Winning The War On Cancer Building the Bridge Between Public Health

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Winning The War On CancerBuilding the Bridge
Between Public Health Primary Care

• Richard C. Wender, MD
• Alumni Professor and Chair
• Department of Family Community Medicine
• Thomas Jefferson University
• Philadelphia, PA

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• Eight key challenges and trends will determine
  the future of cancer in the United States and
  around the world

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1. The changing epidemiology of cancer deaths
2. The relentless spread of tobacco use
3. The obesity epidemic
4. The inversion of the age pyramid
5. Determining the true value of the early detection
   of cancer
6. The emergence of personalized treatment
7. The growing number of cancer survivors
8. The urgent need to reduce the cost of care

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Trend 1

• The changing epidemiology of cancer deaths

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The Global Burden of Cancer Continues to Increase

• In 2008
• 12.7 million cancer cases
• 7.6 million cancer deaths
• are estimated to have occurred

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• Cancer is the leading cause of death in
  economically developed countries and the second
  leading cause of death in developing countries

Jemal A, Bray F, et al. CACan J Clin.
20116169-90
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Affluence Contributes To Cancer

• Associated with more obesity and more alcohol
  intake
• Only aggressive counter-tobacco policies have
  helped to mitigate the interaction of affluence
  and tobacco use

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• As we develop a global economy and relative
  affluence reaches more people in more countries,
  we can expect the westernization of cancer
  epidemiology

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The Other Side of the Cancer Epidemiology Story

• High resource nations are making dramatic
  progress in the war on cancer

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• We are making great progress in cancer amenable
  to prevention or early detection and very
  little progress in all other solid tumors

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• Trend 2 The relentless spread of tobacco use

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• Tobacco use remains the leading cause of
  preventable death and illness in the US
• Half of all smokers will die from a smoking
  related illness
• In 2010, 19.3 of US adults were current smokers
  compared to 20.9 in 2005
• At the rate of decline, US smoking rates will
  reach approximately 17

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• 5.4 million people died worldwide from
  tobacco-related illnesses in 2006
• Unless action is taken, tobaccos annual death
  toll will rise to more than eight million by the
  year 2020, with over 80 of those deaths
  occurring in low-income countries
• WHO Report on the Global Tobacco Epidemic, 2008
  The MPOWER Package

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The Tobacco WarsWe Know What Works

• Make it more expensive
• Make it hard to get a pack of cigarettes
• Counter-advertising
• Make it difficult to smoke
• Encourage smoking cessation

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• What is the impact of FDA regulation on tobacco
  use?

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• Trend 3 The worldwide obesity epidemic

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The Obesity Epidemic

• If we are going to accelerate cancer prevention,
  we must find strategies to address the public
  heath challenge of our time the epidemic of
  overeating and sedentary living

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Obesity Rates
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The Worldwide Obesity Epidemic

• 68 of all Americans are overweight
• Close to 34 are obese
• Worldwide, obesity rates doubled between 1980 and
  2008

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Obesity and Cancer

• 85,000 U.S. cases per year are obesity-related
• Basen-Engquist K, Chang M. Curr Oncol Rep. 2011
  Feb13(1) 71-6.

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• Continuation of the current obesity trend will
  lead to about 500,000 additional cancer cases in
  the US by 2030

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Obesity is Associated With Increased Risk of
These Cancers and Probably Others

• Esophogus
• Pancreas
• Colon and rectum
• Breast (after menopause)
• Endometrium
• Kidney
• Thyroid
• Gallbladder

http//www.cancer.gov/cancerfactsheet/risk/obesity

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NCI Best Estimate

• If every adult reduced their BMI by 1 percent,
  this could actually result in the avoidance of
  100,000 new cases

www.cancer.gov/cancertopics/factsheet/risk/obesity

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Can We Apply the Policies of the Tobacco Wars to
the Food Challenge?

• Taxes
• De-normalization

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Heres What We Dont Know About Losing Weight (
... the short list)

• Can community and family-focused interventions
  enhance one by one approach?
• Will losing weight lower cancer risk?
• By how much?
• For which cancers?
• What primary-care based interventions are
  effective and at what cost?

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Managing Obesity in the Office
Six minute counseling framework for overweight
patients
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Message 1Its Not Your Fault!
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We produce 4,000 calories per person per day in
the U.S. The food industry works to make sure
each of us eats our share
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Message 2Losing weight and keeping it off for
the rest of your life is very difficult
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Message 3But it can be done!
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Set a Realistic Goal for Lifelong Weight Loss

• Maintaining 10 lower than initial weight is
  fabulous (24 pounds in the 240 pound patient)
• Maintaining 5 lower than initial weight is very
  good (12 pounds in the 240 pound patient)

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Message 5This is just like tobacco and alcohol

• Not a single puff
• Not a single sip
• Not a single unhealthy portion

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Message 5Diets dont work! Why.? Because
they end
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• Can you imagine celebrating 6 months of being
  tobacco free by smoking a pack?
• No?

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• But can you imagine celebrating achieving a 20
  pound weight loss by having a big steak dinner?
• ..happens every day!

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Message 6Commercial weight loss programs work.
Use them. But recognize that the commitment is
to life-long change
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• Some smokers reach the phase of no longer
  craving cigarettes virtually cured of their
  addiction
• Very few overweight individuals reach this phase
  (PIC)

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• Maintaining weight loss (in most people)
  requires constant support, frequent
  (preferably daily) weighing, and a
  concrete plan

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Message 8Be as physically active as you can
possibly be
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The key to winning the dangerous food war HOPE
OPTIMISM
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Years ago, none of us counseled about smoking
because we were sure that nothing worked. People
DO lose weight and keep it off. We can help it
to happen
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Its time to tell the truth. Its time to
tackle the greatest public health challenge
confronting our nation.
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• Trend 4 The inversion of the age pyramid

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Arenson Aging Slide
2008
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Population Pyramids, USA
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Population Pyramids, China
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Geriatric Oncology

• Demographics
• Leading cause of death men/women age 60-79
• 80 cancer-related deaths in US are 65 and older
• 20 of US population over age 65 by 2030
• 70 of all cancers
• 85 of all cancer related deaths
• Behavior of certain cancers change with age

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• Our aging population will lead to a tsunami of
  cancer

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Address High Costs of Critical Care

• Begin a re-examination of how we think about
  critical care and care at the end of life

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• Critical care has gotten lost in the shuffle in
  health care reform

• Stephanie Silverman, CEO of Venn Strategies
• www.vennstrategies.com 1/12/2012

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We Dedicate A Lot Of Resources To Terminal
Patients

• 30 of Medicare expenditures are attributable to
  the 5 who die each year
• One third of this is spent in the last month.
  Terminal hospitalizations account for 7.5 of
  all inpatient costs, the majority for ICU care

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• We must bring about a shift in societal values
  
• Embrace a life model that promotes many years of
  high-quality, disability free life while
  accepting and enhancing the experience of dying
  in America

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• Challenge 5 Determine the true value of the
  early detection of cancer

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• Based on what we know about cancer today, there
  are only two ways to reduce mortality from the
  solid cancers that affect adults
• Stop carcinogenesis
• Block metastasis through early detection and
  destruction or removal of the primary cancer

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• Any cancer can be cured if its caught early
  enough
• Cancer develops in a place in the body, in any
  organ. As long as it hasnt spread to other
  organs, it generally can be removed
• - Bert Vogelstein

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• Why are we moving away from screening?

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Randomized Trials of Cancer Screening Usually
Underestimate Benefit

• Randomized trials of cancer screening are
  imperfect
• They are trails of invitation, not of screening
• Some usual care patients get screened
• Some intervention patients dont get screened
• Trials require very long follow-up
• Screening is only offered for a few years

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Mounting Concern About Over-diagnosis

• Cancers that, had they not been diagnosed, would
  never have become clinically meaningful and would
  not have resulted in death or disability

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• Estimating mortality reduction and over-diagnosis
  from a clinical trial is very difficult
  requiring 15 to 20 years of follow-up for slower
  moving cancers

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Observational Trials of Cancer Screening Are
Undervalued

• Observational studies are subject to lead and
  length time bias and also require long follow-up
  but it is possible to compare a program of
  screening to no screening over many years

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Cancers With Rising Incidence

• HPV related oropharynx
• Esophageal adenocarcinoma
• Pancreas cancer
• Liver and intrahepatic bile duct
• Thyroid cancer in men
• Kidney and renal pelvis
• Melanoma of the skin

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2012 Predictors Cancers With Increasing
Incidence
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Cancers With Increasing Incidence Plausible
Contributing Factors
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Lung Cancer - 2013

• Estimated new cases 228,190
• Estimated deaths 159,480

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National Lung Screening Trial

• 53,000 current or ex-smokers ( 30 pack-year)
  ages 55-74
• Randomly Assigned

Low dose helical (spiral) CT
Chest X-Ray
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NLST Preliminary Results

• 20 fewer lung cancer deaths in spiral CT group
• Results were highly statistically significant
  7 reduction in all-cause mortality!

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• Research directed at the early detection of solid
  tumors offers our best opportunity to convert
  survivorship into cure

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• Trend 6 The emergence of personalized therapy

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• Research will increasingly allow us to
• Use molecular markers to identify cancers that
  will and will not respond to therapy
• Use tailored, targeted therapies given by mouth
  with tolerable adverse effects
• Convert a certain and rapid death into a chronic
  seige

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We Need Personalized Treatment Not Just
Personalized Therapy

• Treat the right patients with the right therapies
  at the right stage

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• Was I right to offer this option?
• The patient was satisfied, does that mean it
  was an appropriate choice?

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• Are there any models that make it acceptable and
  safe to choose less treatment?

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• Can we subject treatment decisions to the same
  type of risk-benefit analysis that we apply to
  screening decisions?

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• Personalized therapy must move beyond genetic
  profiling of tumors
• We must find effective ways to communicate the
  risks and benefits of therapy

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• Trend 7 The growing number of cancer survivors

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6. Cancer Survivors
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• Challenge 8 The urgent need to reduce the cost
  of care

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• Amidst the debate about health care reform,
  there appears to be near unanimity around the
  fact that a reformed U.S. health care system
  requires at its foundation a robust system of
  primary care.
• Landon BE, Gill JM, Antonelli RC, Rich EL, J. Gen
  Int Med 25(6) 581-3

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Expectations For Primary Care Performance Have
Skyrocketed

• Primary care can
• Improve health
• Narrow health disparities
• Reduce health care spending

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More Specialists Mean Higher Spending
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While GPs Are Associated With Less Spending
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As It Turns Out, Cost Is Inversely Related To
Quality
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And More Specialists Predict Lower Quality Ranking
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While more GPs predict higher quality ranking
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• The Patient-Centered Medical Home (PCMH) has
  emerged as the leading strategy around which
  primary care will be redesigned

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The Medical Home Is Something Fundamentally
Different

• Usual Care
• Relies on the clinician

• Medical Home
• Relies on the team

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Usual Care Care provided to those who come in
Medical Home Care provided for all
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Usual Care Performance is assumed
Medical Home Performance is
measured
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Usual Care Innovation is infrequent
Medical Home Innovation occurs
regularly
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Usual Care Includes only primary care
Medical Home Includes mental health, Pharm Ds
and others
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Usual Care Navigation and care management not
available
Medical Home Navigation and care management are
required
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Usual Care H.I.T. may or may not support care
Medical Home H.I.T. must support care
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The PCMH Requires A Substantial Shift In How We
Pay For Health Care From High Volume To High
Value

• Payment linked to the volume of care and the
  performance of procedures impedes system redesign
  
• The potential of the PCMH cannot be realized
  without meaningful payment reform

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Medical Homes Work

• They reduce ED visits, hospitalizations, and cost
  of care
• They improve access and care coordination
• They improve measures of diabetes control

Grumbach K, Bodenheimer T. The Outcomes of
Implementing Patient-Centered Medical Home
Interventions PCPCC.net 2012
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Is Cancer Being Left Out of the Medical Home?
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The Most Important Barrier is the Economic Impact
of Increasing Cancer Screening

• The need to slow health care spending is urgent
  and the need to see results is immediate

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Health Care Costs As A Percent Of GDP
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• Prevention interventions alone can save money
  (e.g. vaccination and disease eradication), but
  they often to not realize cost savings in the
  short term.

Are We There Yet? Seizing the Moment to
Integrate Medicine and Public Health.
Scotchfield FD, Michener JL, Thacker SB. An J Pub
Health/Suppl 3, 2012, Vol 102 NoS3
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• Cancer screening is cost effective but it is
  not cost saving.
• Tobacco control can impact costs both long and
  short term but requires substantial investment to
  take on the tobacco industry
• We are still figuring out how to tackle obesity
  but it is naïve to imagine that success will not
  require real resources

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• Cancer screening may not reduce the total cost of
  care, but screening does accomplish one very
  important outcome
• Cancer screening prevents premature
  cancer deaths.

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What Are Our Societal Values?
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Best Practices In Achieving Very High Cancer
Screening Rates

• A population registry is used to identify all
  eligible patients and tracks each individuals
  screening status
• Non-physician staff are assigned to monitor
  screening gaps and to reach out to individuals
  who are due
• Systems to smooth scheduling and reporting are in
  place
• Open access colonoscopy is an example

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Increasing Cancer Screening

• Navigation is available to help patients overcome
  barriers
• Reminder systems are in place to promote
  screening at the time of office visits,
  regardless of the reason for the visit,
  (Opportunistic Screening)
• Screening rates are tracked teams receive
  individual feedback, including how their rates
  compare to peers

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The 8th Attribute of the PCMH
Usual Care Clinicians function within the walls
of the office
Medical Home Partners with communities and
public health infrastructure to address social
determinants of disease
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• Why has it been so hard to link public health and
  primary care?

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What Factors Are Impeding Public Health Primary
Care Collaboration

• Incentives are not aligned
• Both are chronically underfunded
• Both operate on the edge of viability leaving
  little time or resources to form new innovative
  partnerships
• The cultures of both disciplines have diverged
  through time
• Its really hard work and its hard to know where
  to start

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We Must Complete Construction On The Primary Care
Public Health Bridge Right Now
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• Achieving very high cancer screening rates will
  require
• Policy solutions
• Public activation
• Systems of care
• High functioning primary care
• Specialists as a part of the team

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• Slowing, let alone, reversing the obesity
  epidemic will require
• Policy change in agriculture, food production and
  industry, tax structure, community development,
  and benefit design
• Community transformation and engagement
• Broad engagement of the medical professions

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• Accelerating progress in the tobacco fight will
  require
• Pursuit of the policies that are proven to work
• Continuing de-normalization of tobacco
• Engagement of the health professions to promote
  tobacco prevention and cessation

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Heres what the Public Health Community needs to
do

• Advocate
• Cancer issues need to be included in every PCMH
  and innovative payment pilot
• Innovative payment models must be designed to
  support and reward population management and
  prevention

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Heres what the Public Health Community needs to
do

• Embrace
• Primary care partners are everywhere
• Organizations
• Hospitals
• Insurers
• Community Health Centers
• Academic Health Centers
• Go to where they are
• Get public health and primary care in the same
  room

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Heres what the Public Health Community needs to
do

• Engage
• Fund projects that test new ways to build the
  bridge
• Create inter-professional programs that are
  expected to achieve measurable outcomes that
  matter
• Put patients at the center of the team

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Reducing Cancer Mortality Relies On The Primary
Care Public Health Partnership

• The epidemics of tobacco and over-eating cannot
  be solved within the walls of an office. Cancer
  screening, tobacco cessation, cancer prevention
  vaccines, and weight reduction require medical
  intervention.

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Primary care is the bridge between
Public Health
Community Engagement
Clinical Care Delivery