Top 15 Causes of Death 2009

Transcription

1 Robb Campbell MD MPH Top 15 Causes of Death 2009 heart disease cancer lung disease stroke accidents Alzheimer's disease diabetes influeza/pneumonia kidney disease suicide septicemia liver disease hypertension Parkinson's disease homicide all other causes 1

2 total male female total male female All Sites 1,529, , , , , ,290 Lung & bronchus 222, , , ,300 86,220 71,080 Breast 209,060 1, ,090 40, , ,900 49,470 53,430 51,370 26,580 24,790 Colon rectal Pancreas 43,140 21,370 21,770 36,800 18,770 18,030 Ovary 21,880 21,880 13,850 13,850 Non-Hodgkin lymphoma 65,540 35,380 30,160 20,210 10,710 9,500 Leukemia 43,050 24,690 18,360 21,840 12,660 9,180 Uterine corpus 43,470 43,470 7,950 7,950 Liver & intrahepatic bile duct 24,120 17,430 6,690 18,910 12,720 6,190 Brain & other nervous system 22,020 11,980 10,040 13,140 7,420 5,720 Kidney & renal pelvis 58,240 35,370 22,870 13,040 8,210 4,830 Urinary bladder 70,530 52,760 17,770 14,680 10,410 4,270 Stomach 21,000 12,730 8,270 10,570 6,350 4,220 Uterine cervix 12,200 12,200 4,210 4,210 Melanoma-skin 68,130 38,870 29,260 8,700 5,670 3,030 Esophagus 16,640 13,130 3,510 14,500 11,650 2,850 Larynx 12,720 10,110 2,610 3,600 2, Mouth 10,840 6,430 4,410 1,830 1, Pharynx 12,660 9,880 2,780 2,410 1, Hodgkin lymphoma 8,490 4,670 3,820 1, Prostate 217, ,730 32,050 32,050 2

3 Male cancer death rate per 100,000 Female cancer death rate per 100,000 3

4 Caused by a growth of abnormal cells Many types of cancerce Each type of cancer is a different disease Different treatment Different prognosis Chromosomes are engineering diagrams of C o oso es a e e g ee g d ag a s o the cell Chromosomes become damaged Abnormal cell growth results 4

5 Most cells control their own reproduction Cancer cells lose this ability Cancer cells reproduce in an uncontrolled fashion Cancer cells break away from their site of growth Spread to other areas Grow there 5

6 Latency Usually takes years between exposure to carcinogen and development of cancer Threshold Is there a possible exposure to a carcinogen which does not produce cancer? Unknown No direct test Ames test--bacteria Animal tests--rats and mice Epidemiology based on statistics 5% chance of wrong answers 6

7 Persons in some families are at increased risk for cancer Retinoblastoma Familial polyposis coli Multiple endocrine neoplasia We carry oncogenes and suppressor genes which may trigger cancer Less than 3% of cancer comes from radiation Skin Bone marrow Breast Thyroid Lung Delay from exposure to disease 2-40 years Cell phones and brain cancer!? 7

8 Tobacco smoke Number 1 cancer causing agent 20 fold increased risk of lung cancer (males) 87% of all lung cancer cases have tobacco exposure Also mouth, larynx, esophagus, stomach, bladder, pancreas, cervix Smokeless tobacco and cigars also Tobacco, continued Smoking causes over 1/3 of men s cancer deaths Smoking causes over 1/10 of women s cancer deaths (catching up) Quitting reduces the risk over the next years 50% of lifetime smokers die prematurely from smoking related diseases 8

9 Certain jobs associated with cancer 1775 Dr. Percival Pott described scrotal cancer in chimney sweeps Benzene Asbestos Vinyl chloride Arsenic Aflatoxin Nickel Radium Radon Coal tar Mustard gas 9

10 Diethylstilbesterol--vaginal cancer in offspring of women taking it in pregnancy Estrogen--uterine cancer Estrogen and progesterone breast cancer Cancer chemotherapy and immunosupressant drugs--may cause cancer years later Accumulating evidence suggests the following cancers are associated with obesity Breast (50% higher), uterine, cervix, ovarian, gall bladder, colon (40% higher), prostate Aim for body mass index <25 Body Mass Index= 704 x weight (pounds) height 2 (inches) Body Mass Index= 704 x 169= 25 69x69 10

11 Controversial Dietary fat and breast cancer Dietary fat and colon cancer Hot dogs and leukemia?! Up to 30% of cancer related to nutrition Therefore, limit animal fat intake Increase plant based foods High proportion of plant foods Especially dark green and dark yellow veggies; cabbage family; soy; legumes; grains Limited amounts of meat and dairy Especially high fat meats and red meat Limit use of alcohol Oral cancer, esophagus, breast 11

12 Garlic may help but dosage unknown Antioxidants prevention results inconsistent Red Wine studies in initial stages Tea results inconclusive Vitamin D effects unclear Exercise can reduce risk of some cancers and help with weight control Colon cancer: 30-40% risk reduction Breast cancer: 20-80% risk reduction Uterine cancer: 20-40% risk reduction Aim for >= 30 minutes of exercise >= 5 days/week 12

13 HTLV-1 and lymphoma Hepatitis epatts B, C and liver cancerce Human papilloma virus and cervical and pharyngeal cancer Preventable with immunization Epstein-Barr virus and lymphoma Human Herpesvirus 8 and Kaposi s sarcoma HIV and numerous cancers Helicobacter pylori and stomach cancer Very controversial EMF associated ated with leukemia? e Electric blankets and breast cancer? 13

14 No test diagnoses all types of cancer No test diagnoses most types of cancerce No test diagnoses many types of cancer There are a few blood tests which help diagnose some cancers hcg: from trophoblastic cancers CEA: elevated in some cases of cancer of colon, pancreas, stomach, lung, breast. AFP: elevated in some cases of liver cancer, testis cancer, occasional GI cancer. also elevated in hepatitis PSA: elevated in prostate cancer and some normal men 14

15 Four types Adenocarcinoma 40% Epidermoid 17% Large Cell 15% Small Cell 25% Smoking Lifetime risk of lung cancer in smokers 11-17%; nonsmokers % 1.4% Risk increases 60 times if smoke 2 packs per day for 20 yrs Passive smoke increases risk 1.5 fold Occupational Radon Gas (mining) Asbestos (mining, milling, brake, HVAC) Acrylonitrile Aluminum Production Beryllium Chloroethers 15

16 Occupational, cont Nickel refining, smelting Arsenic Chromium ore, pigments Coal Carbonization coke ovens Mustard Gas workers Vinyl Chloride polymers None Early diagnosis (Chest x ray) does not improve survival Chest CT? (National Lung Cancer Screening Trial) 20% death reduction but false positives are a problem Best Strategy Stop smoking/smoke exposure Control occupational exposures Check house for radon 16

17 Whole Body CT scans? Expensive $ High radiation exposure 2007 Americans had 72 Million CT scans 2009 NCI estimates fatal cancers due to CT Likely to find suspicious-looking things which aren t cancer False positive problem 17

18 Lifetime risk Men 1:41 Women 1:42 Diet increased animal fats decreased fiber Hereditary factors polyposis coli--100% cancer Inflammatory Bowel Disease 8-30% Polyps <1% cancer 25% of colonoscopies find a polyp Aspirin or other NSAIDS? Folate? oate Calcium? Estrogen replacement works but increased breast cancer risk + increased heart attack Not vitamins or fiber 18

19 Digital Rectal Exam--age over 40?? Hemoccult Test over age 50 every e 2 years Flexible Sigmoidoscopy every 3-5 yrs over 50 Virtual Colonoscopy? Genetic screening tests? Colonoscopy every 10 years YES!! Everyone over 50; 3M s nickel Younger if at risk Lifetime risk women 1:8; men much lower Types Invasive ductal 80% Infiltrating lobular 10% medullary 5% 19

20 70-80% occur in women without risk factors Age most common after age 50 Genetic 2-3x risk if present in close family Endocrine Early menarche Late menopause Nuliparity Late first pregnancy 2x risk if age 24 (compared with age 18) 3x risk if age over 30 Post menopause hormone use 20

21 Radiation Diet fat intake obesity alcohol intake Ovarian cancer Lack of exercise Self breast exam Self breast exam Annual physical Exam Mammogram annually for women over 50 Weight control + exercise Tamoxifen? For high risk Mastectomy for BRCA1, BRCA2? 21

22 Most common cancer in men only 1/3 cases of autopsy cases suspected 16% risk of dz; 3.4% risk of death Race increased in African Americans (150% risk) least risk in Asians Age rare before age 50 Family history (200% increased risk) 22

23 Digital rectal exam Over age 40 controversial Prostatic Specific Antigen Very controversial (still!) 4-10 ng/ml expect 80% false + 76% biopsies show no cancer 60% overdiagnosis Prostate cancer incidence and mortality 23

24 Assume a cancer with 0.6% prevalence 6 out of 1000 persons has this cancer Assume screening test is 90% sensitive 90% of persons with this cancer will be correctly identified Assume screening test is 96% specific 96% of persons without this cancer will be correctly identified 4% risk of false positive 6 have cancer 994 don t have cancerce All persons with cancer will be identified 40 persons without cancer will be told that they have cancer 46 persons will be told they have cancer; only 6 really have cancer This test can t tell you which h of these really have it. Overdiagnosis is finding cancers which won t hurt you. 24

25 PLCO US study of men over 7 years Found prostate cancer screening did not reduce death ERSPC European study of men over 9 years 0.7 deaths saved per 1000 men 1410 men should be screened and 48 treated to save one life Side effects of surgery 30% ED JAMA February 8,

26 Risk factors age gender (male>female) race (black>white) Smoking (doubles risk of cancer) Stomach surgery chronic pancreatitis (2X risk) Obesity (70% increased risk); Diabetes Physical activity ty reduces risk among obese 30% reduction Screening none Treatment none 26

27 Risk Factors??eating partially spoiled food; radiation; rubber workers; farm workers; coal miners, H pylori infection Screening None Japanese use endoscopy No one suggesting screening/treatment for H pylori H pylori is protective for esophagus cancer 27

28 Lifetime risk males 1:139 females 1:303 Risk factors Age: usually Gender: males>females Other risk factors Recurrent GU infections, recurrent renal stones, schistosoma infection, Medicines: cyclophosphamide, phenacetin Hair dye prior to 1980 Increased risk in hairdressers Smoking The greatest single risk factor 28

29 Occupational Aromatic amines, 2-naphylamine Sluminum production, benzidine 4-aminobiphenyl 4,4 -Methylene dianiline? Leather production Polycyclic aromatic hydrocarbons?asbestos Hair dye Earliest symptom: blood in urine Lifetime risk males 1:286 females 1:500 Types Basal cell 70-80% Squamous cell 20% Melanoma <~5% Risk factors Light complexion, ease of sunburn, xeroderma pigmentosum, radiation, UV-A and UV-B exposure, arsenic, family history, polycyclic aromatics, multiple and unusual moles, age 29

30 Prevention Sunscreen (UVA and UVB; at least 15 SPF) Protective clothes and hat Avoid mid day sun (10 am-4 pm) Avoid sun lamps and tanning beds Self exam of skin Dermatologist screening if family history Screening Asymmetry Border irregularity Color variation Diameter > 6 mm Evolving lesion Dermoscopy 30

31 Risk factors very common in India age, alcohol, tobacco, iron/vitamin deficiency, Betel Nuts, UV radiation HPV Screening dental check up 31

32 Lifetime risk 1:196 Risk factors Obesity Age Chronic anovulatory cycles Diabetes Hypertension Estrogen replacement Tamoxifen Early menarche; late menopause Nulliparity Risk factors Younger women Non white Many sex partners Single mothers Early age for intercourse STD Smoking HPV infection 32

33 Screening Pap smear Of 13,000 women dying of cervix cancer this year, 50% never had a Pap smear and another 10% last had a Pap 5 yrs ago. Imperfect screening test No tobacco in any form Limited alcohol, if any Plant sources of diet; vitamins Limit red meat consumption Regular exercise Maintain a healthy weight (BMI <= 25) Limit sun exposure Safe Sex Radon testing 33

34 Mammogram annually after age 50 Colonoscopy every 5-10 yrs after 50 Pap Smear 1-3 years Oral Exam annually (dental check up) Skin exam for melanoma Asymmetry, Border irregularity, Color variation, Diameter>6mm, Evolving lesion Breast or testis self exam monthly Hepatitis B immunization HPV immunization 34

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