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

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

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

Most are carcinomas and initiate in

the lining of the airways
http://www.nccn.org/patients/guidelines/nscl/index.html#8
• Bronchi
• Bronchiole
• Alveoli

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

NSCLC further
characterized
histologically into:

• Adenocarcinoma
• Squamous Cell
• Large Cell

Molecular Challenges in Lung Cancer

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

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 Global Lung Cancer Incidence and Mortality

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

11/4/2014 http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx 5
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 http://apps.nccd.cdc.gov/uscs/toptencancers.aspx
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
Average age at diagnosis 70

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

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 Lung Cancer Incidence and Mortality Rates Decreasing
in the US

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http://seer.cancer.gov/statfacts/html/lungb.html
The Agent For Over 80% of Lung Cancers is Tobacco

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

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

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

BeTobaccoFree.gov. (2014). Nicotine

Addiction and Your Health. Retrieved on
October 29, 2014 from
http://betobaccofree.hhs.gov/health-
Centers for Disease Control and Prevention. (2014). Economic Facts About U.S. Tobacco Production and Use,
effects/nicotine-health/index.html
Retrieved on October 24, 2014 from
11/4/2014
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/index.htm 10
 Natural History in the Male or Female Human Host

Approximately 85%
5 year survival 16.8%
of diagnoses at a
Localized – 54%
late stage
Distant – 4%

DNA
Abnormal Pathological
damage to Lesion Metastasis Diagnosis Treatment Death
cell growth Evidence
cells

Damage Few symptoms CT

accumulates in early stages PET/CT
with age and
Biopsy
exposure to MRI
Screening test Early stage –
agents e.g. Staging
(LDCT) not Surgery and
tobacco.
generally possible adjuvant
Average age
available until chemo/radiation
of diagnosis is
70 2015
Late stage –
http://www.nccn.org/patients/guidelines/nscl/index.html palliative and life
11/4/2014 http://seer.cancer.gov/statfacts/html/lungb.html extension 11
 The Environment Comprises Government
Policies and Social Context
Warning Labels on Tobacco Products Lung cancer incidence reduced from
42% in 1965 to 18% in 2012
• Many now advocating for “plain
packaging” Decline in teen smoking
incidence leveling off.
Ban on Cigarette and Smokeless Tobacco
Advertising on TV and Radio 5.6 million youths will die
prematurely of tobacco related
Smoking Restrictions in Public Places illness

New threat E-cigarettes

Increased Cigarette Taxes
• 10% increase reduces consumption 3 Unintended consequence is
to 5% stigmatization of people with lung
cancer increasing the disease burden
Tobacco Master Settlement Agreement
• Dollars go into general fund. Not being Large tax revenues and strong
used for original intent of tobacco lobbying stymie will to make tobacco
control illegal

http://www.surgeongeneral.gov/library/reports/50-years-of-progress/50-years-of-
Graphic CDC Anti-smoking Campaign
11/4/2014 progress-by-section.html
12
http://www.cdc.gov/tobacco/data_statistics/by_topic/policy/legislation/
Primary Prevention: States Have Failing Grades
for Most Tobacco Control Measures
Spending
Excise Taxes

Cessation
Smoke Free Air Laws

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

• 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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 National Screening Trial Results
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 The National Lung Screening Trial Research Team . N
20% Reduction in mortality with LDCT Engl J Med 2011;365:395-409.

11/4/2014 Low Dose Lung Cancer Screening 15

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

67.1 VS 33.2

20.5 VS 52.5

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
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-
11/4/2014 2013/Targeting-Tumors-Early-Trials-Push-Novel-Agents-to-Forefront/2 17
 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/
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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 smoking
portray smoking as lifestyle choice
Tobacco control policies de-normalized smoking and stigmatized smokers
smoking as environmental health issue (2nd hand smoke)
legislation of smoke free public areas and work places
portraying smoking as a personal choice leading to a horrible death
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Stuber J, Galea S, Link BG. Smoking and the emergence of a stigmatized social status. Social Science in Medicine. 2008;67(3):420–430.
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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 LUNG CANCER (LC) STIGMA CONCEPTUAL MODEL

Tobacco Control Policies Adverse LC patient impacts

Stigmatized smokers
Reduced LC Advocacy

Decreased Smoking Prevalence

Increased LC Stigma

Reduced LC Research

Reduced LC Incidence Low Survivability

Tobacco control policies effective at decreasing

smoking prevalence however stigmatized smokers
and people with lung cancer. Reduction in incidence of lung
cancer offset by low survivability due to stigma resulting in negatively
reinforcing loops of increased stigma, adverse patient impacts,
less advocacy and reduced research. Andrea Borondy Kitts April 2014
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 Public Health Policy Implications
Improve 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

Need CMS to cover LDCT

lung cancer screening.

Continuation of tobacco
control policies should add
lung cancer screening as a
teachable moment for smoking
cessation. Also, switch focus from
negative portrayal of smokers and
focus on tobacco and e-cigarette industry
actions targeting addiction & marketing to youths
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