Cancer is an individual and community tragedy, both physically and financially. More needs to be done. More can be done. Awareness is growing around the world. In the US, there are still large--and largely unaddressed--racial disparities that require immediate attention. The consequences of inaction are tragic for individuals and entire communities.

1. Don’t give up on cancer
January 2012
Richard M. Stein

2. Highlights – 5 points to remember
1. Cancer remains a major problem in the United States.
The problem is worse in the African American community.
2. Many cancers can be prevented or treated.
Knowing the facts—education—is important.
Eliminating high risk behavior matters.
Early access for screening, detection and treatment matters.
3. Right now, not enough is being done.
Budget reductions are cutting money for research, screening
programs and more…
4. This year, the President’s Cancer Panel addressed racial disparities
for the first time.
The Annual Report is a call to act, now.
5. Greater Philadelphia is a great place to start.
The region is rich in appropriate resources to make a difference.
NOW is the time to begin. Philadelphia should lead the way. 2

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4. Summary
Cancer remains a major problem in the United States.
It is a health tragedy and a financial nightmare.
MORE needs to be done to improve outcomes & survival.
More money for research and cancer control programs.
More outreach and greater education efforts to prevent some
cancers while detecting and treating others sooner.
More comprehensive cancer screening programs for at risk
communities and populations.
Surprisingly, right now, LESS is being done.
Budget reductions are cutting money for research, screening
programs, insurance coverage and more…
These “savings” today will raise public and personal costs in the
future…
NOW is the time to act. NOW is the time to get involved.
Inaction will make things worse.
Doing nothing will result in more cancer cases, more deaths,
and economic hardship for families, communities & the public. 4

5. In August 2009, I produced a report for the Economist Intelligence Unit on
the global burden of cancer, with co-authors from the Harvard School of
Public Health.
• The project was sponsored by LIVESTRONG (The Lance Armstrong
Foundation).
• It was released at LIVESTRONG’s first Global Cancer Summit, in Dublin,
Ireland.
• The project estimated:
• The number of new cancer cases (incidence) in 2009 and 2020.
• The costs (medical, non-medical and lost productivity) associated with those
new cases—the global economic burden of cancer—for 2009.
• It included important “firsts”:
• Estimates of the cost of applying the most “effective” cancer treatments on a
worldwide scale—a global treatment expenditure standard.
• Estimates of the spending “gap” between present day spending and what it
would cost to achieve the global treatment expenditure standard.
http://www.livestrong.org/What-We-Do/Our-Actions/Programs-Partnerships/LIVESTRONG-Summit
http://www.eiu.com/LAF 5

6. The project represented a major contribution to the global public health
community…
LIVESTRONG Global Cancer Summit;
Press conference; August 24, 2009.
http://www.livestrong.com/lance-armstrong/blog/summit-press-
briefing/
…raising awareness and focusing attention on the rapidly growing tidal
wave of cancers and their impact in the developing world…
6

7. The global burden of cancer—some facts:
Cancer is the second leading cause of death and
disability in the world.
More people die from cancer every year around the world,
than from AIDS, tuberculosis and malaria, combined.
Cancer deaths occur with 6 time the frequency of traffic
fatalities and 42 times the frequency of deaths from war.
More than 50% of new cancer cases and two-thirds of
cancer deaths occur in the developing world.
The overall risk of developing cancer during your
lifetime is rising—from 1:3 to 1:2.
Cancer is not just a health tragedy. It is a financial and
economic nightmare for individuals and communities…
7

8. Big Numbers—cancer costs real money
Total costs* of new cancer cases worldwide, 2009
Europe
Europe
US$ 83bn
US$ 8,742m Asia
Asia US$1,928m
US$44bn
Americas
Americas
US$154bn
US$17,221m Africa US$76m
Africa Oceania
US$849m US$461m
Oceania
US$4bn
Global economic burden of cancer in 2009= US$286bn
*Includes medical costs, non-medical costs and lost income (productivity). 8

9. The project attracted a lot of attention and helped focus resources for
tackling cancer in the most impoverished countries around the world…
“…5% of global resources for cancer are
spent in the developing world…” (p.9)
• 160,000+ search results (Google).
“Breakaway: The global burden of cancer”
• 906,000+ search results (Google).
Cited in formation of Global Task Force on
Expanded Access to Cancer Care and
Control in Developing Countries (GTF.CCC)
• Expansion of cancer care and control in
countries of low and middle income: a call to
action (Lancet; August 2010;
http://www.lancet.com/journals/lancet/article/PIIS0140-6736%2810%2961152-X/fulltext?version=printerFriendly ).
• GTF.CCC ( http://isites.harvard.edu/icb/icb.do?keyword=k69586&pageid=icb.page334798 )
9

10. That got me thinking…
What’s happening on the cancer front at home?...
...So I started to investigate…
10

11. What I discovered came as a surprise…
11

12. Sadly, changes—and action—abroad do not equate to
change at home
Change in US Death Rates*, 1991 to 2006
Cancer…
Remains the second leading cause of
death in the United States.
Accounts for nearly one-fourth of US
deaths annually.
Deaths increase each year, as the
population ages.
Number of US Cancer Deaths, 1930-2006 400 Rate Per 100,000
300,000
Men 313.0
300
250,000
Women
200,000 215.1
200.2
200 180.7
150,000
Down
Down
36% Down
100,000 100 31% Down
63.3
49%
16%
43.6 34.8
50,000 17.8
0
0 Heart diseases Cerebrovascular Influenza & Cancer
1930 1940 1950 1960 1970 1980 1990 2000 diseases pneumonia
*Age adjusted to 2000 US standard population.
Sources: US Mortality Data, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009. 12

13. The war on cancer began forty years ago, when President
Richard Nixon signed into law the National Cancer Act…
President Nixon signing
After adjusting for the size and age of the the National Cancer Act,
December 23, 1971.
population, deaths from heart disease and
stroke*, have dropped significantly since
the 1950s… …while cancer death rates
remain singularly stubborn.
US Cancer Death Rates* by Sex,
1975-2005
300 Rate Per 100,000 Men
250
Both Sexes
200
150 Women
100
50
0
1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005
13 *Age adjusted to 2000 US standard population.
Sources: US Mortality Data, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

14. Since the National Cancer Act became law (1971), the
federal government has spent over $105bn on the effort…
But…
Cancer remains the second leading cause of death in the United States.
Cancer causes as many deaths each year as the next five causes of death
combined:
US Mortality, 2007
Rank Cause of Death No. of Deaths % of all deaths
1. Heart Diseases 616,067 25.4
2. Cancer 562,875 23.2
3. Cerebrovascular diseases 135,952 5.6
4. Chronic lower respiratory
diseases 127,924 5.3
5. Accidents/unintentional injuries 123,706 5.1 533,596 22.0%
6. Alzheimer disease 74,632 3.1
7. Diabetes mellitus 71,382 2.9
Source: US Mortality Data, National Center for Health Statistics,
Centers for Disease Control and Prevention, 2010.
As it is around the world, cancer in the US is a financial and economic nightmare
as well as a health tragedy:
$143bn = cost* of new cancer cases in the United States, 2009
*Includes medical costs, non-medical costs and lost income (productivity). 14

15. And it’s not getting better quickly…
15

16. It’s worse for some groups than for others…
US Cancer Death Rates* by Race and Ethnicity, 2002-2006
16

17. …It’s particularly bad for African American men…
US Cancer Death Rates* by Sex and Race, 1975-2006
Cancer death rates are much higher for African American men than for white men.
Death rates for African American women are worse than for white women.
17

18. Cancer Sites in Men for Which African American Death Rates*
Exceed White Death Rates*, 2002-2006
18

19. Cancer Sites in Women for Which African American Death Rates*
Exceed White Death Rates*, 2002-2006
19

20. New cancer rates (incidence) are also worse for African Americans—
especially men—than for other groups…
US Cancer Incidence Rates* by Race and Ethnicity, 2001-2006
Rate Per 100,000
20

21. The outlook for new cancer cases (incidence) is not particularly
good—especially in African American men…
US Cancer Incidence Rates* by Sex and Race, 1975-2006
Rate Per 100,000
According to the President’s Cancer Panel 2009-2010 Annual Report:
Between 2010 and 2030, cancer incidence among minorities is expected to nearly double.
By comparison, cancer incidence in non-Hispanic whites is expected to grow by 31 percent.
21

22. If you are African American and contract cancer, that’s a problem…
Cancer Survival*(%) by Race, 1999-2005
22

23. A serious problem…
Cancer: 5-Year Relative Survival by Year of Diagnosis,
Race and Sex (All Sites, All Ages)
African American men and women fare worse than white
men and women, even after diagnosis, year after year.
African American men
Percent
African American women
30
White men
Cancer sites include invasive cases only. African American men
5-year survival estimates calculated using monthly intervals.
Survival source: National Cancer Institute, Surveillance White women
Epidemiology and End Results (SEER).
African American women
23

24. The bad news is that you have a large chance of developing cancer if you’re a man…
Lifetime Probability of Developing Cancer (Men), 2004-2006*
For men and women,
the overall risk of
developing cancer
during one’s lifetime
is increasing.
24

25. …or a woman…
Lifetime Probability of Developing Cancer (Women), 2004-2006*
For men and women,
the overall risk of
developing cancer
during one’s lifetime
is increasing.
25

26. As bad as it seems, there is a
lot that can be done to fight
cancer…
Community and individual actions
matter…
26

27. 3 important cancer control actions:
1. Prevention
1. Detection
1. Treatment
Half of the annual cancer deaths in the
United States are preventable (American
Cancer Society).
Several activities that you control, matter:
Don’t smoke—tobacco control
Eat right, lose weight and get active
Follow cancer screening guidelines
27

28. Each year, smoking causes about 443,000 premature deaths, including…
…171,000 cancer deaths…
… 49,000 deaths among nonsmokers (from secondhand smoke exposure)
Tobacco Use in the United States, 1900-2006
28

29. Tobacco use remains the single
largest preventable cause of
disease and premature death in
the United States…
29

30. Tobacco use increases the risk of cancers of the:
lung
mouth
nasal cavities
larynx
pharynx
esophagus
stomach
colorectum
liver
pancreas
kidney
bladder
cervix
ovary
myeloid leukemia…
…
30

31. Each year, smoking causes about 171,000 cancer deaths…
Annual Number of US Cancer Deaths Attributable to Smoking, 2000-2004
Male Female
31

32. …171,000 cancer deaths from smoking nationwide…
Cigarette Smoking Among Adults (18+) in Southeastern Pennsylvania
(Percentage of adults by county who smoke every day or some days)
17.1%
14.5%
27.3%
15.7%
19.2%
About 20,000 Pennsylvanians die each year, as a result of smoking.
In Pennsylvania, smoking related health costs were estimated at $5.19bn in 2004.
Source: 2008 Southeastern Pennsylvania Household Health Survey, Community Health Data Base, Public Health
Management Corporation; Centers for Disease Control and Prevention. 32

33. If you don’t smoke, you don’t have to quit…
Smokers and Quitters, 1985-2009
AFRICAN
AMERICAN
In Philadelphia, among high school students who smoked cigarettes, 38% did not try to quit during
the prior twelve months.
Funding for tobacco prevention and cessation in Pennsylvania declined from $50.5 million (‘02-’03)
to $14.7 million (‘10-’11)—nearly 71%.
Source: Centers for Disease Control and Prevention; 2009 Youth Risk Behavior Surveillance System Survey Data;
Commonwealth of Pennsylvania.
33

34. Each year, poor nutrition, obesity and physical inactivity cause
about 188,000 cancer deaths…
…Obesity is worse for African Americans than for other groups
Obesity in US Adolescents (12-19 years), by Gender, Race/Ethnicityt 1976-2008
34

35. …188,000 cancer deaths from poor nutrition, obesity and physical inactivity
nationwide…
Philadelphia: Children (6-17 years) who are Overweight* or Obese* (%), 2008
Citywide average (6-17 years) = 46.9%
*BMI>=85th percentile for age and gender.
Source: 2008 Southeastern Pennsylvania Household Health Survey, Community Health Data Base, Public Health Management
Corporation; Giridhar Mallya, MD, MSHP; Philadelphia Department of Public Health.
35

36. Each year, poor nutrition, obesity and physical inactivity cause
about 188,000 cancer deaths…
…It’s no better for African Americans adults…
Obesity* in US Adults (20-74 years), by Gender, Race/Ethnicityt, 1976-2008
36

37. Poor nutrition is also about access…
Food deserts are areas that lack access to affordable…foods that
make up the full range of a healthy diet.*
Philadelphia has the second lowest number of
supermarkets in the United States, per capita.
In this map of Philadelphia, blue areas represent
areas of greatest need, with low supermarket
sales, low income, and high rates of death due to
diet-related diseases.
Orange dots represent stores that have been
opened under the Pennsylvania Fresh Food
Financing Initiative (PFFFI).
Yellow dots represent stores financed by the
PFFFI program and under construction at the time
of mapping.
Source: Access to Affordable and Nutritious Food—Measuring and
Understanding Food Deserts and Their Consequences: Report to Congress;
US Department of Agriculture, Economic Research Service; June 2009
(http://www.ers.usda.gov/publications/ap/ap036/)
Figure provided courtesy of Robert Wood Johnson Foundation and The Food
Trust (http://www.rwjf.org/files/newsroom/profiles/foodtrust/)
*Centers for Disease Control and Prevention 37

38. Food deserts are not only short on the right resources…
…They are often full of the wrong resources…
Too few supermarkets (healthy choices) = poor food selection = overweight and obesity
Philadelphia: Children (6-17 years) who are
Philadelphia’s food desert
Overweight* or Obese* (%), 2008
Citywide average – 46.9%
Blue areas
represent
areas of
greatest
need, with
low
supermarket
sales, low
income, and
high rates of
death due to
diet-related
diseases.
Source: Access to Affordable and Nutritious Food—Measuring and
Understanding Food Deserts and Their Consequences: Report to Congress; *BMI>=85th percentile for age and gender.
US Department of Agriculture, Economic Research Service; June 2009 Source: 2008 Southeastern Pennsylvania Household Health Survey, Community Health Data
(http://www.ers.usda.gov/publications/ap/ap036/) Base, Public Health Management Corporation; Giridhar Mallya, MD, MSHP; Philadelphia
Figure provided courtesy of Robert Wood Johnson Foundation and The Food Department of Public Health; Centers for Disease Control and Prevention 2009 Youth Risk
Trust (http://www.rwjf.org/files/newsroom/profiles/foodtrust/) Behavior Surveillance System Survey Data.
38

39. …And the wrong resources lead to poor choices…
…and poor outcomes…
Since 2000, 24,000 Philadelphians have died of diseases caused by poor diet and physical inactivity.
Nearly 25% of children and 30% of adults get one
or fewer servings of fruits and vegetables per day.
Philadelphia: Children (6-17 years) who
are Overweight* or Obese* (%), 2008
Over 80% of high school students report getting less
than 100% of the recommended daily servings of
fruit and vegetables.
Nearly 25% of adults consume fast food/take-out
at least 3 times per week.
30% of African American adults consume fast food/
take-out at least 3 times per week.
1 in 3 high school students drink soda daily.
School children buy, on average, 360 nutrient-poor
calories from corner stores for just over $1 per visit:
—Chips, candy and sugar sweetened beverages. Citywide average – 46.9%
*BMI>=85th percentile for age and gender.
Source: 2008 Southeastern Pennsylvania Household Health Survey, Community Health Data Base, Public Health Management Corporation;
Giridhar Mallya, MD, MSHP; Philadelphia Department of Public Health;
Centers for Disease Control and Prevention 2009 Youth Risk Behavior Surveillance System Survey Data.
39

40. Poor choices…poor outcomes…188,000 cancer deaths in the United
States from poor nutrition, obesity and physical inactivity every year…
In Philadelphia, one-fourth of children do not get 30 minutes of
sustained physical activity even once a week.
Nearly half of the adults report exercising less than 3 times per
week.
Over half of Philadelphians report that they never use City parks
or recreation facilities.
Over half of the high school students report watching television 3
or more hours per day.
Over one-third of high school students report playing video games
or using computers for other than school work at least 3 hours per
day.
Source: 2008 Southeastern Pennsylvania Household Health Survey, Community Health Data Base, Public Health Management
Corporation; Giridhar Mallya, MD, MSHP; Philadelphia Department of Public Health;
Centers for Disease Control and Prevention 2009 Youth Risk Behavior Surveillance System Survey Data.
40

41. A lot can be done to fight cancer…
…What you do matters…
Don’t smoke—tobacco control
…Where you live matters, too…
=
School children buy, on average, 360 nutrient-poor calories from corner stores
for just over $1 per visit: chips, candy and sugar sweetened beverages.
Detection
Follow cancer screening guidelines
Treatment
…Detection and treatment are both easier with health
insurance coverage… 41

42. …where you live matters, too…
Percentage of Adults (18-64) Without Health Insurance,
Southeastern Pennsylvania
In Philadelphia, 16% of adults are without
public or private health insurance.
In Bucks and Delaware Counties, more
than 7% of adults are without health
insurance.
In Chester County, 6% of adults
have no health insurance.
In Montgomery County,
about 5% of adults have
no health insurance.
Source: 2008 Southeastern Pennsylvania Household Health Survey, Community Health Data Base, Public Health
Management Corporation 42

43. …where you live matters, too…
Percentage of Adults (18-64) Without Health Insurance
In Philadelphia, 16% of adults are without
public or private health insurance.
In Upper North Philadelphia, more
than one quarter (26%) of adults have
no health insurance.
In South Philadelphia, 21% of adults
have no health insurance.
Source: 2008 Southeastern Pennsylvania Household Health Survey, Community Health Data Base, Public Health Management
Corporation 43

44. …where you live matters, too…
Breast cancer: In Pennsylvania, the rate of mammography and/or
clinical breast exam is nearly 50% lower among women 40 and older
with no usual source of medical care and/or no health insurance.
Nationwide, it is also 50% lower.
Cervical cancer: In Pennsylvania, the rate of Pap test is nearly one-
third lower among women 40 and older with no usual source of
medical care and/or no health insurance. Nationwide, it is nearly one-
quarter lower than in Pennsylvania.
Colorectal cancer: In Pennsylvania, the rate of endoscopy is nearly
50% lower among adults 50 and older with no usual source of medical
care and/or no health insurance. Nationwide, it is nearly 75% lower
than in Pennsylvania.
Source: Cancer Prevention & Early Detection Facts & Figures 2010; American Cancer Society.
44

45. Conclusion: Key Takeaways
Cancer is a worldwide problem.
The growing tidal wave of new cancer cases (and their
impact) has attracted attention from the global public
health community.
Cancer remains a big problem in the United States.
It is worse for the African American community than
almost every other ethnic group.
Individuals Individuals can do a lot to prevent
cancer and reduce cancer risk...BUT…
…there remains a large need for public—
government and community group—intervention:
—$$$
—Policy / law
—Education
NOW is the time to act!!! 45

46. These people have declared war on
cancer around the world…
Paul Farmer, MD; Founding Director, Partners in Health; Harvard Medical School
Julio Frenk, MD; Dean, Harvard School of Public Health
Felicia M. Knaul, PhD; Director, Harvard Global Equity Initiative
Lawrence N. Schulman, MD; Chief Medical Officer and Senior Vice President, Dana-Farber Cancer Institute
Sir George Alleyne, MD; Director Emeritus, Pan American Health Organization
Lance Armstrong; 7-time champion, Tour de France; Founder and Chairman, LIVESTRONG / Lance Armstrong Foundation
Prof. Rifat Atun; Director, Strategy, Performance & Evaluation, Global Fund to Fight AIDS, Tuberculosis and Malaria
Douglas Blayney, MD; Medical Director, Stanford Cancer Center; Immediate Past President, American Society of Clinical
Oncology
Lincoln Chen, MD; President, China Medical Board
Prof. Sir Richard Feachem; Executive Director, UCSF Global Health Sciences; Professor of Global Health, University of
California, San Francisco and University of California, Berkeley
Mary Gospodarowicz, MD; Professor, University of Toronto, Princess Margaret Hospital; President-elect, Union for
International Cancer Control (UICC)
Julie Gralow, MD; Seattle Cancer Care Alliance; Fred Hutchinson Cancer Research Center, University of Washington
Sanjay Gupta, MD; Chief Medical Correspondent, CNN
Ana Langer, MD; Coordinator of the Dean’s Special Initiative in Women and Health, Harvard School of Public Health
Julian Lob-levyt, MD; Chief Executive Officer, Global Alliance for Vaccine and Immunization (GAVI)
Claire Neale, MPH; Senior Director for Mission, LIVESTRONG / Lance Armstrong Foundation
Anthony Mbewu, MD; former Executive Director, Global Forum for Health Research; past President, Medical Research
Council of South Africa
HRH Princess Dina Mired; Director General, King Hussein Cancer Foundation; Honorary Co-President, Harvard Global Task
Force for Expanded Access to Cancer Control and Care in the Developing World
Peter Piot, MD; Director, London School of Hygiene & Tropical Medicine; founding Executive Director, UNAIDS
K. Srinath Reddy, MD; President, Public Health Foundation of India
Prof. Jeffrey Sachs, PhD; Director, Earth Institute, Columbia University
Mahmoud Sarhan, MD; Chief Executive Officer and Director General, King Hussein Cancer Center 46
John R. Seffrin, PhD; Chief Executive Officer, American Cancer Society

47. …Focus on tackling cancer in the most impoverished countries
around the world… “…5% of global resources for cancer are spent in the developing
world…” (p.9)
• 160,000+ search results (Google).
“Breakaway: The global burden of cancer”
• 906,000+ search results (Google).
Global Task Force on Expanded Access to Cancer Care and
Control in Developing Countries (GTF.CCC)
• Expansion of cancer care and control in countries of low and middle
income: a call to action (Lancet; August 2010).
• GTF.CCC
…While at home…
The American Lung Association gave
Pennsylvania an “F” for tobacco prevention
control and for cessation efforts in 2010.
The Pennsylvania Auditor General reports that $1.34 billion was
diverted from uses originally intended by the Tobacco
Settlement Act of 2001.
• More than 41,000 residents lost state-subsidized health insurance
coverage, as a result.
“racial disparities in cancer outcomes”
• 220,000 search results (Google).
47

48. What are we going to
do about it at home?

49. Don’t give up on cancer
Richard M. Stein

50. up on cancer
Don’t give
n
chard M. Stei
Ri
50