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Measuring Progress in Cancer Control: A Bird’s Eye View

^a Department of Population Health Sciences and ^b Cancer Epidemiology Program, University of Wisconsin Comprehensive Cancer Center, Madison, Wisconsin, USA

Correspondence: Patrick L. Remington, M.D., MPH, Department of Population Health Sciences, University of Wisconsin Comprehensive Cancer Center, 610 North Walnut Street, Room 760, Madison, Wisconsin 53726, USA. Telephone: 608-263-1745; Fax: 608-262-6404; e-mail: plreming{at}wisc.edu

On Dec. 23, l971, President Richard M. Nixon declared war on cancer when he signed into law bold legislation that mobilized the country’s resources to fight cancer. The National Cancer Act infused enough dollars and authority into the National Cancer Institute to make the "conquest of cancer a national crusade" [1]. The 30 years of investment in cancer research that followed produced an impressive record of scientific discovery and spawned a nationwide network of trained oncologists. New discoveries have provided exceptional progress on some fronts, but on others progress has been minimal, or we have even lost ground [2].

Measuring progress in our efforts to win the war on cancer may be difficult from the ‘bird’s eye view’ of the treating oncologist. Population-level changes in cancer incidence or mortality rates may not be reflected in—or recognizable from—an individual clinic. Physicians may not be able to determine whether cancer therapies are increasing patient survival, or whether patients simply know that they have cancer longer. And finally, as treatments become more aggressive, physicians and patients must weigh potential gains in survival with potential decreases in quality of life.

In this issue of The Oncologist, Ries and colleagues from the Surveillance Research Program at the National Cancer Institute report an updated assessment of recent trends in cancer [3]. This assessment provides, for the practicing oncologist, a profile of today’s cancer patient population, information on survival probabilities, and an assessment of progress in controlling cancer.

The authors first provide information on the incidence and age distribution at diagnosis, and the lifetime probability of developing cancer is presented for most major cancer sites. This overview will be helpful to oncologists and health care organizations when planning future cancer care services. For example, 58% of cancer diagnosed during 1996–2000 was among persons over the age of 65. This is likely to increase over time, due to the aging U.S. population. Also, the median age of cancer patients for many sites will likely increase as the "baby boomers" approach their mid- and late-60s.

Second, Ries et al. present 5-year survival rates in several forms: overall relative survival, stage- and site-specific relative survival, observed survival, and conditional survival assuming 1, 2, and 3 years of life after diagnosis. This latter information is unique and valuable for oncologists who council newly diagnosed patients and who are involved with surveillance of patients for the months and years following diagnosis. These survival rates may be especially encouraging for patients whose initial prognosis may be discouraging, since 5-year survival improves substantially among those who have successfully survived 1–3 years after diagnosis.

The stage-specific survival rates are also helpful, but should be interpreted with caution. Because breast, prostate, and colorectal cancer are commonly diagnosed through screening tests, survival rates for these tumors are susceptible to the effects of lead-time bias (diagnosis may be advanced but death may not be delayed) and length bias (slow-growing tumors are more likely to be detected than fast-growing tumors). These effects may lengthen apparent survival time without providing benefit to the patient.

The final contribution of the paper relates to the assessment of progress in the war on cancer. Mortality rates for the major types of cancer are declining in all race groups—except lung cancer among women. Although these trends are encouraging, measuring progress to reduce the burden of cancer is a complex task [4, 5]. Progress in reducing the overall burden of cancer can be summarized as follows:

• Risk factor prevalence (e.g., tobacco use)—minimal progress. Tobacco use remains the single most important cause of cancer in the U.S. Although progress in reducing smoking among men has led to recent declines in lung cancer incidence, lung cancer mortality continues to increase among women.
  
• Incidence—difficult to interpret. Recent trends in overall cancer incidence are hard to interpret given the impact of screening on the incidences of prostate, breast, and colon cancers (due to lead-time bias and the overdiagnosis of tumors).
  
• Survival—difficult to interpret. Overall cancer survival rates are increasing, but it is not clear how much of this increase results from true improvements in survival, rather than apparent increases in survival—a result of detecting cancers earlier and lead-time and length-time biases.
  
• Mortality—some progress. Cancer mortality rates have declined about 10%–15% since 1990, resulting in about 64,000 fewer deaths than expected [2]. However, these declines are minimal compared with the remarkable progress in reducing deaths from heart disease and stroke.
  

Today, in the presence of new threats to our health and safety, we may be less inclined to use battle language to characterize our fight against cancer. Yet we are challenged to work harder toward the elimination of cancer as a cause of death [6]. Clearly, the primary goal in cancer control is to prevent cancer from occurring in the first place, primarily by reducing smoking rates in the population. But if we fail at prevention, advances in early detection and treatment may someday change cancer into a manageable chronic—but not fatal—disease.

	REFERENCES

Top References

 

1. National Institutes of Health. The 1971 National Cancer Act: investment in the future. http://www.nih.gov/news/pr/mar97/nci-26c.htm. Released March 26, 1997. Accessed October 12, 2003.
2. Andersen LD, Remington P, Trentham-Dietz A et al. Assessing a decade of progress in cancer control. The Oncologist 2002;7:200–204.[Abstract/Free Full Text]
3. Reis LA, Reichman ME, Lewis DR et al. Cancer survival and incidence from the Surveillance, Epidemiology, and End Results (SEER) program. The Oncologist 2003;8:541–552.[Abstract/Free Full Text]
4. Weir HK, Thun MJ, Hankey BF et al. Annual report to the nation on the status of cancer, 1975–2000, featuring the uses of surveillance data for cancer prevention and control. J Natl Cancer Inst 2003;95:1276–1299.[Abstract/Free Full Text]
5. National Cancer Institute. Annual report to the nation on the status of cancer, 1975–2000—featuring the uses of surveillance data for cancer prevention and control. http://seer.cancer.gov/report_to_nation/1975_2000/. Accessed October 12, 2003.
6. Miller M. 2015: a target date for eliminating suffering and death due to cancer [Interview with NCI director Andrew C. von Eschenbach]. May 16, 2003. http://www.cancer.gov/benchmarks/archives/2003_04_public/feature_article.html Accessed October 12, 2003.

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