Cancer Statistics

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Cancer Statistics

• Ray M. Merrill, PhD, MPH
• Department of Health Science
• Brigham Young University

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Did you know?

• In the United States
• 1 in 3 people will develop cancer in their
  lifetime
• 1 in 8 women will develop breast cancer in their
  lifetime
• 1 in 6 men will develop prostate cancer in their
  lifetime
• Over 1,400,000 people will be diagnosed with
  cancer this year
• Over 550,000 people will die from cancer this
  year
• In Utah
• Approximately 5,600 people will be diagnosed with
  cancer this year
• Approximately 2,500 people will die from cancer
  this year
• Overall, cancer rates are 15-20 percent below the
  national average
• Lung cancer rates in Utah are less than half the
  national average

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These and other statements regarding cancer are
made possible byStatistics Obtained through
Cancer Surveillance

• The systematic collection, analysis,
  interpretation and dissemination of information
  on cancer
• Timely and effective use of such information
  important in the war against cancer

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Fifteen Leading Causes of Death, US, 2004
Percent () of Total Deaths
Rank
Cause of Death
Number of Deaths
Death Rate
Rates are per 100,000 population and
age-adjusted to the 2000 US standard population.
Source US Mortality Public Use Data Tape, 2004,
National Center for Health Statistics, Centers
for Disease Control and Prevention, 2006.
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United States 2007

• From Jemal, A. et al. CA Cancer J Clin
  20075743-66.

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United States 2007Rates age-adjusted to the U.S.
2000 population
From Jemal, A. et al. CA Cancer J Clin
20075743-66.
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United StatesRates age-adjusted to the U.S. 2000
population
From Jemal, A. et al. CA Cancer J Clin
20075743-66.
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Prostate CancerRisk Factors

• Age
• Race
• Diet
• Male Hormones
• Environmental Exposures
• A Vasectomy, BPH, STD
• Family History of Prostate Cancer

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Prostate cancer LDS to nonLDS rate ratios for
Utah Males, 1985-1999 Poisson regression
Adjusted for age, stage, year, TURP- vs.
nonTURP-detected

• 1.31 (95 CI 1.26 1.36)
• 1.13 (1.01 1.27) Ages 50-59
• 1.48 (1.38 1.58) Ages 60-69
• 1.28 (1.21 1.36) Ages 70-79
• 1.16 (1.04 1.28) Ages 80
• 1.36 (1.31 1.43) Local/regional stage
• 0.97 (0.84 1.11) Distant stage
• 1.17 (1.04 1.31) Unstaged
• Source BMC Cancer 2003314.

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Percentage of men receiving a PSA test in the
past yearAges 50 years and older

• 50-59 60-69 70 50
• _______________________________________________
• LDS 55.8 71.2 71.6 65.3
• NonLDS 52.9 62.7 65.1 58.3
• _______________________________________________
• Source BMC Cancer 2003314.

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United States, MalesRates age-adjusted to the
U.S. 2000 population
From Jemal, A. et al. CA Cancer J Clin
20075743-66
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United States, FemalesRates age-adjusted to the
U.S. 2000 population
From Jemal, A. et al. CA Cancer J Clin
20075743-66
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United States Rates age-adjusted to the U.S.
2000 population
From Jemal, A. et al. CA Cancer J Clin
20075743-66
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What is cancer?

• Cancer is a collective name that refers to a
  group of many diseases with one common
  characteristic uncontrolled cell growth or loss
  of the cell's ability to perform apoptosis (cell
  suicide).

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What is cancer?

• Normal controls that govern the process of cell
  growth and death become altered
• Gradual increase in the number of uncontrolled
  dividing cells
• Mass of tissue occurs called a tumor (also
  called a neoplasm)

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Different Kinds of Cancer

• Carcinomas
• Most common types of cancer
• Arise from the cells that cover external and
  internal body surfaces Lung, breast, prostate,
  and colon are the most frequent cancers of this
  type in the United States
• Sarcomas
• Arise from cells found in the supporting tissues
  of the body such as bone, cartilage, fat,
  connective tissue, and muscle
• Lymphomas
• Arise in the lymph nodes and tissues of the
  body's immune system
• Leukemias
• Cancers of the immature blood cells that grow in
  the bone marrow and tend to accumulate in large
  numbers in the bloodstream

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Loss of Normal Growth Control

• In normal tissues, the rates of new cell growth
  and old cell death are kept in balance
• In cancer, this balance is disrupted
• This disruption can result from uncontrolled cell
  growth or loss of a cell's ability to undergo
  "apoptosis."
• Apoptosis, or "cell suicide," is the mechanism by
  which old or damaged cells normally self-destruct.

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Normal balance between cell division and cell
loss is disrupted
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Cancer spreads by two mechanisms
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Why Cancer Is Potentially Dangerous

• A malignant tumor, a "cancer," is a more serious
  health problem than a benign tumor because cancer
  cells can spread to distant parts of the body.

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Cancer Detection and Diagnosis

• Early detection affects the outcome of the cancer
• When cancer is found (type and how fast it is
  growing)
• Invasion
• Metastasized

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Early Cancer May Not Have AnySymptoms

• Screening methods are designed to check for
  cancer in people with no symptoms. Some examples
  of screening methods are
• Pap Test
• Mammograms
• Blood Tests (PSA)
• Fecal Occult Blood Test (FOBT)

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Diagnose the presence of cancer

• Screening tests indicate the possible existence
  of cancer, a doctor must then perform a biopsy
• For leukemias, a small blood sample serves the
  same purpose
• Microscopic examination will tell the doctor
  whether a tumor is actually present and, if so,
  whether it is malignant (i.e., cancer) or benign.

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Microscopic Appearance of Cancer Cells
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CIS - Cancer confined to cells in which it
originated and has not spread to other tissues
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Tumor Grading

• Microscopic examination also provides information
  regarding the likely behavior of a tumor and its
  responsiveness to treatment.
• A low number grade (grade I or II) refers to
  cancers with fewer cell abnormalities than those
  with higher numbers (grade III, IV).

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Tumor Staging

• Based on the answers to the following questions,
  the cancer is assigned a "stage."
• 1. How large is the tumor, and how far has it
  invaded into surrounding tissues?
• 2. Have cancer cells spread to regional lymph
  nodes?
• 3. Has the cancer spread (metastasized) to other
  regions of the body?

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Tumor grade and stage are related to cancer
survival
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What Causes Cancer?
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Heredity? Behaviors? Other Factors?

• In theory, differences in heredity or
  environmental risk factors might be responsible
  for the different cancer rates observed in
  different countries.

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Tobacco Use and Cancer

• Cigarette smoking linked with cancer of the
• lung
• Mouth
• Larynx
• Esophagus
• Stomach
• Pancreas
• Kidney
• Bladder
• Cervix
• Current estimates suggest that smoking cigarettes
  is responsible for at least one out of every
  three cancer deaths.

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Tobacco smoking prevalence () in Utah and U.S.
adult populations, 18 years of age and older, by
selected years 1965-2000

• Year Utah United States Year Utah United States
• 1965 NA 42.4 1991 14.3 25.7
• 1966 NA 42.6 1992 15.6 26.5
• 1970 NA 37.4 1993 14.4 25.0
• 1974 NA 37.1 1994 15.7 25.5
• 1980 NA 33.2 1995 13.2 24.7
• 1978 NA 34.1 1996 15.9 23.4
• 1979 NA 33.5 1997 13.8 23.2
• 1983 NA 32.1 1998 14.2 22.9
• 1985 15.6 30.1 2000 12.9 23.2
• 1986 18.2 NA 2001 13.2 22.9
• 1987 15.0 28.8 2002 12.8 23.1
• 1988 14.7 28.1 2003 11.9 22.0
• 1989 16.4 NA 2004 10.5 20.8
• 1990 16.7 25.5 2005 11.5 20.5
• Data source Behavior Risk Factor Surveillance
  System.

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Smoking-Related CancersRelative Risks

• Ex-smoker Current Smoker
• Lip Oropharangyeal 1.76 4.55
• Oesophageal 1.79 4.01
• Stomach 1.11 1.41
• Anal 1.83 3.18
• Pancreatic 1.15 3.18
• Laryngeal 2.86 7.48
• Lung 6.75 M 13.0 M
• 5.07 W 11.4 F
• Cervix 1.31 1.75
• Vulvar 1.37 3.42
• Penile 1.6 1.8
• Bladder 1.7 2.7
• Renal Parenchymal 1.61 1.64
• Renal Pelvic 1.95 3.96
• Source Single et al., Am J Public Health
  199989385-390.

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Smoking and NonSmoking-Related CancersUtah
MalesAge-adjusted cancer incidence rates by sex,
1995-1999(LDS standard population)
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Smoking and NonSmoking-Related CancersUtah
FemalesAge-adjusted cancer incidence rates by
sex, 1995-1999(LDS standard population)
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Low-Strength Radiation

• Some atoms give off radiation, which is energy
  that travels through space. Prolonged or repeated
  exposure to certain types of radiation can cause
  cancer.

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High-Strength Radiation

• X-rays or radiation emitted from unstable atoms
  called radioisotopes
• Stronger than ultraviolet radiation
• Can penetrate through clothing and skin and into
  the body
• High-strength radiation can cause cancers of
  internal body tissues

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Viruses

• A few viruses also can trigger the development of
  cancer
• Cannot reproduce on their own
• Viruses are small infectious agents
• Enter into living cells and cause the infected
  cell to produce more copies of the virus
• Causes the cell to become malignant

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Examples of Human Cancer Viruses
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Bacteria and Stomach Cancer

• The bacterium H. pylori, which can cause stomach
  ulcers, has been associated with the development
  of stomach cancer

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Heredity and Cancer

• Cancer is not considered an inherited illness
  since 80 to 90 percent occur in people with no
  family history of the disease
• E.g., only about 5 percent of breast cancers are
  thought to be due to inheritance of particular
  form(s) of a "breast cancer susceptibility gene."

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Breast cancer risk factors

• Reproductive
• Age at first birth
• Number of births (parity)
• Lifetime duration of breastfeeding
• Non-reproductive
• Alcohol drinking
• Exogenous hormones
• Heavy body weight
• Diet
• Environmental factors (exposures to pesticides,
  radiation)

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Mean age at first birth among parous LDS vs.
nonLDS women in Utah

• LDS NonLDS None
• RA LRA RA LRA
• Age at first birth 23.4 21.4 22.9 22.9 23.7
• Age at first birth 24.1 23.4 25.0 24.5 26.1
• (excluding teen births)
• RA religiously active (attend church weekly)
• LRA less religiously active
• Sample size 848
• Source Preventive Medicine 20043828-38.

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Mean pregnancies/parityAdjusted for age,
education, income, smoking, and alcohol drinking

• Average P value Average P value
• Pregnancies (20 wks) Parity
• Active LDS 4.5 (SE.12) 3.9 (.09)
• Less active LDS 3.4 (.22) lt .0001 2.9
  (.16) lt .0001
• Active nonLDS 3.2 (.29) lt .0001 2.8
  (.22) lt .0001
• Less active nonLDS 3.2 (.25) lt .0001 2.7
  (.20) lt .0001
• No Religion 3.0 (.29) lt .0001 2.5 (.22)
  lt .0001
• Note P values comparing each category to active
  LDS
• Source Preventive Medicine 20043828-38.

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Mean breastfeedingAdjusted for age, education,
income, smoking, and alcohol drinking

• Average P value Average P
  value
• Total years Months/child
• Active LDS 2.05 (SE.12) 7.89 (.34)
• Less active LDS 1.18 (.22) .0013 6.52
  (.70) .0947
• Active nonLDS 1.34 (.30) .0367 7.87 (.92)
  .9688
• Less active nonLDS 0.83 (.27) .0002 6.19
  (.69) .0997
• No Religion 0.70 (.30) lt .0001 5.53 (1.01)
  .0342
• No significant difference in months/child.
• Note P values comparing each category to active
  LDS.
• Source Preventive Medicine 20043828-38.

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Breast cancer incidence rates white women in Utah
(by LDS status) and SEER (without Utah) by year
of diagnosis
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Heredity Can Affect Many Types of Cancer
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Genes and Cancer

• Genes are altered, or "mutated," in various ways
  as part of the mechanism by which cancer arises
• Chemicals and radiation act by damaging genes
• Viruses introduce their own genes into cells
• Heredity passes on alterations in genes that make
  a person more susceptible to cancer

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Gene Mutations and Cancer

• Some cancer-causing mutations are simply
  spontaneous errors that appear in normal DNA
  molecules when cells duplicate their DNA prior to
  cell division

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Gene Mutations and Cancer

• The mutations that contribute to the development
  of cancer affect three general classes of gene
• Oncogenes
• Tumor suppressor genes
• DNA repair genes

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So when does cancer occur?

• When the accumulation of mutations occur
  involving oncogenes, tumor suppressor genes, and
  DNA repair genes

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Cancer Risk and Aging
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Cancer Tends to Involve Multiple Mutations

• The formation of cancer usually requires multiple
  mutations, with the chance increasing for
  mutations to accumulate and cancer to develop
  with more years of life (Doll Peto, 1981).

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Summary of What Causes CancerSource CDC
Sexual Factors
Alcohol Overuse
Environmental Occupational Factors
Tobacco Use
Other Factors
Diet Physical Activity
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Cancer Prevention

• Many of the behaviors or exposures linked to
  cancer can be prevented

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Ways to prevent cancer

• Maintain a healthy weight
• Eat no more than two or three servings of red
  meat per week
• Take a multivitamin with folate every day
• Drink less than one alcoholic drink a day
• Eat five or more servings of fruits and
  vegetables per day
• Eat more high fiber foods such as whole grains,
  wheat cereals, bread, and pasta
• Include cruciferous vegetables in your diet (such
  as broccoli, cabbage, etc.)
• Do not smoke
• Protect yourself from the sun
• Avoid certain workplace exposures
• Protect yourself and your partner(s) from
  sexually transmitted infections and
• Exercise regularly.

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Is There a Cancer "Epidemic"?

• A person's chance of developing cancer within his
  or her lifetime is almost twice as great today as
  it was a half century ago
• Age-adjusted rates say No
• Much of the rise prior to that was due to
  cigarette smoking, a well established and
  avoidable cause of cancer

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Common Cancer Statistics

• Ratios
• Risk Ratio, Rate Ratio, Odds Ratio
• Proportions
• Prevalence Proportion
• A proportion with the added dimension of time
• Cumulative Incidence (Risk)
• Incidence Density (Rate)
• Mortality Rate
• Note that proportions are typically multiplied by
  10n, where n2, 3, 4, or 5, in order to express
  the statistic per 10n.
• Other statistics
• Age-conditional Risk, Years of Potential Life
  Lost, Survival

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2 by 2 table
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Cumulative Incidence (Risk)Cohort Study

• What is the risk of lung cancer?
• It(ac)/n
• What is the risk of lung cancer among those who
  smoke?
• Ie a/(ab)
• What is the risk of lung cancer among those who
  do not smoke?
• Io c/(cd)
• What is the risk ratio (also called relative
  risk)?
• Risk Ratio Ie/Io

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Risk RatioCohort Study

• Suppose the Risk Ratio 13
• Interpret?
• Smokers are 13 times more likely to develop lung
  cancer than non smokers.

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Attributable Risk PercentCohort Study

• AR (Ie-Io)/Ie x 100 (RR-1)/RR x 100
• If RR 13 then AR (13-1)/13 x 100 92
• Interpret?
• Of lung cancer patients who smoke, 92 of those
  cases are attributed to their smoking.

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AR Example

• Data from Doll and Hill cohort study, 1951-61
• Lung cancer death per 1000
• 0.07 for nonsmokers ---
• 0.57 for 1-14 cigarettes per day 8.1
• 1.39 for 15-24 cigarettes per day 19.9
• 2.27 for 25 cigarettes per day 32.4
• AR (0.57-0.07)/0.57 x 100 87.7
• AR (1.39-0.07)/1.39 x 100 95.0
• AR (2.27-0.07)/2.27 x 100 96.9

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Population Attributable Risk PercentCohort Study

• PAR (It-Io)/It x 100

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PAR ExamplesLung Cancer and CHD

• Lung cancer risk
• It 60 per 100,000
• Ie 180 per 100,000 for smokers
• Io 20 per 100,000 for nonsmokers
• PAR (60 20)/60 x 100 66.7
• Coronary heart disease risk
• It 240 per 100,000
• Ie 420 per 100,000 for smokers
• Io 180 per 100,000 for nonsmokers
• PAR (240 180)/240 x 100 25
• Interpret? If smoking were eliminated, we would
  expect almost a 67 decrease in lung cancer and a
  25 decrease in CHD.

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Expected of cancer cases that could be avoided
in Utah if everyone had the same risk profile as
LDS

• Males Females
• Smoking Related 13.7 21.9
• Nonsmoking Related -0.1 5.3
• Total cancer 2.9 7.9
• Lung Bronchus 25.7 30.2
• Prostate -3.4
• Breast 4.8

Source Ann Epidemiol 2003 Nov13(10)704-11.
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Odds RatioCase-Control Studies

• Suppose the Odds Ratio looking at the
  relationship between smoking and lung cancer is
  18
• Interpret?
• The Odds Ratio approximates the Risk Ratio when
  the disease is rare (affecting less than 10 of
  the population)

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Incidence Density RateCohort Study with
Person-YearsModified 2 by 2 Table
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Rate Ratio
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Prevalence Proportion

• All existing cases at a point in time
• Some estimates for 2003
• Ratio
• Female Breast - 2,356,795 (211,300 new cases)
  11.1
• Prostate 1,937,798 (220,900 new cases) 8.8
• Lung 354,989 (171,900 new cases) 2.1
• Sources NCI and CA Cancer J Clin 2003 535-26
  

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Now Consider the Following
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Age-conditional Risk of Developing Invasive
Cancers Within Selected Age Intervals, by Sex, US

• Birth to 39 ()
• 1.42 (1 in 70) - Males
• 2.03 (1 in 49) - Females
• 40 to 59 ()
• 8.69 (1 in 12) - Males
• 9.09 (1 in 11) - Females
• 60-69 ()
• 16.58 (1 in 6) - Males
• 10.57 (1 in 9) - Females
• 70 and Older ()
• 39.44 (1 in 3) - Males
• 26.60 (1 in 4) - Females
• Birth to Death ()
• 45.31 (1 in 2) - Males
• 37.86 (1 in 3) - Females

Source CA Cancer J Clin 2007 5743-66
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Years of Potential Life Lost

• Quantify premature mortality
• A measure of public health related to the value
  of human life and the economic implications of
  the loss of individuals in a society
• Improvements in life expectancy can cause the
  increase in an available work force which, in
  turn, benefits society by increased productivity

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YPLL through age 89 due to Lung cancerLDS vs.
Non-LDS in Utah, 1994-1998

• LDS Men Non-LDS Men
• 5,743 6,244
• (154 per 100,000) (473 per 100,000)
• LDS Women Non-LDS Women
• 2,497 3,867
• (65 per 100,000) (306 per 100,000)

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Cancer Survival

• A measure of the lethality of disease
• Relative survival
• A net survival measure representing cancer
  survival in the absence of other causes of death.
  
• Defined as the ratio of the proportion of
  observed survivors in a cohort of cancer patients
  to the proportion of expected survivors in a
  comparable set of cancer free individuals.

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Source Ries LAG, Harkins D, Krapcho M, et al.,
eds. SEER Cancer Statistics Review, 19752003,
National Cancer Institute, based on November 2005
SEER data submission, posted to the SEER Web
site, 2006.
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Source Ries LAG, Harkins D, Krapcho M, et al.,
eds. SEER Cancer Statistics Review, 19752003,
National Cancer Institute, based on November 2005
SEER data submission, posted to the SEER Web
site, 2006.
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Source Ries LAG, Harkins D, Krapcho M, et al.,
eds. SEER Cancer Statistics Review, 19752003,
National Cancer Institute, based on November 2005
SEER data submission, posted to the SEER Web
site, 2006.
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Contact Information

• Ray M. Merrill, PhD, MPH
• Professor
• Brigham Young University
• Department of Health Science
• 229-A Richards Building
• Provo, Utah 84604
• Ray_Merrill_at_byu.edu
• 801-422-9788 (work)
• 801-422-0273 (fax)