Emerging Cancer Trends

~10% of all colorectal cancer cases are diagnosed in patients < 50; EO-CRC rates are predicted to increase by 90% for colon cancer and 140% for rectal cancer for 2030, with a yearly increase of 2%.

• In California, 1,906 cases of EO-CRC were diagnosed in 2017, and 372 people died from their disease.

• In addition, these cases were diagnosed at a higher rate of late-stage disease, with 67.6% late stage compared to 60.1% for those aged 50-64 and 63.4% for those 65+.

• Nationally, one in four EO-CRC patients (26%) is diagnosed with metastatic disease compared to 19% of those 65 and older.

Although early-onset colorectal cancer (EO-CRC) has different definitions based on age, the general guideline is that patients who present with colorectal cancer should be referred before the age of 50.

We need to appropriately identify those most at risk of developing the disease to reduce EO-CRC incidence. Some of the challenges of diagnosing at-risk patients include understanding the root causes such as genetic or familial risk, lifestyle, environment, inflammatory bowel disease, the microbiome, or other causes before the disease is diagnosed at the early stage.

• Understanding who may be at increased risk is important for patient advocacy efforts and efficient use of health systems’ limited resources.

To improve the colorectal cancer care continuum for all impacted Californians, the increase in cases and resulting deaths are a public health concern that needs to be addressed. The colorectal cancer section includes an objective and strategies for reducing EO-CRS patients diagnosed with late-stage CRC.

The human papillomavirus (HPV) is a common virus that can cause six types of cancer (cervical, vaginal, vulvar, anal, penile, and oropharyngeal).

• In the U.S., 80% of people will contract HPV and 10% will develop chronicity, putting them at high risk for HPV-associated cancers.

• HPV infection causes 34,800 cases of cancer in U.S. men and women annually. Approximately 10% of these cancers occur among California residents.

• In 2016, oropharyngeal cancer was the most common HPV-associated cancer nationally and in California, where there were 1875 new cases compared to 1495 new cervical cancer cases.

• Oropharyngeal cancer in men has steadily increased by an average of 1.9% per year over the past nine years (2008-2017) in California. Currently, cervical cancer is the only HPV-associated cancer for which screening is recommended.

Fortunately, the HPV vaccine prevents over 90% of HPV-associated cancers. This safe and effective vaccine was first introduced in the U.S. in 2006, but HPV vaccination rates still lag behind those of other pre-teen vaccines.

• California ranks number 13 in HPV vaccination rates among U.S. states, according to the National Immunization Survey - Teen (2018).

• There is still much room for improvement as 73% of California adolescents have started the series, but only 53% have completed it. Thus, over one million California teens are unprotected against future HPV-associated cancers.

Increasing HPV vaccination is important for decreasing the number of HPV-associated cancers every year.

Some evidence-based recommendations include:

• Patient reminders

• EHR alerts

• Standing orders

• Tracking HPV vaccination rates at the provider level

In October 2018, the California HPV Vaccination Roundtable, co-founded by the ACS and the CDOC, was launched to carry out these recommendations to increase by HPV vaccination rate by 80% by 2026.

One of the fastest-growing trends in cancer in the U.S. is frequency and death from liver cancer.

• In recent decades, incidence and mortality rates decreased in Asian populations who have historically had the highest rates, while rates rose dramatically in all non-Asian groups.

• In 2016, the highest mortality rates were observed among American Indian/Alaskan Native and Hispanic populations and the lowest among non-Hispanic Whites.

• Liver cancer is the 6th most common cause of cancer-related death in the U.S. California has liver cancer incidence and mortality rates that are among the highest in the nation.

Liver cancer is mostly preventable, as prevention and detection are crucial to preventing the untreatable advanced stages (most patients survive < 6 months (5-year survival = 2%).

• However, only 44% of liver cancers are detected at a localized stage.

• Early detection that includes identifying blood-based biomarkers and improving imaging surveillance is still being researched.

Leading risk factors for liver cancer include obesity, diabetes, and related complications attributable to almost 40% of diagnoses.

• As such, evidence has suggested that a healthy diet and regular exercise may reverse liver damage from obesity and diabetes (non-alcoholic fatty liver disease; NAFLD) and lower the risk of liver cancer.

• Alcohol is also responsible for a growing fraction of liver cancer cases; stopping alcohol intake can lower liver cancer risk by 6-7% a year.

Among the Asian population, Hepatitis B (HBV) infection is the main cause of liver cancers. Starting from 1991 and earlier, universal HPV vaccination in infants has resulted in decreasing HBV infection rates. For individuals who are already infected, antiviral therapy can reduce the risk of cancer.

Hepatitis C (HCV) infections remain a top cause of liver cancer in non-Asian populations. A highly effective antiviral therapy that directly acts on the virus can eradicate HCV infection and reduce the risk of cancer. Future cancer incidence can also be dramatically reduced by screening high-risk populations for HCV and preventing the liver's late-stage scarring, cirrhosis.

Fewer than 10% of pancreatic cancer patients survive to 5 years after diagnosis. Although there are 4,500 cases a year in California, more than 4,000 people the same year die from pancreatic cancer, and trends continue despite the fact that smoking, a well-established risk factor for pancreatic cancer, has been decreasing in California.

• One suspected risk factor for the increasing rate of pancreatic cancer is the rising burden of obesity and health problems associated with visceral and organ fat. Obese individuals have an increased risk of 20%-to-50% of pancreatic cancer compared to individuals of normal weight, so it is important that controlling obesity is a priority for all cancer prevention.

• Although early detection is key to improve the outcome of pancreatic cancer survivorship, early detection guidelines for the general U.S. population are lacking.

• Endoscopic screening is currently approved for those with a family history of pancreatic cancer and patients with cystic lesions but consists of only a small minority of diagnosed patients.

• New-onset hyperglycemia and diabetes are common among pancreatic cancer patients and may signal tumor growth in the pancreas. In the U.S. and abroad, research is underway to identify diabetes-specific markers that would warrant pancreatic screening and surveillance, as well as clinical prediction models to identify high-risk individuals.

Over the past 20 years, the number of people diagnosed with thyroid cancer has nearly doubled, with 54,020 estimate casts since 2019. In 2017, there were 5,243 new cases of thyroid cancer diagnosed, and the incidence continues to increase in the U.S. and worldwide due to widespread improvements in the use of ultrasounds and other imaging tests, leading to greater numbers of cancer diagnoses.

Fortunately, since 2009, the 5-year survival rate for thyroid cancer has remained quite high, between 98.2% to 99.9%, depending on the tumor’s location at diagnosis.

• Many factors, however, are associated with greater mortality risk, including the development of distant metastasis, age over 55+, and medullary or anaplastic subtypes of the disease.

The mainstay of treatment is:

1. Surgery to remove the thyroid gland,

2. Medication to reduce the body’s supply of thyroid hormone while suppressing the pituitary gland’s production of thyroid stimulation hormone (TSH).

Radioactive iodine treatments and other forms of radiation are often included for treating patients with high-risk features.

Uterine cancer is the most common gynecologic cancer in the U.S.; in 2020 there will be an estimated 65,620 new cases and 12,590 deaths. In California, 6,336 women were diagnosed with uterine cancer and 1,204 died from it in 2017. Over the last 10 years, new uterine cancer cases have been rising 1% each year, on average.

Obesity is a known risk factor for uterine cancer. For a woman who is 50 pounds overweight, evidence indicates she is ten times more likely than a woman with a normal body mass index (BMI) to get endometrial cancer. As the rate of obesity in the U.S. increases, so does the rate of endometrial cancer.

Due to the common symptom of abnormal uterine bleeding, ~80% of uterine cancer is diagnosed early, leading to biopsy and diagnosis. Patients with early-stage disease may require minimally invasive surgery with a laparoscopic hysterectomy.