THE SCOPE OF LUNG CANCER IN MINNESOTA

November 2014

Key Findings • More people die each year from lung cancer than prostate, breast and colorectal cancer combined, making it the leading cancer killer in America. • In Minnesota, American Indians are disproportionately affected by lung cancer. There are proportionally more cases and deaths among American Indians than any other group. • Not only smokers develop lung cancer. Among respondents to the American Lung Association’s Lung Health Survey that had been diagnosed with lung cancer but reported never smoking, more than half (56%) reported secondhand smoke exposure and about 1 in 8 (13%) reported radon exposure. See more about the Lung Health Survey on page 6. • Lung cancer is hard to detect in its early stages. The majority of lung cancers in Minnesota are diagnosed after the cancer has metastasized (spread). New recommendations from the American Lung Association could help find lung cancer earlier and improve survival. 1

Lung cancer is… …cancer that starts in the lung, usually in the cells lining air passages. It can often metastasize

(spread) to other areas of the body, like the brain, liver, other areas M OF THE COMPOSITION of the lung, and elsewhere. …the leading cause of cancer deaths in Minnesota. Lung cancer kills more than twice as many men as prostate cancer and nearly CONVEX LEFT twice as many women as breast cancer in Minnesota. …usually caused by one or more of these risk factors: smoking (accounts for 80-90% of lung cancer), radon and secondhand smoke. A family history of lung cancer also increases risk.

Most Common Types of Cancer Deaths CONVEX RIGHT

FEMALES

MALES

LUNG & BRONCHUS 24%

LUNG & BRONCHUS 27%

BREAST 15%

PROSTATE 11%

COLON & RECTUM 10%

COLON & RECTUM 9%

PANCREAS 6%

PANCREAS 6%

OVARY 6%

LEUKEMIA 5%

Minnesota cancer deaths for 2001-2010 combined

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Lung cancer patterns are different for men vs women The rate of new cases of lung and bronchus cancer in females increased by 40% between 1988 and 2004, with a similar increase in deaths, but both rates have been stable since then. In contrast, the rate of new cases in males decreased by 18% since 1988, with a small decrease in the rate of deaths, as well. This difference in trends likely reflects national smoking patterns over the past 50 years.

Age-adjusted rate per 100,000 people

Incidence (new cases) and Mortality (deaths) 90 80 70 60 50 40 30 20 10 0

1988

Male cases

Female cases

Male deaths

Female deaths

1993

1998

2003

2008

Year of diagnosis or death Source: Minnesota Department of Health. Incidence data (new cases) are for 1988-2011. Mortality data (deaths) are for 1988-2010. 1988-2010.

There are racial/ethnic disparities for lung cancer Proportionally more American Indians in Minnesota are diagnosed with and die from lung cancer than any other race/ethnicity category. White Hispanic people have the lowest rate of lung cancer deaths, followed by Asian/Pacific Islanders.

Rate* per 100,000 people

Rate of new cases

Rate of deaths

140 120 100 80 60 40 20 0

American Indian

Black

White (nonHispanic)

White (Hispanic)

Asian/Pacific Islander

Race/ethnicity * Average annual age-adjusted rate per 100,000 people. Source: Minnesota Department of Health. Incidence data (new cases) are for 2002-2011 combined. Mortality data (deaths) are for 2001-2010 combined.

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Lung Cancer Deaths Increase With Age Mortality rate* per 100,000 people

Male 500 450 400 350 300 250 200 150 100 50 0

Female

45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 years years years years years years years years

85+ years

Age group

*Average annuall rate per 100,000 people. Source: Minnesota Department of Health. Data are for 2001-2010 combined.

Lung cancer, like most types of cancer, mainly occurs in older adults. Fewer than 2% of all lung cancer cases nationwide are found in people younger than 45. The mortality rate is highest among adults 70 years and older. Lung cancer deaths are more common among males, reflecting the historically higher prevalence of smoking among males.

“I wish they would have tested me for (biological) markers.“ Lung Health Survey Respondent

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Lung cancer is most often diagnosed after it has spread Lung cancer cases are most frequently diagnosed in the distant stage, which means the cancer has spread to distant organs. Few lung cancer cases are diagnosed in the early stages when survival is better. The graph below shows: • In Minnesota, 52% of lung cancer deaths were diagnosed in the distant stage (after it had spread), emphasizing the importance of early detection and screening. • People whose cancer is detected in the early stages (localized, even regional) have better five-year survival rates.

With better screening tools, it would be possible to find and diagnose a lung cancer earlier, which could lead to better survival. (See Lung Cancer Screening section on page 3.)

“I had no idea what type of cancer I had and wish the doctors explained more about it.

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Lung Health Survey Respondent

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RISK FACTORS: Smoking, Radon and Secondhand Smoke

Lung Health Survey The American Lung Association created a Lung Health Survey to identify patient wants, needs, and experiences regarding his or her diagnosis. Patients that had

Smoking is not the only risk factor for lung cancer

a recent lung cancer diagnosis in the Mayo, Allina, and North Memorial health systems received a survey confidentially.

No personal identifiers were released. Data • About 80-90% of lung cancers shown here are for the 748 patients that in the U.S. are caused by smoking, and it increases the responded to the survey between August risk of developing many other 2013 and May 2014. types of cancer. • However, not only smokers develop lung cancer: 17% of respondents to the Lung Health Survey conducted by the American Lung Association had lung cancer but never smoked. Radon and secondhand smoke are among the top three risk factors for lung cancer. • About 8% of all respondents reported ever being exposed to radon. • Among the respondents who never smoked but had developed lung cancer, more than half (56%) reported exposure to secondhand smoke.

More Minnesotans should test their homes for radon Radon is a serious public health issue in Minnesota, where 2 in 5 I wish I would have homes have radon levels that pose connected with a support a significant health risk. Because group immediately. of Minnesota’s natural geology, nearly 80% of counties are rated Lung Health Survey Respondent high radon zones. • Despite this, only a quarter (25.8%) of respondents had ever tested their home for radon. • About 1 out of 8 (13%) respondents who had tested their home found levels of radon above 4 pCi, the Minnesota Department of Health’s recommended mitigation level (action level). In Minnesota, 40% of homes have elevated radon levels. • The Minnesota Radon Awareness Act, passed in 2013, requires sellers of residential real estate property to provide buyers with information on any radon testing done on the home, what the results were (if tested), and a radon brochure created by MDH on the health effects relating to radon exposure. •

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Earlier diagnosis means better survival In a quarter (25%) of the respondents, the lung cancer was not identified in the first two months after symptoms began. About 9% of respondents said it took 12 months or longer to reach a lung cancer diagnosis. An earlier diagnosis means better survival. New recommendations from the American Lung Association could help find lung cancer earlier in some people. (See Lung Cancer Screening section.) About 30% of Lung Health Survey respondents that answered the question said they were diagnosed with other conditions before their health care provider identified lung cancer. These included lung diseases (14%), other cancers (11%), and blood or heart diseases (4%). Source: ALA Lung Health Survey, 2013-2014.

No symptoms before diagnosis

38%

Frequent coughing

24%

Shortness of breath

19%

Fatigue

14%

Pain in chest, shoulder, back, arm

10%

Repeated pneumonia or bronchitis

10%

Wheezing

8%

Loss of appetite and weight loss

7%

Coughing up Blood

5%

Hoarseness

4%

General pain Swelling in face or neck

3% 1% 0%

10%

20%

30%

40%

50%

Percent of respondents

Symptoms experienced before lung cancer diagnosis The three most common symptoms that patients experienced, before reaching a lung cancer diagnosis, included: • Frequent coughing (24%) • Shortness of breath (19%) • Fatigue (14%)

“I wish they would have taken my steadily progressive symptoms more seriously.

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Lung Health Survey Respondent

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Lung cancer screening Lung cancer screening aims to detect lung cancer at an earlier stage, where it can be more successfully treated. Results from the National Lung Screening Trial sponsored by the National Cancer Institute show that annually screening people at high risk of lung cancer with a low dose computed tomography (CT) scan reduced mortality by 20%. Screening high-risk patients will save lives, but it must only be used for people at high risk and used carefully.

New recommendations for high-risk people Based on results from the National Lung Screening Trial, the American Lung Association now recommends that high-risk people should be annually screened for lung cancer with a low dose CT scan. High-risk people are those that meet all of the following criteria: • Current or former smokers aged 55-74 years • A smoking history of at least 30 pack-years (for example, a pack a day for 30 years) • No history of lung cancer

What are the risks of lung cancer screening? Lung cancer screening is not recommended for everyone. There are some risks to lung cancer screening: • A lung cancer screening test My primary care doctor was fabulous and can have a falserequested a chest xray immediately. Even though positive result, the radiologist suggested a recheck xray in which suggests three months since it looked like pneumonia. My that a person has primary doctor pushed for a CT scan, then PET, lung cancer when then biopsy. no cancer is present, and can Lung Health Survey Respondent lead to further testing and unnecessary invasive procedures that may cause harm if the person does not have cancer. • There is some radiation risk. A low-dose CT scan uses about 15 times more radiation than a chest x-ray. However, a low dose CT scan uses five times less radiation than a conventional CT.

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Patients should review the possible benefits and risks of being screened for lung cancer and should be referred to a facility that uses “best practices” for CT screening. Lung cancer screening is not a substitute for quitting smoking, but early diagnosis is key for better survival and screening can be lifesaving in some patients.

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Does insurance cover lung cancer screening? Health insurance companies may not cover the cost for lung cancer screening and patients should contact their insurance companies to see what is covered. At this point, Medicare does not cover lung cancer screening. The U.S. Preventive Services Task Force’s recent recommendation means that marketplace plans and many other private plans would be required to cover the screening in accordance with the Affordable Care Act. Some private insurance companies have already elected to cover the screening.

“There is a possibility of a long battle instead of a short one. More encouragement would have helped.“ Lung Health Survey Respondent

What can I do about my risk for lung cancer? • Don’t smoke. If you smoke, quit. This is the best way to reduce your risk of developing or dying from lung cancer. Approximately 90% of lung cancers in males and 80% in females are caused by smoking, which increases the risk of developing many other cancers as well. • Test your home for radon and follow through on the results-based recommendations. Radon is a colorless, odorless radioactive gas that seeps up from the earth and damages the cells that line the lung when inhaled. It’s the second leading cause of lung cancer. To learn more and to get a radon test kit, go to the Minnesota Department of Health’s Radon in Minnesota Homes (www.health.state. mn.us/divs/eh/indoorair/radon/). • Avoid secondhand smoke. Also known as environmental tobacco smoke, it is the third leading cause of lung cancer. • Ask your doctor about lung cancer screening if you smoke. Your healthcare provider can help determine whether screening is right for you.

What patients from the Lung Health Survey want professionals to know: • Patients want to learn more about their diagnosis and often report a lack of clarity on their diagnosis. • Patients want more information on their type of lung cancer. • Patients want more education about genetic predispositions and biomarker testing. • Providers need to emphasize optimistic advice.

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Resources • Lung cancer is the #1 cancer killer of women, yet only 1% of women cited it as a “top-of-mind” cancer affecting women. The American Lung Association’s LUNG FORCE campaign will unite women to stand together against lung cancer and for lung health. www.LUNGFORCE.org • Use an interactive tool to find out whether you meet lung cancer screening guidelines at LungCancerScreeningSavesLives.org • Learn more about lung cancer screening at: . For patients: Is It Right for Me? www.lung.org/lung-disease/lung-cancer/ lung-cancer-screening-guidelines/lung-cancerscreening-for-patients.pdf . For physicians: Should My Patient Be Screened? www.lung.org/lung-disease/lung-cancer/lung-cancer-screeningguidelines/lung-cancer-screening-doctor.pdf) Lun g he Free, 7 days a week 8 a.m. - midnight EST 7 a.m. - 11 p.m. CST

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Asthma COPD Lung Cancer Smoking Cessation Staffed by experienced registered nurses, respiratory therapists and certified cessation counselors

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Lung HelpLine 1-800-LUNG-USA (800-586-4872) www.Lung.org rt. xpe an e Ask front

• Learn more about Talking with Your Patients About Screening for Lung Cancer from the U.S. Preventative Services Task Force. www.uspreventiveservicestaskforce.org/ Home/GetFileByID/796 • Call the Lung HelpLine at 1-800-LUNG-USA.

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Data sources for this report Cancer incidence data are collected by the Minnesota Cancer Surveillance System, which is Minnesota’s central cancer registry at the Minnesota Department of Health (MDH). Cancer mortality data are collected by the Minnesota Center for Health Statistics at MDH and analyzed by the Minnesota Cancer Surveillance System. The American Lung Association created a Lung Health Survey to identify patient

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wants, needs, and experiences regarding his or her diagnosis. Each partnering clinic system mailed the survey for all patients in their roster with an ICD-9 diagnosis codes of 162 (trachea, bronchus, and lung); 163 (pleura); and 165 (Other in the respiratory system) (i.e. lung cancer) within the past 5 years and living in Minnesota. Partnering systems were: Mayo, Allina, and North Memorial. There was a 32% response rate (748 responses) from August 2013 – May 2014 capturing 74 out of 87 counties in Minnesota. A little over half (51.3%) were female, 37.8% male, and about 10% did not provide gender. Among the respondents that answered the question on age, 1.6% were age 45 and under, 31.1% were between the ages of 46 and 65, and 67.3% were 66 years of age and over.

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The Minnesota Department of Health’s Environmental Public Health Tracking Program (MN Tracking) gathers and analyzes data about the environment, people’s exposure to environmental hazards, and health effects. These data are available at Minnesota Public Health Data Access (https://apps.health.state.mn.us/ mndata).

The American Lung Association is the leading organization working to save lives by improving lung health and preventing lung disease through education, advocacy and research.

49 0 C o n co rd i a Ave l S t . P a u l , M N 5510 3 Ph: 651-227-8014 F: 651-227-5459 [email protected] LungMN.org

CONCAVE RIGHT 651-201-5900 800-205-4987 toll-free [email protected]