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Don’t give up on cancer March 2014 Richard M. Stein


Highlights – 5 points to remember 1.

Cancer remains a major problem in the United States. 9 The problem is worse in the African American community.

2.

Many cancers can be prevented or treated. 9 Knowing the facts—education—is important. 9 Eliminating high risk behavior matters. 9 Early access for screening, detection and treatment matters.

3.

Right now, not enough is being done. 9 Budget reductions are cutting money for research, screening programs and more…

4.

The President’s Cancer Panel addressed racial disparities for the first time only recently. 9 The Annual Report is a call to act, now.

5.

Greater Philadelphia is a great place to start. 9 The region is rich in appropriate resources to make a difference. 9 NOW is the time to begin. Philadelphia should lead the way. 2


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o d o t d e e n e w , r e . Togeth s r e w s n a d n i f o t g n i h t some Note: While some of the data in this presentation has not been updated, the key points remain unchanged (March 2014).

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Summary 9 Cancer remains a major problem in the United States. 9 It is a health tragedy and a financial nightmare. 9 MORE needs to be done to improve outcomes & survival. 9 More money for research and cancer control programs. 9 More outreach and greater education efforts to prevent some cancers while detecting and treating others sooner. 9 More comprehensive cancer screening programs for at risk communities and populations. 9 Surprisingly, right now, LESS is being done. 9 Budget reductions are cutting money for research, screening programs, insurance coverage and more… 9 These “savings” today will raise public and personal costs in the future… 9 NOW is the time to act. NOW is the time to get involved. 9 Inaction will make things worse. 9 Doing nothing will result in more cancer cases, more deaths, and economic hardship for families, communities & the public.

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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 project estimated: • •

It was released at LIVESTRONG’s first Global Cancer Summit, in Dublin, Ireland.

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

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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


The global burden of cancer—some facts: 9 Cancer is the second leading cause of death and disability in the world. 9 More people die from cancer every year around the world, than from AIDS, tuberculosis and malaria, combined. 9 Cancer deaths occur with 6 time the frequency of traffic fatalities and 42 times the frequency of deaths from war. 9 More than 50% of new cancer cases and two-thirds of cancer deaths occur in the developing world. 9 The overall risk of developing cancer during your lifetime is rising—from 1:3 to 1:2. 9 Cancer is not just a health tragedy. It is a financial and economic nightmare for individuals and communities… 7


Big Numbers—cancer costs real money Total costs* of new cancer cases worldwide, 2009

Europe Europe US$ 83bn US$ 8,742m Americas Americas US$154bn US$17,221m

Africa US$76m Africa US$849m

Asia Asia US$1,928m US$44bn

Oceania US$461m Oceania US$4bn

Global economic burden of cancer in 2009= US$286bn *Includes medical costs, non-medical costs and lost income (productivity).

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The project attracted a lot of attention and helped focus resources for tackling cancer in the most impoverished countries around the world… 9 “…5% of global resources for cancer are spent in the developing world…” (p.9) •

160,000+ search results (Google).

9 “Breakaway: The global burden of cancer” •

906,000+ search results (Google).

9 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

).

)

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That got me thinking… What’s happening on the cancer front at home?...

...So I started to investigate…

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What I discovered came as a surprise‌

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Sadly, changes—and action—abroad do not equate to change at home Change in US Death Rates*, 1991 to 2006

Cancer… 9 Remains the second leading cause of death in the United States. 9 Accounts for nearly one-fourth of US deaths annually. 9 Deaths increase each year, as the population ages. Number of US Cancer Deaths, 1930-2006

Rate Per 100,000

400

300,000

313.0

Men

300

250,000

Women 200,000

200 150,000

100

100,000

215.1

200.2

180.7

Down 36%

Down 31% 63.3

43.6

Down 49% 34.8

50,000

Down 16%

17.8

0 0 1930

1940

1950

1960

1970

1980

1990

2000

Heart diseases

Cerebrovascular diseases

Influenza & pneumonia

Cancer

*Age adjusted to 2000 US standard population. Sources: US Mortality Data, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

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The war on cancer began over forty years ago, when President Richard Nixon signed into law the National Cancer Act… President Nixon signing the National Cancer Act, December 23, 1971.

After adjusting for the size and age of the 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

Women

150

100

50

0 1975

13

1978

1981

1984

1987

1990

1993

*Age adjusted to 2000 US standard population. Sources: US Mortality Data, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

1996

1999

2002

2005


Since the National Cancer Act became law (1971), the federal government has spent over $105bn on the effort‌ But‌ 9 Cancer remains the second leading cause of death in the United States. 9 Cancer causes as many deaths each year as the next five causes of death combined: US Mortality, 2007 Rank 1.

Cause of Death Heart Diseases

No. of Deaths 616,067

2.

Cancer

3. 4.

Cerebrovascular diseases 135,952 Chronic lower respiratory diseases 127,924 Accidents/unintentional injuries 123,706 Alzheimer disease 74,632 Diabetes mellitus 71,382

5. 6. 7.

562,875

% of all deaths 25.4 23.2 5.6 5.3 5.1

533,596

22.0%

3.1 2.9

Source: US Mortality Data, National Center for Health Statistics, Centers for Disease Control and Prevention, 2010.

9 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).

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And it’s not getting better quickly…

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

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…It’s particularly bad for African American men… US Cancer Death Rates* by Sex and Race, 1975-2006

9Cancer death rates are much higher for African American men than for white men. 9Death rates for African American women are worse than for white women.

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

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

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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

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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: 9Between 2010 and 2030, cancer incidence among minorities is expected to nearly double. 9By comparison, cancer incidence in non-Hispanic whites is expected to grow by 31 percent.

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

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A serious problem‌ Cancer: 5-Year Relative Survival by Year of Diagnosis, Race and Sex (All Sites, All Ages) 9African American men and women fare worse than white men and women, even after diagnosis, year after year.

Percent

African American men

African American women

30

White men Cancer sites include invasive cases only. 5-year survival estimates calculated using monthly intervals. Survival source: National Cancer Institute, Surveillance Epidemiology and End Results (SEER).

African American men White women African American women

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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*

9For men and women, the overall risk of developing cancer during one’s lifetime is increasing.

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…or a woman… Lifetime Probability of Developing Cancer (Women), 2004-2006*

9For men and women, the overall risk of developing cancer during one’s lifetime is increasing.

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As bad as it seems, there is a lot that can be done to fight cancer‌

Community and individual actions matter‌ 26


9 3 important cancer control actions: 1. Prevention 1. Detection 1. Treatment

9 Half of the annual cancer deaths in the United States are preventable (American Cancer Society). 9 Several activities that you control, matter: 9 Don’t smoke—tobacco control 9 Eat right, lose weight and get active 9 Follow cancer screening guidelines 27


Community and individual actions matter…

…And we’re not doing enough…

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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

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Tobacco use remains the single largest preventable cause of premature death in the United States… •Update: January 11, 2014 marked the 50th anniversary of the first Surgeon General’s Report on Smoking and Health. Over 20 million Americans have died because of smoking since the first report, in 1964. At current rates, 5.6 million Americans alive today & younger than 18, will die prematurely from smoking-related diseases. Smoking causes one out of three cancer deaths, 87 percent of lung cancer deaths, 32 percent of coronary heart disease deaths and 79 percent of chronic obstructive pulmonary disease (COPD) in the United States. Women’s disease risks from smoking have risen over the past 50 years— now = men’s risks for lung cancer, cardiovascular disease and COPD (with more women dying from COPD than men)!

Economic costs attributable to smoking and exposure to tobacco smoke now approach $300 billion annually!! 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…

… Smoking also causes diabetes mellitus; rheumatoid arthritis; increased risk for tuberculosis; ectopic pregnancy; cleft lip and cleft palate in babies born to smokers; age-related macular degeneration and much more… 31


Each year, smoking causes over 171,000 cancer deaths. Smokers today are at greater risk of developing lung cancer than in 1964‌ Annual Number of US Cancer Deaths Attributable to Smoking, 2000-2004

Male

Female

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‌ over 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%

15.7%

27.3% 19.2%

9About 20,000 Pennsylvanians die each year, as a result of smoking. 9 Almost 6,400 Pennsylvanians die each year from lung cancer. 9In Pennsylvania, economic costs of smoking are estimated at $9.4 bn. 9 This includes $5.2 bn in health costs and $4.2 bn in lost productivity. Source: 2008 Southeastern Pennsylvania Household Health Survey, Community Health Data Base, Public Health Management Corporation; Centers for Disease Control and Prevention; American Lung Association; Campaign for Tobacco-Free Kids.

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42 million adults plus 3 million middle & high school students smoke.

If you don’t smoke, you don’t have to quit! Smokers and Quitters, 1985-2009 AFRICAN AMERICAN

9In Philadelphia, among high school students who smoked cigarettes, 38% did not try to quit during the prior twelve months. 9Funding for tobacco prevention and cessation in Pennsylvania declined from $50.5 million (‘02-’03) to $14.2 million (‘12-’13)—nearly 72%. 9

This is just 9.1% of the CDC recommended spending.

Source: Centers for Disease Control and Prevention; 2009 Youth Risk Behavior Surveillance System Survey Data; Commonwealth of Pennsylvania; American Lung Association; Campaign for Tobacco-Free Kids.

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Axis of Evil Obesity now creates more preventable illness and disease than tobacco. Current trends suggest it will become the single largest preventable cause of deaths in the future‌

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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

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‌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.

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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

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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.* 9Philadelphia has the second lowest number of supermarkets in the United States, per capita. 9In 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. 9Orange dots represent stores that have been opened under the Pennsylvania Fresh Food Financing Initiative (PFFFI). 9Yellow 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

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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 Overweight* or Obese* (%), 2008

Philadelphia’s food desert

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; 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/)

*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.

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…And the wrong resources lead to poor choices… …And poor outcomes… 9Since 2000, over 24,000 Philadelphians have died of diseases caused by poor diet and physical inactivity. 9Nearly 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

9Over 80% of high school students report getting less than 100% of the recommended daily servings of fruit and vegetables. 9Nearly 25% of adults consume fast food/take-out at least 3 times per week. 930% of African American adults consume fast food/ take-out at least 3 times per week. 91 in 3 high school students drink soda daily. 9School 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.

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Poor choices…poor outcomes…188,000 cancer deaths in the United States from poor nutrition, obesity and physical inactivity every year… 9In Philadelphia, one-fourth of children do not get 30 minutes of sustained physical activity even once a week. 9Nearly half of the adults report exercising less than 3 times per week. 9Over half of Philadelphians report that they never use City parks or recreation facilities. 9Over half of the high school students report watching television 3 or more hours per day. 9Over 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.

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A lot can be done to fight cancer… 9 …What you do matters… 9 Don’t smoke—tobacco control

9 …Where you live matters, too… = 9School children buy, on average, 360 nutrient-poor calories from corner stores for just over $1 per visit: chips, candy and sugar sweetened beverages.

9 Detection 9 Follow cancer screening guidelines

9 Treatment …Detection and treatment are both easier with health insurance coverage…

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‌Where you live matters, too‌ Percentage of Adults (18-64) Without Health Insurance, Southeastern Pennsylvania 9In Philadelphia, 16% of adults are without public or private health insurance. 9In Bucks and Delaware Counties, more than 7% of adults are without health insurance. 9In Chester County, 6% of adults have no health insurance. 9In 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

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‌Where you live matters, too‌ Percentage of Adults (18-64) Without Health Insurance, Philadelphia 9In Philadelphia, 16% of adults are without public or private health insurance.

9In Upper North Philadelphia, more than one quarter (26%) of adults have no health insurance. 9In South Philadelphia, 21% of adults have no health insurance.

Source: 2008 Southeastern Pennsylvania Household Health Survey, Community Health Data Base, Public Health Management Corporation

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‌Where you live matters, too‌ 9Breast 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. 9Cervical cancer: In Pennsylvania, the rate of Pap test is nearly onethird lower among women 40 and older with no usual source of medical care and/or no health insurance. Nationwide, it is nearly onequarter lower than in Pennsylvania. 9Colorectal 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.

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Conclusion: Key Takeaways 9 Cancer is a worldwide problem. 9 The growing tidal wave of new cancer cases (and their impact) has attracted attention from the global public health community.

9 Cancer remains a big problem in the United States. 9 It is worse for the African American community than almost every other ethnic group.

9 Individuals Individuals can do a lot to prevent cancer and reduce cancer risk...BUT… 9…There remains a large need for public— government and community group—intervention: —$$$ —Policy / law —Education

NOW is the time to act!!!

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These people have declared war on cancer around the world‌ 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

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 John R. Seffrin, PhD; Chief Executive Officer, American Cancer Society

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…Focus on tackling cancer in the most impoverished countries around the world… 9 “…5% of global resources for cancer are spent in the developing world…” (p.9) •

9

“Breakaway: The global burden of cancer” •

9

160,000+ search results (Google).

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… 9

The American Lung Association gave Pennsylvania an “F” for tobacco prevention control and for cessation efforts in 2013.

9

The Pennsylvania Auditor General reports that $1.34 billion was diverted from uses originally intended by the Tobacco Settlement Act of 2001. •

9

“racial disparities in cancer outcomes” •

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More than 41,000 residents lost state-subsidized health insurance coverage, as a result.

220,000 search results (Google).


What are we going to do about it at home?


Don’t give up on cancer Richard M. Stein Stein.richard@ymail.com


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Don’t give up on cancer (March 2014)