University of Maryland Marlene and Stewart

Greenebaum Cancer Center

Cancer Disparities
September 15, 2009
 2009 Estimated US Cancer Deaths*

Lung & bronchus 30% Men Women 26% Lung & bronchus
292,540 269,800
Prostate 9% 15% Breast
Colon & rectum 9% 9% Colon & rectum
Pancreas 6% 6% Pancreas
Leukemia 4% 5% Ovary
Liver & intrahepatic 4% 4% Non-Hodgkin
bile duct lymphoma
Esophagus 4% 3% Leukemia
Urinary bladder 3% 3% Uterine corpus
Non-Hodgkin 3% 2% Liver & intrahepatic
lymphoma bile duct
Kidney & renal pelvis 3% 2% Brain/ONS
All other sites 25% 25% All other sites

ONS=Other nervous system.

Source: American Cancer Society, 2009.
 US Mortality, 2006
No. of % of all
Rank Cause of Death deaths deaths
1. Heart Diseases 631,636 26.0

2. Cancer 559,888 23.1

3. 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 1.9

10. Septicemia 34,234 1.4

*Includes nephrotic syndrome and nephrosis.
Source: US Mortality Data 2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.
 Change in US Death Rates* from 1991 to 2006

Rate Per 100,000

400
1991
313.0
300 2006

215.1
200.2
200 180.7

100
63.3
43.6 34.8
17.8
0
Heart diseases Cerebrovascular Influenza & Cancer
diseases pneumonia
* 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.
 Cancer Death Rates* by Sex, US, 1975-2005

300 Rate Per 100,000

Men

250
Both Sexes
200
Women

150

100

50

0
1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 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.
 Tobacco Use in the US, 1900-2005
5000 100

4500 90
Per Capita Cigarette Consumption

Age-Adjusted Lung Cancer Death

4000 80

3500 Per capita cigarette 70

consumption
3000 60

Rates*
2500 50
Male lung cancer
2000 death rate 40

1500 30

1000 20

500 Female lung cancer 10

death rate
0 0
1900
1905
1910
1915
1920
1925
1930
1935
1940
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
Year
*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.
Cancer is a disease of aging

7
We are getting older

8
 Obesity, Diet and Cancer
 Doll and Peto estimated that 35% (or
as high as 70%) of US cancers were
diet related.
 High fat, low fiber diet in Western
societies implicated in early studies.

9
Mortality and Body Mass Index

rB ay - rP oc. NY cad
A ci,
S 891 ref1

10
Obesity and Cancer Mortality

Deslypere - Metabolism 4:4,2 591 Ref 2

11
 Trends in Obesity* Prevalence (%), Children and Adolescents,
by Age Group, US, 1971-2006
20
18
17
16 16

15

12
Prevalence (%)

11 11
10
10
7
7
6
5 5 5
5 4

0
2 to 5 years 6 to 11 years 12 to 19 years

NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94)

NHANES 1999-2002 NHANES 2003-2006

*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.
 Trends in Obesity* Prevalence (%), By Gender, Adults
Aged 20 to 74, US, 1960-2006†
45

40
35 36
33 34 34 35
35 32
31
30 28
Prevalence (%)

26
25 23
21
20 17
16 17
13 15 15
15 12 13
11
10

0
Both sexes Men Women

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

*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.
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

14
Obesity Trends* Among U.S. Adults
BRFSS, 1986
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

15
Obesity Trends* Among U.S. Adults
BRFSS, 1988
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

16
Obesity Trends* Among U.S. Adults
BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

17
Obesity Trends* Among U.S. Adults
BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

18
Obesity Trends* Among U.S. Adults
BRFSS, 1994
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

19
Obesity Trends* Among U.S. Adults
BRFSS, 1996
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

20
Obesity Trends* Among U.S. Adults
BRFSS, 1998
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

21
Obesity Trends* Among U.S. Adults
BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

22
 Obesity Trends* Among U.S. Adults
BRFSS, 20
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Source: Behavioral Risk Factor Surveillance System, CDC

23
 Obesity Trends* Among U.S. Adults
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

198 20

Source: Behavioral Risk Factor Surveillance System, CDC

24
 Mammogram Prevalence (%), by Educational Attainment and
Health Insurance Status, Women 40 and Older, US, 1991-2006
70

All women 40 and older

60

50
Prevalence (%)

Women with less than a high school education

40

30
Women with no health insurance

20

10

0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2004 2006
Year
*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.
 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
 Disparities in Health
 The concept that some populations (however
defined) do worse than others

 The measure can be:

 Incidence
 Mortality
 Survival
 Quality of life
 All Sites – Cancer Mortality Rates 1973-2004
By Race, Males and Females
300
African American

250
Caucasian
Rate

200

150 AI/AN
Hispanic

API
100
'75 '78 '81 '84 '87 '90 '93 '96 '99 '02
Year
Incidence and mortality rates per 100,000 and age-adjusted to 2000 US standard population
SEER Cancer Statistics Review 1975-2004.
 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
 Studies of differences among
populations

 Should focus on individuals and families and

genetic markers (personalized medicine)

 Should not focus on race

 A sociopolitical categorization
 Not based on biology
 A categorization Americans are fixated on
 Studies of differences among
populations

 Advocacy for such studies should not

drown out concerns about lack of adequate
treatment

 Concerns about genetic differences should

not become excuses allowing us to accept
disparities in health
Adjusted Breast Cancer Survival by Stages and
Insurance Status, among Patients Diagnosed in
1999-2000 and Reported to the NCDB
 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
 Trends in Recent* Flexible Sigmoidoscopy or Colonoscopy
Prevalence (%), by Educational Attainment and Health
Insurance Status, Adults 50 Years and Older, US, 1997-2006

60 56
1999 2001 2002 2004 2006
50
50
44 44 45 43
41
37
Prevalence (% )

40 36 36

30 25
22 21 21 22
20

10

0
Total Less than a high school No health insurance
education
*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.
 U.S. Colorectal Cancer Mortality 1975-2005

40.0

35.0

30.0
Rate per 100,000

25.0 Blalck Male

WhiteMale
20.0
Black Female
15.0 White Female

10.0

5.0

0.0
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
 Adjusted Colorectal Cancer Survival by Stages
and Insurance Status, among Patients Diagnosed
in 1999-2000 and Reported to the NCDB
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%
 Survival Rates RMS Titanic
Concept of Dr. Lisa Newman

First Class 60%

Second Class 43%

Third Class 20%

RACIAL DISPARITIES IN HEAD AND
NECK CANCER
 RACIAL DISPARITIES IN HEAD AND
NECK CANCER

“If you get cancer, whether you live or die shouldn’t be determined by
your zip code.” Stewart Greenebaum
 Race – a neglected biomarker in
cancer

 African American men with cancer are 30% more

likely to die than whites

 African American women with breast cancer are

17% more likely to die than whites
Cancer Prev Res 2009;2(9) September 2009
Black patients with locally advanced HNSCC show
poor survival compared to whites – University of
Maryland Chemo/RT experience 1995-2006
 Impact of Race on Survival
University of Maryland

All Patients Oropharynx Non-Oropharynx

 HPV Positive Tumors Have
Excellent Prognosis – TAX 324

All Patients Oropharynx

 Impact of Race on Survival
TAX 324 Study

All Patients Racial Disparities

Racial disparity is due to large number of white patients with

good prognosis HPV positive tumors – rate of HPV positive tumors
very low in blacks.
Otis W. Brawley, M.D.
Chief Medical Officer
Executive Vice President
American Cancer Society

Professor of Hematology, Oncology,

Medicine and Epidemiology
Emory University
 “Perhaps advances in our
understanding of biology will lead us
away from concerns about race and
we will better define high-risk
populations using pathological
markers of disease.” – Otis Brawley