Tobacco Documents Online

TRENDS IN! CANCER INCIDENCE' AND MIORTEYLITI*. IN THE UNITED STATES SUBCO.'SM2TTEE ON H'.EAI.TH' AND SCIENTIFIC RESEARCH

Hr. Chairman,and members of the Committee, I'have three things to say ~ you today. First,, I wiLli telll you some news that is not so good: cancer incid'ence,is still' increasing, and'the inereases are not,all accounted' for by cigarette smoking nor by the increased detection of breast cancerr resulting from the fears:which sent so many women to their doctors late . in 1974' and'early 1975, following Mrs.: Ford"s:and,Mrs. RockefeliLer"s surgery. 8econd„ I wi1L tel& you where things are,getting, better -- how cancer mortality is going d'nwn in younger (younger s 1'ess:than 45 or, 50 years old) persons, and I will try to tell you why we think this has . come about. Finally, I will tell you about some:progress we have made in both treatment and, prevention, and a~out our prospects for the future. ,In this regard,, I would like to consider where our research, efforts ought be taking us, I will try, in the course of'giving you the data on these tables and' charts,,to also tell you some of the things that concern me,,and that have not yet appeared!in the statistics. , Before I proceed,, I think,a word or two about the comparison of incidence and!mortaLity data may be in order. Incidence means new disease and'is the best measure of causation. A decline in incidence:may tell us that prevention measures are,succeeding,. Hortality reflects both,incidence and treatment. I wiLl'al'so show some survival'data, which indicate the . degree of success we,have achieved in detection and treatment. There are some forms of cancer for which incidence has gone up but where mortality has not. Whilie thi's says something about the success of',earlier diagnosis V7

Page 2' and improved treatment, it also tells us to look harder for the causess chart that I wi11 show. Additional charts and'tables are includ'ed.to. Attached' to my statement is a small repr.oduction,of each table or and'„ if we succeed' in identifying them,,try to eliminate them, help answer specific questions you may have. The data concerning d'eath,from cancer were provided by the National Center for Health Statistics. Mrs. Rice, the Director for VCliS, is here y tod'ay and I wish, to express my thanks to her staff„particul arly Dr. Jack Feld.aan and,Dr. Harry Hosenberg,for reviewing all this material'. The incidence d'ata come from the National Cancer Instiiute"s SEER Program (Surveillance,, Epidemiology and End,Resuits)' and is based,on roughly a 10'pereent sample of,the United! States population. I will try to make clear to you where there are solid data,about cancer and'where my remarks Cancer incidence (Table 11) and'mortality have continued to increase $owever„ the increases in older people have overwhellined' the decreases in the 1970"s,,incidence somewhat more rapidly than mortality - probably reflecting,, in, part, improvements in treatment andi earlier d'iagnosis. Even when the smoking-related, lung,cancers are removed from the incidence' data, there were still increases in incidence from 1969 through 1976, the year of our most recent complete data. Fbr, white mea the rate of increase was about 1'/2' perpent a year, and for white,women, nearer 1 pertent'a year.. mortality over-all is increasing (Figure 1)', so that it is the only major cause of death, which has continued' to rise from 19'00 through 1976. But among,the younger people so that when we look at the total' d ata,, cancer recently thils rate of increase has begun to deci'ine. . 3~1'

Page 3 There are some important decreases in, cancer incid'ence and' mortality, too -- especially in younger persons -- people under age 45 (Figure 2; Table 2 ' The decreases have come about, in, part', through reduced incidence of breast cancer in younger women„ lung cancer in younger men, and the chiUdhood leukemias and Hodgkin"s d'isease. The mortali'ty data, also reflect , substantial improvements in treatment for the childhood leukemias and 19odglain` disease. The,survi'va1 rates for these two diseases have improved' significantl since the early 1!950's (Figures 3 & 4; Tables 3& 4). some of which (in addition to the ones mentioned' earlier) are decreasing,. I would' now like to.discuss in more detail trend's inn some of the more prevalent forms of cancer.. ,. (These data~are summarized on,Tables 5-7)'. ~ . . Cancer is not one disease. It is'many diseases,,some of whi'ch,are Mbst,, but not all, of the increased incidence of lung cancer is dhe to cigarette smoking. Today, approximately 85'percent of the deaths 1'ung, cancer are attributable to smoking. Ilf we subtract the lung, deaths related to cig;arette smokimg,,, total! cancer mortality has been declining overall (Figures 5 & 6; Table 8). It has been,steady for men and literally d'ecreasing,for women, whereas you will recall that the incid'ence, - of cancer, even when correcting for smoking-related 1'ung,cancer, is continuing to rise for all groups (Table 1)'. When the data are broken down by age and' sex, (Figures 7=10,, Table 9 the trends are qui'te interesting andlwe see that even the lung,cancer - picture is not,without some signs of improvement.: Both the incidence and mortality rates for lung,cancer in men are leveling off or perhaps even decreasing, up to age 65. This may be due in part,,to, the lowered smoking,

rates among, older men,, and, possibly to the lower tars and nicotine in modern cigarettes. I hope that it also reflects improvements in , the work environ:nent. E. C Eowever,, this is not true for women. In fact, we see some very discouraging, things when we look at the smoking-related cancers in women. Not only is lung cancer going upy. but cancer of the larynnx,,, esophagus, and' bl!adder as well. At one time there were 10' deaths among, men fromi larynx cancer for eachl death among women. In about 15 years this has dropped 7' to 1. In most countries of the world,, the male excess is greater, reaching 30 or 40, to one as in Switzerland d and France. Cancer in several other sites continues to, increase, both in incidencs and mortality (Figure 11; Tables 5, 6, 7, & 10). Breast cancer mortality is~~ down s~i~gnific~~antly~ in~ younger women (~Figur~es~ 12' &~~ 13; Tables 11 & 12), due primarily to improved treatment and detection. women over age 50, the mortality rate continues to increase, a reflection of the fact that the incidence of breast cancer (Table 13) is still rising, in all g,roups, with the exception o f' what appears to be a slightly lowered incidence in white women under age 45. Mortality rates of cancer of the colon, bladder and pancreas, as. ~ well as melanoma are increasing (Figure 1I!; Table 10!) . While there now seems to be a leveiing, off of pancreatic cancer in men, the incidence :.t of' the remainder of these cancers (Tables 51 & 6) continues to go up for 4?37323a9 reasons which we cannot yet describe. Epidemiological studies are now underway to, determine if there i& ai connection between occupational,

dietary,,..or environmental exposures to carcinogens. (including ionizing, ' '~ radiation) and these and other cancers of increasing, incidence. However, definitive data are not yet at hand. In contrast,, there are other relatively common cancers that, have been decreasing in mortality (Figure 14, Table 14) - including cancer of the stomach, cervix, uterus and rectean. We really don't know arhy .. r. these cancers are decreasing. The incidence of stomach cancer is perhaps going down because of dietary changes, such'as the increase in the consumption of fresh or froaen fruits and vegetablles.- B'ut,' this ~k is a tenuous concl'usion. Current research in nutrition is examining the relationship between diet and' the various types of cancer. Because of the better, early diagnosis through Fap smears, the . ,,,.. , reduced' number of 'cervixes throughhysterectomy,, and possibly better - personal hygiene,, both the, incidence of and' mortality due to cancer the cervix ~~ have~~ declined sharply. There are no good explanations at hand' for the decrease cancer. Is it a problem of definition of where the rectum end's and the colon begins? The incidence of colon cancer is increasing. There are different trends for men and women. _. The period of time which a cancer patient lives, or is free of' new cancer, after the initial diagnosis of' cancer is a useful indicator -off the success of treatment. Trends in survival indicate whether or not we are making progress in treating a particular type of cancer. There have been small gains in survival in several', of the cancers, as shiown in. 0373231Q - Table a but these gains are not yet reflected in the total mortality

. page6 statistics. The "'survival"' chart (Figure 15; Table 15) is d'ivided' into two parts (to refl'ect the earlier charts) -one part showing cancers of increasing incidence and one part showing cancers of decreasing incidecice'.`` We needmost to make gains in the treatment of those diseases that are increasing in incidence and where only small gains have been made in reported to be rising rapidly (despite increased hysterectomies), one special case is worth mentioning: cancer of the endometrium ('the lining, of the uterus) . This is a, disease in which incidence was survival. a rise which has been Linked' to the use of post-menopausal estrogens. the sales of these materials declined and the reported 'incidence of this publicity, and coincident with FDA requiring warning package inserts, Publicity was given to this link through Congressional hearings and' publication in the professional literature. Within the year of this There are other important clues, to, w&ere we should look that will that is, a long time span between the, first exposure and the cliinical appearance of the disease. very short time, even, though~ cancer in general has a long latent period' results of interfering with the action of a promoter can be seen in a and for basic research in cancer induction, telling us that estrogens very likely are 1ate-stage carcinogens or "promoters", and that the This has important iTnplicaCions for both direct cancer prevention disease also declined (Figure 16,; Table 16). us to inquire about those industries that are in the same areas where help us find other causes of cancer. The maps in this room have led there are high cancer rates --chemical, petroleuwn refining,, shipbuild'in

Fage a IKortality and incidence rates for men are higher forr almost all sites. This cannot all be due to the fact that males are the weaker sex. Nor, . as I remarked eari'i'er,,, can all of lung,cancer be,accounted, for by cigarette smoking. vation we must look,eTsewhere, particularly at industrial exposures which smoke are smoking lower tar cig,arettes. Thus, to account for this obser- In fact, in recent years less is probably due to smoking, than in : the past because fewer older men are smoking and those who continue to lung cancer, even though on the average they appear to smoke less. Nor do we know why they have more cancer of the esophagus or less bladder genetie. ~Ww'e do not know why black men have more prostate cancer or more, SimiQarTy,, the differences between blacks and' whites cannot be all would be much more likeiy to affect men. cancer than white men, but they d'n,, and investigations are underway to will soon see a turn d'ownward' in breast cancer mortality„ particularly lhere are some encouraging prospects are the liorizon. We think we try to find out why. in younger women, as the new multipYe,therapies are introduced' into We also think our gains in lung cancer survival are ready to grow .,know when these effects can be expected to be reflected in the national into larger gains with several encouraging,treatments at hand. We don't mortaLiLy statistirs. 30 or so years, probably). Pf we had perfect treatment, prevention: If we had perfect prevention, we,would not need treatment (after

Page 8' would be much less important., It is obvious that we have neither perfect prevention nor perfect treatment and' that we must work on~both. The gains we have made in both prevention and' treatment encourage us to believe that bi, gains are possible for both. . byrgovernment of carcinogens in the environment, the workplace and'in what we eat and, drink. 1h-aly effective prevention of cancer may mean There i's more to the prevention of'cancer than the,regulation . a that people will have to change the way they live, what they eat, dzink,, smoke, and' perhaps even their sex lives. These are hard, but not impossible, things to change. rWith the problems that,many people see ' I o uncover why some people and families appear to be more susceptible than in iinplementing prevention, and',the problems still other observers see in,improving,treatment, it is essential that we turn toward basic.research others, why cells change from normal to malignant„ and' what we can find in celTs that have begun the progression toward'cancer,, so that we can interfere with thi~s progression. The answers to all of these need to come, and we think they will come, from basic research.3 Thus,,the program of the NCI has three major, pieces to it - research,to'find'causes so that preventive action can: take place;, answer your questions, prevent cancer. - This concludes my testimony. Eoth:lfrs. Rice and I will be happy to o take,,or where treatment will not be able to make up for ourr failures the cancer process when, we see that some preventive actions will,be hard' research to improve treatment; and' research to find'other ways to untrack,

TABLE 1 TRENDS IN CANCER INCIDENCE: WHITES 1!969-1'976 RAT!ES' PER', 100~,000 AGE STANDARDIZED TOTAL CANCERS'- AND TOTALS LESS SPECIFIC CANCERS' WRITE MALES " 1L857GLC* Total T-852'LC* -Stomach 34'6.6 341.7 337.2 271._9' 268.6 270.91 285. 9 305.0 1 301.5 ; 1976 295.2 Annual Change (+ 1%) 286.61 271.2 282.9 268.8 277.7 264.3 292.8 279.1 . . 301.8 288.7 298.5 285.9 297.8 285.9' ('-t-0,4x)1• (+0. 7x) WHITE FEMALES ; 260.9 • .257.1 258', 5 271.8 ' 289: 0 284.1 276.9 (+0.8Y.) T 801CLC* -Stomach -Cprvrix 237.8 235.6 • 237.9 ' ~ 251. 3' 2'71. 7. LTnusual'ly high ~ breast cancer. 268',0 incidence •260'.9 (+1.2X). *LC = Lung cancers. Approxiimately 85% of lung,cancer in men and',80X in women is attributable to cigarette smoking,_ a