The New York Times (pg. A14) [Printer-friendly version] January 18, 2007 SECOND DROP IN CANCER DEATHS COULD POINT TO A TREND By Denise Grady The number of cancer deaths in the United States has dropped for the second year in a row, the American Cancer Society reported yesterday. The finding suggests that the small drop reported last year -- the first in more than 70 years -- was real, possibly the start of a continuing decrease and not merely a statistical fluke, researchers said. Much of the decrease is due to smoking cessation and improved detection and treatment of colorectal, breast and prostate cancers. But it has taken enormous efforts and ingenuity to produce relatively small gains. From 2003 to 2004, cancer deaths fell by 3,014, considerably more than the previous year's decline, 369. (These are the latest years for which figures are available.) Although the drop is notable, it still pales in comparison with the number of cancer deaths, 553,888 in 2004. Cancer is the second leading cause of death in the United States, after heart disease. By far the greatest decreases in mortality have been in colorectal cancer -- 1,110 fewer deaths in men, 1,094 fewer in women. Dr. Elizabeth Ward, a managing director in epidemiology and surveillance at the cancer society, said the most important factor in the decrease was screening for colorectal cancer, which can detect the disease early when it is most treatable, or even prevent it entirely by finding precancerous polyps, which can be removed before they turn malignant. Progress has been significant even though only about half the adults who should be screened have been. If more people were screened, there would be even steeper declines in death and the incidence of the disease. The screening methods include stool tests; colonoscopy, which examines the entire large intestine; and sigmoidoscopy, which examines the lower part of it. Dr. Alfred I. Neugut, the director of cancer prevention and control at Columbia University Medical Center, said colorectal screening was comparable to the Pap test, which led to an 85 percent decrease in the incidence of cervical cancer in this country. Improved treatment has also played a part in lowering the death rate from colorectal cancer, Dr. Neugut said. "There was a revolution in treatment between 1998 and 2000, and revolution is a mild word," he said. "We went from having one drug to having six or seven good drugs. The cure and survival rates have increased dramatically as a result. The cost of care has also gone up, but you get what you pay for." The death rate from cancer has been falling by slightly less than 1 percent a year since 1991, but until 2003 the actual number of deaths kept rising because the population was growing and aging. Then, in 2003, the cumulative drop in death rates finally became large enough to outpace aging and population growth. "The decline in the cancer death rates, which has ultimately resulted in a decline in the total number of deaths, really reflects the years of effort and investment in tobacco control, programs for early detection and screening, and programs in clinical and basic research," Dr. Ward said. "We've made a great deal of progress, but we still have a long way to go." One great concern, Dr. Ward said, is that African-Americans have markedly higher death rates than whites from nearly every type of cancer. Researchers do not fully understand why. Having less income, education and access to health care account for much of the difference, but not all of it, researchers say. "If we really want to continue to make progress by applying what we know," Dr. Ward said, "we have to figure out a way to make sure to reach all populations with the information they need to prevent cancer, and make sure that all populations have access to early detection and treatment -- quality treatment -- so that 10 to 20 years from now we don't see the same big differences." The report also notes differences with other racial groups. American Indians and Alaska natives have the highest incidence and death rates from kidney cancer, but the reason is not known. Compared with whites, Pacific Islanders and Asian-Americans have a higher incidence and death rate from stomach and liver cancers. The main reason is that they are more likely to be exposed to the hepatitis B virus, which can cause a chronic liver infection that leads to cancer, and to the bacterium Helicobacter pylori, which can lead to ulcers and stomach cancer. Hepatitis B can be prevented by a vaccine. There is no vaccine for Helicobacter, but infections can be treated with antibiotics. Originally, the new statistics were to be made public on Friday, but the cancer society changed the release date to Wednesday at the request of the director of the National Cancer Institute, who wanted the announcement to coincide with President Bush's visit to the institute. Lung cancer is still the leading cause of cancer mortality in the United States, with 160,390 deaths expected in 2007. In men, deaths have been decreasing, but in women they are still increasing slightly, because women quit smoking later. Now, the lung cancer epidemic may be starting to plateau in women just as it did in men about 15 years ago, Dr. Ward said. Another cancer is likely to increase, not in rates, but in numbers as the population ages. "I think prostate cancer is going to be the bane of the next century," Dr. Neugut said. The incidence of the disease probably will not change, he said, but the number of cases will increase. About 219,000 new cases are expected in 2007, and 27,000 deaths. "As the baby boom generation reaches the age where everyone's getting prostate cancer, it's going to absolutely go through the roof in the next decade or two," Dr. Neugut said. "It's going to be a good time to be a urologist. We'll hit 300,000 cases in the next 10 to 20 years. From a public health perspective, it means we'll be doing more surgery and spending more on prostate cancer." Screening is controversial, because not all prostate cancers are deadly, yet once they are found many men feel they must have surgery to remove the entire prostate gland. "We're overdiagnosing it," Dr. Neugut said, adding that although he is a cancer specialist, he does not endorse screening for prostate cancer, not even for himself. "My wife gets mad at me and screams," he said. Breast cancer incidence, which had been climbing steadily for decades, has leveled off. One reason may be that many women abandoned menopausal hormone treatment after a major study in 2002 found that it increased the risk of breast cancer. Another reason may be that rates of mammography -- and therefore of new diagnoses -- have also leveled off. Death rates have been decreasing, but in women ages 20 to 59, breast cancer is still the leading cause of cancer death. Death rates from a few other cancers have increased. One is esophageal cancer in men, an increase Dr. Ward said was probably linked to obesity. Being overweight increases the risk of acid reflux, in which stomach acid backs up into the esophagus, causing a chronic inflammation that can eventually lead to cancer. Liver cancer has also increased in both men and women, almost certainly because of hepatitis viruses; about 3 million people in the United States have chronic hepatitis C infections, and 1.25 million have chronic hepatitis B. Hepatitis B is especially common among Asian immigrants, many of whom were infected at birth. But obesity may also raise liver cancer rates, Dr. Ward said.