The Descriptive Epidemiology of Lung Cancer

Andrea Borondy Kitts

November 3, 2014

Agenda

• Description and Classification

• Disease Distribution

• Disease Frequency in the US Population

• Epidemiological Triad

• Prevention– Primary

– Tertiary

• Summary

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Lung Cancer is a Non-Infectious Chronic Disease

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http://www.nccn.org/patients/guidelines/nscl/index.html#8

ICD-9CM 162Malignant Neoplasm of trachea bronchus and lung

ICD-10-CM 33 and 34Malignant neoplasms of respiratory and intrathoracic organs

Most are carcinomas and initiate in the lining of the airways

• Bronchi• Bronchiole• Alveoli

87% Non-Small Cell Lung Cancer (NSCLC); 13% Small Cell Lung Cancer (SCLC) Histology

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Molecular Challenges in Lung CancerBen Leach Published Online: December 17, 2012http://www.targetedonc.com/publications/targeted-therapy-news/2012/November-2012/Molecular-Challenges-in-Lung-Cancer

NSCLC further characterized histologically into:

• Adenocarcinoma• Squamous Cell• Large Cell

Global Lung Cancer Incidence and Mortality

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Most common cancer worldwide • 1.6 million deaths in 2012

Fifty eight percent of new cases in underdeveloped regions

Highest incidence and mortality in men • Central and Eastern Europe• Eastern Asia

Women have lower incidence and mortality • Highest in North America – cultural

differences in smoking prevalence • Lag in when women started smoking

http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx

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

Lung Cancer is the Leading Cause of Cancer Deaths in the US

• The leading cause of cancer deaths in both men and women

– 160,000 die each year, more than breast, colon, prostate and pancreatic cancer combined

– 5 year survival at 16.8% essentially unchanged since 1975

http://www.cancer.org/acs/groups/content/@research/documents/webco

ntent/acspc-042151.pdf

Overall Lung Cancer Incidence in US is 60.1 cases per 100,000; Highest in African American Men at 93.0 per 100,000

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http://seer.cancer.gov/statfacts/html/lungb.html

Average age at diagnosis 70

Lung Cancer Incidence and Mortality Rates Decreasing in the US

11/4/2014 8http://seer.cancer.gov/statfacts/html/lungb.html

The Agent For Over 80% of Lung Cancers is Tobacco

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Other agents include:• Radon • Asbestos• Air Pollution• Arsenic• Cadmium• Chromium• Diesel Fumes• Nickel• Silica• Cooking Fires

U.S. Department of Health and Human Services. (2014). The Health Consequences of Smoking – 50 Years of Progress A Report of the Surgeon General. Retrieved from http://www.surgeongeneral.gov/library/reports/50-years-of-progress/50-years-of-progress-by-section.html

The Vectors for Lung Cancer are the Tobacco Companies Marketing and Producing Tobacco Products

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• $8.4 Billion spent on advertising annually• $23 million every day

• 90% of regular smokers start smoking by age of 18• Smoking harder to quit

than heroin

Centers for Disease Control and Prevention. (2014). Economic Facts About U.S. Tobacco Production and Use, Retrieved on October 24, 2014 from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/index.htm

BeTobaccoFree.gov. (2014). Nicotine Addiction and Your Health. Retrieved on October 29, 2014 from http://betobaccofree.hhs.gov/health-effects/nicotine-health/index.html

Blakeslee, Sarah. (1987). Nicotine: Harder To Kick...Than Heroin. Retrieved October 29, 2014 from The New York Times website: http://www.nytimes.com/1987/03/29/magazine/nicotine-harder-to-kickthan-heroin.html

Natural History in the Male or Female Human Host

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DNA damage to

cells

Abnormal cell growth

Lesion Pathological

EvidenceMetastasis Diagnosis Treatment Death

Damage accumulates with age and exposure to agents e.g. tobacco. Average age of diagnosis is 70

Few symptoms in early stages

Screening test (LDCT) not generally available until 2015

Approximately 85% of diagnoses at a late stage

Early stage –Surgery and possible adjuvant chemo/radiation

Late stage –palliative and life extension

CTPET/CTBiopsyMRIStaging

5 year survival 16.8%Localized – 54%Distant – 4%

http://seer.cancer.gov/statfacts/html/lungb.html

http://www.nccn.org/patients/guidelines/nscl/index.html

The Environment Comprises Government Policies and Social Context

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Warning Labels on Tobacco Products• Many now advocating for “plain

packaging”

Ban on Cigarette and Smokeless Tobacco Advertising on TV and Radio

Smoking Restrictions in Public Places

Increased Cigarette Taxes • 10% increase reduces consumption 3

to 5%

Tobacco Master Settlement Agreement • Dollars go into general fund. Not being

used for original intent of tobacco control

Graphic CDC Anti-smoking Campaign

Lung cancer incidence reduced from 42% in 1965 to 18% in 2012

Decline in teen smoking incidence leveling off.

5.6 million youths will die prematurely of tobacco related illness

New threat E-cigarettes

Unintended consequence is stigmatization of people with lung cancer increasing the disease burden

Large tax revenues and strong lobbying stymie will to make tobacco illegal

http://www.cdc.gov/tobacco/data_statistics/by_topic/policy/legislation/

http://www.surgeongeneral.gov/library/reports/50-years-of-progress/50-years-of-progress-by-section.html

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Primary Prevention: States Have Failing Grades for Most Tobacco Control Measures

Spending

Cessation

Excise Taxes

Smoke Free Air Laws

http://www.stateoftobaccocontrol.org/state-grades/state-rankings/

Secondary Prevention: Lung Cancer Screening with LDCT now Recommended for the Population at High Risk

“The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery."

• More than 10 million Americans in the recommended population to screen

• Estimated to save more than 20,000 lives a year

• Additional benefit for smoking cessation– Published smoking cessation rates in lung cancer screening trials and studies show

2 to 3 times the cessation rate as compared to the general population (11 to 22% vs 5 to 7%)

Sifferlin, Alexandra. 2013. "Surviving Lung Cancer." Time 182, no. 7: 15. Academic Search Premier, EBSCOhost (accessed October 28, 2014).

Moyer VA, on behalf of the U.S. Preventive Services Task Force. Screening for Lung Cancer: U.S. Preventive Services Task Force Recommendation Statement. (2014). Annals of Internal Medicine, 160:330-338. doi:10.7326/M13-2771

Townsend, C. O., Clark, M. M., Jett, J. R., Patten, C. A., Schroeder, D. R., Nirelli, L. M., Swensen, S. J. and Hurt, R. D. (2005). Relation between smoking

cessation and receiving results from three annual spiral chest computed tomography scans for lung carcinoma screening. Cancer, 103:, 2154–2162. doi:

10.1002/cncr.21045

Tammemagi, M.C., Berg, C.D., Riley, T.L., Cunningham, C.R., Taylor, K.L. (2014). Impact of Lung Screening Results on Smoking Cessation. Journal of the

National Cancer Institute, 10:6, DOI:10.1093/jnci/dju84

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http://www.uspreventiveservicestaskforce.org/uspstf/uspslung.htm

National Screening Trial Results

The National Lung Screening Trial Research Team . N Engl J Med 2011;365:395-409.

More Lung Cancers found in LDCT Arm

• Total Cases• LDCT 1060

• CXR 941

• Cases per 100k person years• LDCT 645

• CXR 572

Difference primarily early stage disease

More Lung Cancer Deaths in CXR Arm

• Total Deaths • LDCT 356

• CXR 443

• Deaths per 100k person years• LDCT 247

• CXR 309

20% Reduction in mortality with LDCT

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67.1 VS 33.2

20.5 VS 52.5

Stage shift seen with LDCT screening in NLST shifts back after screening stopped - greater than 20% mortality improvement possible

The National Lung Screening Trial Research Team . N Engl J Med

2011;365:395-409

Tertiary Prevention: Surgical Treatment in Early Stages; Systematic Treatment in Late Stages

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Surgical Options include wedge resection, lobectomy, bilobectomy, and pneumonectomy via traditional, minimally invasive (VATS) or robotic surgery • sometimes preceded by, or followed

with, adjuvant chemotherapy and/or radiation

Systematic treatments include chemotherapy, radiation, targeted molecular treatments, and immunotherapy

• Approximately 67% of NSCLC have an identified genetic mutation

http://www.onclive.com/publications/Oncology-live/2013/January-2013/Targeting-Tumors-Early-Trials-Push-Novel-Agents-to-Forefront/2

Stigma due to Strong Link with Smoking

People with lung cancer blamed and/or blame themselves for their disease

http://cancergeek.wordpress.com/2013/11/16/cancer-the-harsh-story-of-lung-cancer-vs-breast-cancer/11/4/2014 18

Deadliness of disease and images of horrible death

Lack of survivors and advocates = less research $’s

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Summary• Lung Cancer is a Non-Infectious Chronic Disease

– More than 80% of cases caused by tobacco use– 90% of regular tobacco use starts by age 18– Smoking harder to quit than heroin – Cigarettes more addictive now than in 1960’s

• Lung cancer is the most common cancer worldwide and the leading cause of cancer deaths in men and women in the US – Mortality rate high due late stage at diagnosis

• USPSTF now recommends LDCT screening annually for the high risk population– 10 million Americans eligible– Estimate more than 20,000 lives saved per year– Need to raise awareness with primary care physician community and the

population at risk

• Tobacco control efforts, although resulting in some success, have failed to eliminate smoking– E-cigarettes threaten to erode smoking incidence reduction achieved to date

• Increased research funding needed for improved screening and treatment modalities

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Lung Cancer is the 2nd Leading Cause of Death in the US

• Lung cancer is the leading cause of cancer deaths in both men and women in the US

– 160,000 die each year, more than breast, colon, prostate and pancreatic cancer combined

– 5 year survival at 16.8% essentially unchanged since 1975

• Most common cancer worldwide

– 1.6 million deaths in 2012

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Tobacco Control Policies Stigmatize Smokers

Tobacco Industry Response to 1964 Surgeon General Report:deny addictive nature of smokingportray smoking as lifestyle choice

Tobacco control policies de-normalized smoking and stigmatized smokerssmoking as environmental health issue (2nd hand smoke)legislation of smoke free public areas and work placesportraying smoking as a personal choice leading to a horrible death

Stuber J, Galea S, Link BG. Smoking and the emergence of a stigmatized social status. Social Science in Medicine. 2008;67(3):420–430.11/4/2014 22

Lung Cancer Stigma has Adverse Impacts on Depressive Symptoms, Quality of Life and Physical Symptoms

• People with lung cancer experience dual burdens of their disease and stigma

• Lung cancer stigma is an independent factor

– 2.1% impact on quality of life (QOL)

– 3% of the impact on depressive symptoms

– 1.3% increase in severity of symptoms

• Depression impacts QOL and QOL prognostic factor for survival (ref below)

Ediebah DE, Coens C, Zikos E.,Qinten C., Ringash J., King MT., Schmucker von Kich J., Gotay C., Greimel E., Fletchner H., Weis J., Reeve BB.,Smit EF., Taphoorn MJ., Bottomley A.Does change in health-related quality of life score predict survival? Analysis of EORTC 08975

lung cancer trial.Br J Cancer. 2014 Apr 17. doi: 10.1038/bjc.2014.208. (Epub ahead of print)

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Tobacco Control Policies

Decreased Smoking Prevalence

Reduced LC Incidence

Reduced LC Advocacy

Reduced LC Research

Low Survivability

LUNG CANCER (LC) STIGMA CONCEPTUAL MODEL

Andrea Borondy Kitts April 2014

Increased LC Stigma

Adverse LC patient impacts

Stigmatized smokers

Tobacco control policies effective at decreasingsmoking prevalence however stigmatized smokersand people with lung cancer. Reduction in incidence of lung cancer offset by low survivability due to stigma resulting in negativelyreinforcing loops of increased stigma, adverse patient impacts,less advocacy and reduced research.

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Public Health Policy ImplicationsImprove lung cancer survivability via USPSTF recommended low dose CT (LDCT) lung cancer screening. Improved survival leads to positively reinforcing loops of reduced stigma, increased advocacy, increased research, increased survival

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Need CMS to cover LDCT lung cancer screening.

Continuation of tobacco control policies should addlung cancer screening as ateachable moment for smokingcessation. Also, switch focus fromnegative portrayal of smokers and focus on tobacco and e-cigarette industryactions targeting addiction & marketing to youths