits
Cancer Screening: Benefits


Improves prognosis
Improves prognosis


Reduces mortality or morbidity
Reduces mortality or morbidity


Less or more effective treatment
Less or more effective treatment


Reassurance from negative screens
Reassurance from negative screens


Increases knowledge of biology
Increases knowledge of biology


Saves health care resources
Saves health care resources
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 22
Cancer Screening: Disadvantage
Cancer Screening: Disadvantage

Earlier diagnosis but same survival
Earlier diagnosis but same survival

Mental anguish
Mental anguish

Morbidity from false positives
Morbidity from false positives

Overtreatment of borderline
Overtreatment of borderline

False reassurance
False reassurance

Poor test performance
Poor test performance

Expense
Expense
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 23
Summary
Summary

Epidemiological Trends
Epidemiological Trends

Definitions of Cancer Prevention and
Definitions of Cancer Prevention and
Control (Screening and Detection)
Control (Screening and Detection)

US Preventive Services Taskforce
US Preventive Services Taskforce
Recommendations for the Common
Recommendations for the Common
Cancers
Cancers

The Benefits and Disadvantages of
The Benefits and Disadvantages of
Screening and Common Biases
Screening and Common Biases
9/25/2008 Dr. Philips, PMCH ( X-29132 ) 24
Lead time bias
Lead time bias
Diagnosis
Onset Early Usual Death
Unscreened ______________________DX____________
∆ ∆∆ ∆
Screened Early Lead
Rx Not Effective ____________DX__time________________
∆ ∆∆ ∆
Screened Early Improved
Rx Effective ____________DX__________________Survival_
∆ ∆∆ ∆

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