Alberta Taking the Lead: The Cancer Legacy Project

1
Alberta Taking the LeadThe Cancer Legacy Project

• Update on Progress, February 2007
• Dr. Heather Bryant, ACB

2
The Targets by 2025

• Reduce the incidence of cancer by 35
• Reduce the mortality from cancer by 50
• Reduce suffering to Albertans diagnosed with
  cancer.

3
(No Transcript)
4
Are Cancer Projections Accurate?

predicted data after 1992
2003 data
5
Figure 4 All Causes of Death in Alberta, Ages
3564, 2002
6
Life at Cancer Risk New Cancer Case Results
Region of Risk
Region of Reward
New Cancer Cases expected to rise 55.5 over the
next 20years (2004-2023) as compared to the
previous 20years (1984-2003)
The essence of human action is the management
towards regions of reward and away from regions
of risk. Cancer control action Maximizing the
reduction of cancer impact possibilities,
Minimizing the increase of cancer impact
possibilities, Under constraints.
7
Potential Role of Prevention and Screening

• One way to the 2025 goals

8
Causes of Cancer Deaths
SourceCancer Causes Control, Volume 7,
November 1996
9
Clustering of Chronic Disease Determinants

• Behaviours Biologic Markers
  Preventable Conditions
•  
• Diet Obesity Ischemic Heart Disease
•  
• Physical Activity High Blood Pressure
  Stroke
•  
• Smoking Disordered Lipids Chronic
  Lung Disease
•  
• Alcohol Misuse Poor Glucose Tolerance
  Several cancers (breast,
• colorectal, lung)

10
So Why Has Prevention Been Underemphasized?

• Not as much immediate social pressure for
  preventive activity
• Lifestyle change can result in victim blaming
• Delayed benefits for ultimate goals (prevention
  of chronic disease, mortality, costs)
• Little energy put into measuring intermediate
  goals (behaviour change, or such benefits as
  reduced absenteeism)

11
Prevention Myth

• There is more delay in results from
  prevention interventions than research for a
  cure.
• Truth
• 5 years (for promotive factors)
• 20 years (for inducers, e.g., tobacco)
• To show major population-based changes in
  mortality often takes the same time as to get
  from basic science findings through clinical
  trial phases through assessment through guideline
  development and implementation through impact on
  mortality.
• Both are investments in the future
• Both hold hope for the future

12
Specific cancer interventions

• While many preventive strategies result in
  multiple gains, there is specific potential in
  some of the major cancers
• Lung
• Colorectal
• Breast

13
Figure 1 New Invasive Cancers by Site, Alberta,
2003
14
Figure 2 Cancer Deaths by Site, Alberta, 2003
15
Lung cancer

• Lung Cancer

16
Age-Standardized Incidence Rates (ASIR) and New
Cases for Males of Invasive Lung Cancer Alberta
(1988 2001)
17
Age-Standardized Incidence Rates (ASIR) and New
Cases for Females of Invasive Lung Cancer
Alberta (1988 2001)
18
(No Transcript)
19
Percentage () of Current Smokers Alberta Trends
T total number of people estimated in Alberta
20
Tobacco Reduction

• California introduced a comprehensive tobacco
  control program in 1988 that stressed clean
  indoor air and policies to create smoke-free
  environments
• This program was more intensive than in other
  states, and included multi-faceted interventions

21
California and USA Adult Per Capita Cigarette
Consumption, Packs Per Fiscal Year, 1980/1981 -
2000/2001
22
Tobacco Goals- General

• Encourage smokers to quit
• Prevent non-smokers from starting
• Advocate for tobacco reduction policies (i.e.
  Smoke-Free Spaces)
• Shift overall attitudes about tobacco use

23
Percentage () of Current Smokers Alberta Trends
by Health Region
24
Source Doll R et al. Mortality in relation to
smoking 50 years observation on male British
doctors. British Medical Journal, 2004 328
1519-.
25
Source Doll R et al. Mortality in relation to
smoking 50 years observation on male British
doctors. British Medical Journal, 2004 328
1519-.
26
Source Doll R et al. Mortality in relation to
smoking 50 years observation on male British
doctors. British Medical Journal, 2004 328
1519-.
27
Smoking Cessation Impact?

• If doctors used known brief intervention tools to
  assist in cessation, we think they could help
  about 2.7 of the people they counsel to actually
  quit
• Is this any help at all?

28
Population Impact of Cessation

• There are about 600,000 smokers in Alberta
• 85 of them see their doctors in a year
• If doctors approached 5 of their smokers to
  quit, and had a 2.7 success rate, 700 people
  would quit (averting 175 to 300 tobacco-related
  deaths)
• If doctors approached 60 of their smokers to
  quit, and had a 2.7 success rate, 8400 would
  quit (averting 2100 to 4200 tobacco-related
  deaths)
• This could be part of a significant policy-based
  strategy

29
Colorectal Cancer

• Screening and Prevention

30
Colorectal Cancer Reduction

• There is room for both primary prevention and
  screening
• Both strategies could have impact on both
  incidence and mortality

31
Colon cancer mortality, female
32
Colon cancer, females, world
Colon cancer mortality, male
33
Male
Female
Number of deaths for invasive colorectal cancer
and age-standardized mortality rates in Alberta
(1987 2003)
34
Male
Female
New cases of invasive colorectal cancer and
age-standardized incidence rates in Alberta
(1987 2003)
35
Randomized Controlled Trials of FOBT for
Colorectal Cancer Screening

36
Population Coverage

• 2006 National Healthcare Quality Report (U.S.)
• the use of proven prevention strategies lags
  significantly behind other gains in health care
• Only about 52 of adults reported receiving
  recommended colorectal cancer screenings
• NAACCR Washington Report, Jan 19, 2007

37
Uptake in Canada

• Recommendations have existed for colorectal
  screening as part of the periodic health
  examination since 2001
• Recommendations have existed for provincial
  colorectal screening programs in Canada since
  2002
• Estimates of current screening rates in target
  population in Alberta 15 to 25

38
Goals of colorectal screening program

• Program goals include high participation, high
  quality, cost-effectiveness.
• But the point of the exercise is to reduce
  incidence and mortality as quickly as possible.
• Cervical cancer screening, without programs, took
  a long time to maximize benefits

39
Cervical cancer incidence and mortality, Canada,
1950 - 1995
40
Is Screening Likely to Prevent Colorectal Cancer?

• Most data exists for secondary prevention.
• Mandels study about 27,000 people (most aged
  50-80) 1975 to 1978 and randomly assigned to
  annual FOBT, biennial FOBT, or usual care.
• Results published in NEJM in 2000 showed a
  reduction of 17 to 20 in colorectal cancer in
  the screened groups.

41
Colorectal Cancer Primary Prevention

• The most effective ways of preventing
• colorectal cancer are
• consumption of diets high in vegetables
• regular physical activity
• low consumption of red and processed
• meat
• - World Cancer Research Fund, 1997

42
Colorectal Cancer Possible Nutritional Risk
Factors

• High body mass
• Greater adult height
• Frequent eating
• Sugar
• Total fat
• Saturated / animal fat
• Processed or heavily cooked meat

43
How Much Colon Canceris Preventable? Design

• Platz et al (Cancer Causes and Control, 2000)
  included data on about 48,000 men aged 40 -75 in
  1986, and followed until 1996.
• Assigned risk factor scores for 6 modifiable
  factors obesity, physical activity, alcohol
  consumption, early adult smoking, red meat
  consumption, low intake of folic acid from
  supplements.
• Developed total risk scores from 6 (lowest) to 30
  (highest).

44
How Much Colon Canceris Preventable? Results

• if habits of high risk group quintile were
  changed to be the same as the as the lowest
  quintile of men, the reduction in colorectal
  cancer in the population would be 39
• if all men had the lowest scores possible (only
  3.1 of men in this study had that low a score),
  71 of colorectal cancer could be prevented

45
However, lets admit

• Obesity has increased markedly in past 30 years
  in North America despite social undesirability
  and knowledge of its risks
• Physical activity at a level sufficient to
  prevent specific chronic diseases is still
  engaged in by a minority of the population
• We need to translate knowledge into population
  behaviour change this is also a key area for
  innovation

46
Breast Cancer

• Successes to date

47
Age-Standardized Mortality Rates (ASMR) and
Deaths for Females of Invasive Breast Cancer
Alberta (1988 2003)
48
The Target by 2025

• Reduce the incidence of cancer by 35
• Reduce the mortality from cancer by 50
• Reduce suffering to Albertans diagnosed with
  cancer.

49
The Art of Prevention

• The Cancer Prevention Program is building a
  foundation of evidence-based practice through the
  collaboration of research expertise, program
  expertise and a dedicated surveillance unit. This
  predated the Legacy Fund, and the core will be
  funded by ACF/ACB, not the fund.
• This collaborative approach to reducing the
  incidence of cancer and other chronic diseases,
  will be achieved through four dedicated program
  areas
• Tobacco Control
• Obesity Prevention
• Carcinogens
• Special Populations

50
Cancer Screening

• All screening mammography data will now come to
  the ABCSP database
• Plan rollout of the rest of cervical screening
  program next fiscal year
• Plan inauguration of colorectal screening next
  fiscal year
• Some developmental aspects have been proposed to
  be allocated to Legacy Funding, and activities
  are underway in this regard

51
The Cancer Prevention Legacy

• How will it move us forward faster?

52
Vision

• Vision without action is a dream.
• Action without vision is a nightmare.
• -Japanese proverb

53
Key components

• Core programming will be part of regular
  activities
• Areas to drive the 2025/Legacy projects include
• Enhanced surveillance of risk factors and
  environment
• Asset mapping
• Population Innovation Projects (to be described)

54
Since Ultimate Benefits Are Deferred

• need to measure agreed upon intermediate
  milestones
• measuring milestones is a part of quality
  indicators

55
Some steps taken to date - surveillance

• Assessment of available sources of risk data in
  Alberta
• Further analysis on CCHS/NPHS data
• Preparation of report on regional risk factors
• Conversations with COMOSH group on surveillance
• Resulted, for example, in looking at data in
  regional patterns other than RHA-based patterns

56
(No Transcript)
57
Further steps -- surveillance

• Doing needs assessment and learning assessment of
  potential interviewing lab to allow for baseline
  improvement and evaluation of future
  interventions
• Developing GIS capability within the ACB
  surveillance group
• Enhanced enrolment to Tomorrow Project underway
  expect 30000 enrolees (up from 18000) by mid-2007

58
(No Transcript)
59
Linking to other chronic diseases

• Have had discussions with groups that have
  interest in diabetes, cardiovascular, and
  osteoarthritis databases
• Offer has been to have them add questions to risk
  factor surveys and/or have access to risk factor
  data to link with their chronic disease databases
  to enhance their etiologic work
• Also have discussed an LOI (Letter of Interest)
  process for assistance in establishing ongoing
  databases Alberta Advisory Committee will advise
  on adjudication of this

60
Who is the Alberta Advisory Committee?

• Members
• AADAC
• Alberta Health and Wellness
• Council of CEOs
• Canadian Diabetes Association
• Heart and Stroke Foundation
• Members at Large
• Ms. Janice Blair, Vice President, Community
  Health, Palliser Region
• Dr. Gerry Predy, MOH, Capital Health Region
• Dr. Kim Raine, Director and Professor, Centre for
  Health Promotion Studies, University of Alberta
• Dr. David Strong, Deputy MOH, Calgary Health
  Region

61
Alberta Healthy Living Network

• The AHLN is a group representing over 100
  multi-sectoral local, regional and provincial
  organizations and government departments with
  over 300 members
• Many chronic disease initiatives are and will be
  vetted through this group to allow partnerships
  to develop, and to ensure broad community advice

62
Asset Mapping

• Has been nearly completed for the Tobacco Area
• Anticipate working with Alberta Healthy Living
  Network Partners for other areas (physical
  activity, nutrition, carcinogens/environmental)

63
The Challenge True Innovation and a True Legacy
in Implementation

• Have developed a model of potential development
  of innovative population based strategies, and
  the testing thereof (approved by Alberta Advisory
  Committee)
• Principles
• To reach the cancer incidence reduction goals
  ASAP
• To incorporate measurement of benefit and
  messaging with other chronic disease groups
• To allow testing of evidence-driven but
  potentially high-risk interventions at a
  population level
• To allow for early identification of success,
  with subsequent recommendations for practice
• To allow for early identification of failure, so
  we can move on without further investment

64
How will we arrive at priorities?

• Working with stakeholders and local experts, and
  international resources, will
• identify background population risks
• existing programs and resources
• evidence based strategies for implementation
• potential strategies for testing

65
Priorities next step

• Those priorities ready for implementation will be
  worked on with advice of Alberta Advisory Group
  and potential involvement of members of Alberta
  Healthy Living Network
• In consultation with experts and stakeholders,
  PHI staff will lead in development of business
  cases for possible strategies not yet ready for
  wide implementation for consideration for
  population testing

66
Priorities decisions

• International advisory panel will consider
  business cases and advise on final
  prioritization, with goal being the most rapid
  progress to cancer incidence reduction

67
International Advisory Panel

• Now assembled with very high-profile individuals,
  and a balance of research/population practice
  experience
• First meeting to take place in spring/summer

68
Who is the International Advisory Committee?

• Dr. David Hill, Director, Victoria Cancer Control
  Council, Australia
• Dr. Don Iverson, Dean, Faculty of Health and
  Behavioural Sciences, Wollongong, Australia
• Dr. Jon Kerner, Deputy Director Prevention,
  National Cancer Institute, USA
• Julietta Patnick, Director of National Cancer
  Screening, UK
• Dr. John Potter, Director, Public Health Sciences
  Division, Fred Hutchison Cancer Research Center,
  Seattle
• Dr. Sally Vernon, University of Texas at Houston,
  School of Public Health

69
Examples of test interventions

• What is the best type of fecal screening test to
  use in Alberta (FIT or FOBT)? Which has the best
  participation, and best results profile in the
  Alberta environment?
• Will incentivization programs be effective in
  enhancing weight loss? If we develop partnership
  programs in one or two RHAs that would provide
  incentives for access to specific weight loss
  programs, will we see high uptake? Actual weight
  loss? A population impact?
• Can we adapt the Harvard cancer assessment tool
  into one that provides local data, but also
  provides links and referrals to appropriate
  intervention resources? Through this line, can we
  collect more information on participants to
  evaluate both the program, and health behaviours
  of a wider range of Albertans?

70
Test intervention implementation

• May be done through ACB staff or contractors, or
  done through any of a number of stakeholders
  (RHAs, NGOs, etc)
• Decisions on best implementation strategy will be
  made with advice from Alberta Advisory Committee
• Surveillance and evaluation of all test
  interventions will be done by ACB
• Results will be considered by Alberta and
  International advisory panels

71
Outcomes of test interventions

• If clearly successful, will recommend fan-out
  throughout the province
• If clearly unsuccessful, will recommend cessation
  of funding to that intervention
• If possibly successful under some conditions,
  could be added to toolbox

72
The Research Legacy

• Currently will be developing ACRI, Alberta Cancer
  Research Institute
• The Tomorrow Project will have a role in both
  surveillance (in order to drive programs) and
  research the expectation is that ongoing
  surveillance will be part of ACF/Legacy(?) Funds,
  but new research questions will be put forward
  for peer reviewed proposals through ACB and other
  agencies

73
The Target by 2025

• Reduce the incidence of cancer by 35
• Reduce the mortality from cancer by 50
• Reduce suffering to Albertans diagnosed with
  cancer.

74
Vision

• Vision without a task is only a dream.
• A task without vision is drudgery.
• But vision with a task is a dream fulfilled.