Disparities in Progress against Cancer in the USA Ahmedin Jemal, DVM, PhD American Cancer Society ASPO Webinar November 29, 2018
Progress in reducing cancer death rates in the US, 1970-2015 240 220 215 Rates per 100,000 persons 200 180 160 140 120 100 1970 1974 1978 1982 1986 1990 1994 1998 2002 2006 2010 2014 159 26%
Trends in cancer death rates for the four major cancers, US, 1970 2016 Lung Colorectal Female breast Prostate 100 100 100 100 Male 48% Rates per 100,000 persons Female 23% 53% 40% 51% 10 1970 1978 1986 1994 2002 2010 10 1970 1978 1986 1994 2002 2010 10 1970 1978 1986 1994 2002 2010 10 1970 1978 1986 1994 2002 2010 Year of death
Large disparities in progress against cancer Race (black vs white) Socioeconomic status Residence (state) The effects of the Affordable Care Act on cancer disparities
Trends in Overall Cancer Death Rates by Race and Sex, US, 1970-2016 400 350 Black Male 47% Non-Hispanic Black 400 350 Female Rate per 100,000 300 250 200 150 100 White Non-Hispanic White 19% 300 250 200 150 100 Black White 20% Non-Hispanic Black 13% 50 50 0 1970 1974 1978 1982 1986 1990 1994 1998 2002 2006 2010 2014 0 1970 1974 1978 1982 1986 1990 1994 1998 2002 2006 2010 2014 Year of death *Rates are per 100,000, age-adjusted to the US standard population. Data Source: National Center for Health Statistics, Centers for Disease Control and Prevention, provided by the SEER program. Year of death 5
Trends in Lung Cancer Death Rates by Race and Sex, US, 1970-2016 Rate per 100,000 140 120 100 80 60 40 Black Male 42% White 18% 20 0 1970 1974 1978 1982 1986 1990 1994 1998 2002 2006 2010 2014 140 120 100 80 60 40 Female White 20 0 Black 10% 1970 1974 1978 1982 1986 1990 1994 1998 2002 2006 2010 2014 Year of death *Rates are per 100,000, age-adjusted to the US standard population. Data Source: National Center for Health Statistics, Centers for Disease Control and Prevention, provided by the SEER program. Year of death
Trends in Adult Smoking Prevalence by Race and Sex, 1965-2014 Source: DeSantis et al. 2016. CA A Cancer J clinician 7
Trends in Daily Smoking among Black and White High School Seniors, 1977-1996 White females White males Black males Black females Source: Jemal A, Center MM, Ward EM. CEBP; 2009.
Trends in Death Rates for Female Breast and Colorectal Cancers by Race, US, 1970-2016 Rate per 100,000 50 45 40 35 30 25 20 15 10 5 0 1970 1974 1978 Female breast 1982 Black White 1986 1990 1994 Year of death 1998 2002 *Rates are per 100,000, age-adjusted to the US standard population. Data Source: National Center for Health Statistics, Centers for Disease Control and Prevention, provided by the SEER program. 2006 2010 2014 45% 50 45 40 35 30 25 20 15 10 5 0 1970 1974 1978 1982 Colon & Rectum Black White 1986 1990 1994 1998 Year of death 2002 2006 40% 2010 2014
Stage Distribution for Female Breast and Colorectal Cancers, SEER 18, 2008-2014 100 Female breast Colorectum Percent 80 60 40 20 63 54 54 30 36 36 6 99 39 38 36 32 21 26 White Bl ack 0 Lo c aliz ed Regiona l Distant Localized Regional Dis tant
Cumulative Probability of Interval CRC by Race, SEER-Medicare 2002-2011 0.08 Cumulative Probabiity of Interval CRC 0.07 0.06 0.05 0.04 0.03 0.02 0.01 Black White 0 6 12 18 24 30 36 42 48 54 Number of Months Since Index Colonoscopy Fedewa et al. Annals of Int Med, 2017
5-year Relative Survival for Female Breast and Colorectal Cancers, SEER 18, 2008-2014 Female breast Colorectum 10 0 80 99 95 86 77 90 86 72 65 White Blac k Percent 60 40 20 28 20 14 10 0 Locali zed Regional Distant Locali zed Regi onal Distant
Receipt of trastuzumab among women with human epidermal growth factor receptor 2 positive breast cancer by stage and race 13 Source: Reeder-Hayes et al. JCO, 2016
1.8 vs. White Risk Ratio 1.6 1.4 56% 1.2 41% 14% 1 0.8 Black Hispanic Asian 14
Contributing factors to Black-White Disparities in Survival Among Women ages 19-64 Years With Stage I-III Breast Cancer, 2004-2013 Source: Jemal et al., JCO 2017
Contributing Factors to Black-White Disparities in Survival Among Persons ages 18-64 Years With Colorectal Cancer, 2004-2013 1.60 Hazard ratio 1.40 1.20 1.40 1.41 1.00 Entire Cohort Demographic Match Insurance Match 1.19 1.18 1.07 1.06 Comorbidity Match Tumor Presentation Match Treatment Match Source: Sineshaw, Gastroenterology 2018 Sequentially matched cohorts
Year of death Source Grubbs et al. JCO, 2013
The Colorectal Cancer Control Program was Cost Effective Cost of screening= $1 million per year ($1.15 per resident) Cost of treatment for all cancers = $6 million Saving = $8.5 million annually from reduced incidence and stage shift to cancers requiring less aggressive therapy Source Grubbs et al. JCO, 2013 18
Disparity in Progress against Cancer by State Most policies that affect cancer prevention and control are designed and implemented at the state level States as laboratories of democracy by Louis Dembitz Brandeis, supreme court justice of the United States 1856-1941
Disparity in Lung Cancer Death Rates by State Lung cancer death rates, 2011-2015 Current cigarette smoking prevalence in adult ages 18+ years, 2016
Proportion of Cancer Deaths Attributable to Smoking, 2014 Lortet-Tieulent et al. JAMA Intern Med. 2016; 176(12):1792-1798 21
State Cigarette Excise Tax Rates, 2018 (dollars per ack) PR $5.10 22
State Funding for Tobacco Control as Percent of CDC Recommendations, Fiscal Year 2018 Sources: Truth Initiative, et. al., 2017. Centers for Disease Control and Prevention, 2014.
State Tobacco Prevention Spending vs. State Tobacco Revenue and CDC Recommendations, 2018 2.6% of total state tobacco revenues 21% of CDC recommended funding level Source: Broken promises to our children: A state-by-state look at the 1998 tobacco settlement 19 years later 24
Decline in Female Breast Cancer Death Rates, 1988-90 to 2013-15 by State Siegel et al. 2018. CA A Can J Clinician
Decline in Colorectal Cancer Death Rates, 1980-82 to 2013-15 by state Siegel et al. 2018. CA A Can J Clinician
Poverty rates by county, 2012 North Carolina/Virginia coastal South-West Appalachian region Lower Mississippi corridor
Early effects of the Affordable Care Act on Cancer Disparity 28
Affordable Care Act March 2010 Dependent coverage expansion January 1, 2014 Elimination of cost-sharing for preventive services State Medicaid Expansion Signed into law To broad range of low-income adults <65 years with annual income of $34,000 or less for a family of four in 2017
30
Studies on Early Effects of the ACA: Medicaid Expansion, January 1, 2014
Changes in Quarterly Percent Uninsured in Newly Diagnosed Cancer Patients Ages 18-64 Years by Income Following the ACA, 2013-2014 18 Medicaid Expansion states 18 Medicaid non-expansion states 16 14 16 14 Low income Uninsured (%) 12 10 8 6 Low income Middle income ACA 12 10 8 6 Middle income High income 4 High income 4 2 2 0 2013 Q1 2013 Q2 2013 Q3 2013 Q4 2014 Q1 2014 Q2 2014 Q3 2014 Q4 0 2013 Q1 2013 Q2 2013 Q3 2013 Q4 2014 Q1 2014 Q2 2014 Q3 2014 Q4 Source: Jemal et al. JCO, 2017 32
Changes in Percent Uninsured by Race/Ethnicity among Newly Diagnosed Cancer Patients Following the ACA Uninsured (%) ACA Han et al. JAMA Oncol 2018
Med Care 2018;56: 944 949) 34
Changes in CRC Screening Prevalence in Age 50-75 Years Following Elimination of Cost Sharing for Preventive Services (2008 vs 2013) by income 12.0% 10.0% 8.0% 6.0% 5.9% 4.0% 2.0% 0.0% 2.4% 1.3% -2.0% -4.0% <$35,000 $35,000-74,999 $75,000 Fedewa et al. 2015 35
Conclusions Pervasive disparity in progress against cancer in the US Considerable opportunities for reducing disparities and accelerate progress against cancer Stronger policies and political commitment for broad and equitable dissemination of known interventions 36
Thank you! 37