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Paper: Closing the Cap: Risks and Interventions for Cancer Authors: Richard Rothenberg, M.D., M.P.H., F.A.C.P. Director, Bureau of Chronic Diseases Prevention New York State Department of Health Philip C. Nasca, Ph.D. Director, Cancer Control Section New York State Department of Health Jaromir Mikl, M.P.H. Research Assistant New York State Department of Health Project Officer: Thomas Welty, M.D. Chronic Diseases Division ~ Center for Environmental Health, CDC Reviewers: Lester Breslow, M.D., M.P.H. Professor of Public Health University of California School of Public Health Saxon Graham, Ph.D. Chairman, Department of Social and Preventive Medicine State University of New York at Buffalo Peter Greenwald, M.D. Director, Division of Cancer Prevention and Control National Cancer Institute Thomas A. Hodgson, Ph.D. Chief Economist, Office of Analysis and Epidemiology National Center for Health Statistics Dwight Janerich, D.D.S., M.P.H. Director, Division of Community Health and Epidemiology New York State Department of Health Earl S. Pollack, Sc.D. Chief, Biometry Branch National Caner Institute David Schottenfeld, M.D. Director of Cancer Control Department of Epidemiology Memorial Sloan-Kettering Cancer Center Edward Sondik, M.D. Director, Operationa Research in Division of Cancer Prevention and Control National Cancer Institute N Kenneth E. Warner, Ph.D. Professor and Chairman, Health Planning and Administration University of Michigan School of Public Health - B33 -

A minimum of 23% of current cancer incidence may be attributed to the action of four major risk factors: smoking, alcohol use, high fat diet and occupational exposures to carcinogens. It is estimated that 113,966 cancer deaths (27.5% of total), 409,195 working years of lost life, 4,823,000 days of hospitalization and close to $3 billion in direct costs for 1980 may be attributed to these factors. These estimates derive from a detailed assessment of nine cancer sites: colon, rectum, pancreas, larynx, lung, female breast, cervix, prostate and bladder. The primary focus of this review is the examination of direct human evidence of the relationship of exposure and disease. In addition, laboratory and animal studies are evaluated and "ecologic" comparisons considered (these compare aggregate population exposure rates with aggregate population disease rates). Finally, concensus estimates were used in areas of ongoing assessment. What emerges is a sub5tantiation of the notion that much of cancer is related to external factors - things imposed on us by the environment or things that we do to ourselves. For these nine tumors, representing almost two-thirds of cancer incidence, elimination of risk from smoking, alcohol use and occupational exposure would reduce their incidence by 27%, primarily through their action on cervix, hladder,•pancreas, larynx and lung. The best consensus estimates suggest that approximately 20% of breast and colon cancer would he eliminated through alteration of dietary fat and protection offerred by cruciferous vegetables and retinoids. The total number of incident cancers attributable to these four_risks (182,868), divided by the total number of cancers for 1980 (807,364) produces the figure of 23%. This is a minimum - B34 -

 a U  U   r I  U U U  figure for the reduction of cancer incidence, since it does not take into account the potential effect of these and other risks on other tumors, nor the potential interaction among risks. In addition to attribution of cancer to specific risks, current evidence also suggests that substantial decreases in cancer mortality are possible through secondary prevention, i.e. early screening and detection of disease. For cancer of the breast, for example, a decrease of 30% in mortality may be attributed to the screening process (mammography, breast self-exam and physician examination). In cancer of the cervix, routine cervical cytology screening may be responsible for prevention of between 10% and 22% of deaths from cervical cancer. Though estimates are more difficult for colorectal disease, there appears to be the potential for substantial benefits from periodic screening as well. The gap to be closed in cancer, then, amounts to one-quarter to one-third of, the current disease burden, based on our current understanding of risks. In choosing targets for intervention, the strength of the association of cancer with risk, the prevalence of the exposure to risk, the feasibility of the interventive program and its potential effects, both positive and negative, must be carefully considered. The primary factors identified here - smoking, eating, drinking and working - are intimately tied to the fabric of our lives, and interventions must be assessed in their broad social, economic and demographic perspective. The social goal is to continue to address the part of the gap that is yet uncharted, and to close as much of it as our current knowledge and ability allow. ..G ~

In the following pages, this review addresses the evidence for risks and potential interventions. Chapter i deals with the data set for cancer (documented in the appendices). Chapter 2 describes those elements of the quality of life that are affected by cancer and a possible framework for viewing that effect. Chapter 3 discusses the problem of attribution, and describes the method used to assess the intensity of a risk and the proportion of dtsease associated with it. Chapter 4, in eight subsections (colon and rectal cancers are considered together) describes the major risks identified for each tumor. In chapter 5, a brief discussion of secondary, prevention, as applied to those diseases where it appears to he beneficial, is offered. Finally, in Chapter 6, the overview of risks and cancers is presented.

SU111AP.Y TABLE 1 Summary of Negative Impact Resulting from the Health Problem Health Problem Area: Cancer NEGATIVE IMPACT RESULTING FROM THE HEALTH PROBLEM SPECIFIC HEALTH Nur,ber of Number of Years Lost PROBLEM Deaths (1980) Before Age 65 Nur;ber of Hospital Days* Cost Associated with Each Specific Health Problem** Colon 46418 110455 ) 915 ) 3225 Rectum 10804 27273 ~ 386 Pancreas 22988 61498 524 244 Larynx 3449 12475 268 240 Lung 88459 334213 3357 1598 Breast 37518 217270 2243 1265 Cervix 5457 39133 565 179 Prostate 22572 12650 1333 519 Bladder 11000 14228 482 409 (+281) TOTAL 248665 829195 12303 6036 h OF ALL CANCER 60lo' 47'~ 57:0 44 -1' * In thousands ** In millions; includes hospital, physician visits, pha rmaceutical costs, home care & 281 million for nursing ho,:e care, not reflected in these categories ziltzIlusZQ[. - B37 - .~

SUMMARY.TABLE 2 Summary of Negative Impact Which Could Be Reduced or. Eliminated Through Implementation of the Intervention Strategies Health Problem Area: Cancer NEGATIVE IMPACT WHICH COULD BE REDUCED OR ELIMINATED THROUGH IMPLEMENTATION OF THE INTERVENTION STRATEGY SPECIFIC HEALTH PROBLEM RISK FACTOR (AR-°o) Number of Deaths (1980) Number of Years Lost Before Age 65 Number of Hospital Days* Cost Associated with Each Specific Health Problem** Cervical Smoking (24.1„) 1320 9431 136000 43 Bladder Smoking (39.0;m-N) , 4347 4513 153000 131 (16. 4%'-F) Occupation (23~) 2530 3272 111000 94 Pancreas Smoking (25.8°0) 5931 15866 135000 63 Larynx Smoking (74°~) 2552 9232 198000 178 Alcohol (16.9;;) 583 2108 45000 41 Lung Smoking (75.9",'~) 67140 253667 2548000 1213 Occupation (12%) 10615 40106 403000 192 Breast Diet (20%) 7504 43454 449000 253 Colorectal Diet (20°0) 11444 27546 645000 260 TOTALS 113966 409195 4823000 2468 % OF ALL CAidCERS 28% 23Z y 23" 18rw * In thousands ** -in millions; includes hospital, physician visits, pharmaceutical costs, home care - B38 - EhL[.ilUisC.uG

a CANC ER: YEARS: 65 Ln '-T a  I I I 1 I I I I I I I Thousands Thousands 250 0 80 / Coln Panc Cerx Rect B1ad Prst Larx CANCER: DEATHS Lung Brst Coln Panc Cerx Rect Blad Prst Larx -B39- N

CANCER: HOSPITAL DAYS Millions 3.5 2.5 1.5 0.5 Lung Brst Coln Panc And Rect r V / Cerx Blad Prst Larx CANCER: COSTS Billions of Dollars Lung Br st m Coln Panc - B40 - Cerx Rect Blad % F Prst Larx