'Looming Crisis' of Rising Pancreatic Cancer Death Rates in US

Neil Osterweil

November 26, 2013

Epidemiologists are at a loss to explain why pancreatic cancer death rates in the United States rose for more than a decade in white adults but decreased in black adults.

From 1995 to 2009, the death rate from pancreatic cancer in white men increased by 0.4% per year and in white women increased by 0.5%. In contrast, the death rate in black men declined by 0.9% per year and in black women declined by 0.5%.

These findings were published in the November 20 issue of the Journal of the National Cancer Institute by Jiemin Ma, PhD, MHS, and colleagues from the surveillance and health services research program of the American Cancer Society in Atlanta.

However, despite this trend, the proportion of blacks who died from pancreatic cancer remained consistently higher than the proportion of whites during the study period.

"We found race-distinct trends in pancreatic cancer death rates during the period from 1970 to 2009 in the United States that are largely unexplainable by known risk factors. The decreasing trend in blacks over the past 10 to 15 years is particularly interesting because the prevalence rates of factors (i.e., obesity, diabetes, and improved diagnosis) that are likely contributing to the recent increases in pancreatic cancer death rates in whites have also increased in blacks," the researchers write.

They recommend smoking cessation and weight control measures to help keep pancreatic cancer deaths in check and research into the causes of pancreatic cancers. These recommendations are endorsed in an accompanying editorial by Dana B. Cardin, MD, MSCI, and Jordan D. Berlin, MD, from the Vanderbilt-Ingram Cancer Center at Vanderbilt University Medical Center in Nashville, Tennessee.

A Looming Crisis

This study "highlights a looming crisis of rising pancreatic cancer death rates in the United States," the editorialists warn.

To answer this concern, the National Cancer Institute (NCI) has prioritized pancreatic cancer research, they note. "However, the funding available to the NCI continues to decline in the face of sequestration and a government focused on partisan bickering and political showmanship. Our country needs to act now, or we will simply be spectators as thousands more people die each year from this devastating illness," they write.

Drs. Cardin and Berlin explain that the federal government regularly subsidizes foods associated with an increased risk for pancreatic cancer, such as meats and foods used as sweeteners, but not the fruits and vegetables associated with healthy diets and a lower risk for obesity and cancer.

Trends Over Time

Dr. Ma and colleagues looked at trends in pancreatic cancer deaths from 1970 to the mid- to late-1980s, and from the 1980s to 2009, using data from the National Center for Health Statistics. They used Joinpoint regression analysis to evaluate temporal trends by sex and race in a population of adults 35 to 84 years of age.

From 1970 to 1995, there was an annual 0.7% decrease in pancreatic cancer death rates in white men — from 24.8 per 100,000 to 20.4 per 100,000. However, from 1996 to 2009, the downward trend was reversed, and death rates rose by 0.4% per year, to 21.5 per 100,000.

In contrast, from 1970 to 1989, death rates in black men increased by 0.5% per year, from 29.0 per 100,000 to 31.3 per 100,000. Thereafter, the rate declined by 0.9% per year until 2009, when the rate was 27.5 per 100,000.

In white women, pancreatic cancer death rates increased from 14.6 per 100,000 in 1970 to 15.3 per 100,000 in 1984, remained flat through 1998, and then started to climb at a rate of 0.5% per year until 2009, when the rate was 15.9 per 100,000.

In black women, death rates increased from 18.3 per 100,000 in 1970 to 23.1 per 100,000 in 1989, and then slipped back to 20.9 per 100,000 in 2009 — a decline of 0.5% per year.

The researchers looked at birth cohorts and found that risk of dying from pancreatic cancer was highest in men born from 1900 to 1910 and in women born from 1920 to 1930. Since the late 1990s, the period effect for both white men and women was significant (P < 0.001 for both). There were similar period effects for black men and women, but the number of deaths was relatively small and the changes observed were not statistically significant, the researchers note.

"Decreased smoking prevalence has been widely recognized as the main contributor to the decreases in pancreatic cancer death rates. However, reasons for the delayed decreases in pancreatic cancer death rates among blacks are unclear. Smoking prevalence has decreased in both blacks and whites since 1965, although black men consistently had a higher rate than white men over the years. In addition, there are no delays for blacks in experiencing decreased lung cancer death rates. This indicates that smoking may act differently in causing these 2 cancers," they write.

Better Trials, Better Drugs

In their editorial, Drs. Cardin and Berlin note that better health, early diagnosis, and more effective therapies will be needed to stem the rising tide of pancreatic cancer. They point out that the current standard treatment regimens of FOLFIRINOX (folinic acid, 5-fluorouracil, irinotecan, and oxaliplatin) and of gemcitabine plus nab-paclitaxel are each associated with a median overall survival of less than 1 year.

A 2007 NCI-sponsored state of the science meeting resulted in a call for better integration of laboratory data into clinical trials, the editorialists explain. It also highlighted "a need to abandon the mindless propagation of the 'gemcitabine vs gemcitabine + your drug here' design used for over a decade."

"With the recent approval of nab-paclitaxel by the US Food and Drug Administration, the greatest concern is that the new clinical trials model will become 'gemcitabine + nab-paclitaxel vs gemcitabine + nab-paclitaxel + your drug here,' once again forsaking science for regulatory needs," they note.

The study was funded by the American Cancer Society. The authors and the editorialists have disclosed no relevant financial relationships.

J Natl Cancer Inst. 2013;105:1675-1676, 1694-1700. Editorial, Abstract

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