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Progress Review

Cancer

U.S. Department of Health & Human Services—Public Health Service

October 16, 2002

Healthy People 2010 logo

Assistant Secretary for Health Eve Slater chaired the third in a series of Progress Reviews on the 28 focus areas of Healthy People 2010. This session dealt with the 15 objectives for Cancer and was presented by the co-lead agencies for this focus area, the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC). (See the chapter text at www.healthypeople.gov/document/html/volume1/03cancer.htm. For an agenda of the meeting and summary data tables and charts, refer to the following site maintained by CDC’s National Center for Health Statistics [NCHS]: www.cdc.gov/nchs/about/otheract/hpdata2010/fa3/cancer.htm.)

Data Trends

Reporting on tracking data for the cancer objectives, NCHS Director Edward Sondik noted that overall cancer death rates decreased in men and women from 1993 through 2000. From 1990 to 2000, overall cancer mortality remained higher in men, but showed a more marked decrease over the decade for men than for women. The four most common cancers are lung, colon/rectum, breast and prostate, which account for about half of all cancer deaths and for each of which there is a Healthy People 2010 mortality objective. Notable disparities in death rates in 2000 were reported for three of these objectives: lung, with rates highest in black males; colorectal, showing a higher rate in men, particularly black men, than in women; and cervical, with a rate of 5.7 per 100,000 for non-Hispanic black women, compared to 2.4 per 100,000 for non-Hispanic white women. A geographical pattern also appeared for cervical cancer, with county mortality rates comparatively low in the Southwest and well above average in a region extending from Maine through Appalachia to the Texas/Mexico border for whites and in the Southeast and Mid-Atlantic regions for blacks.

For the eight mortality objectives, projections from current data trends show the targets for four objectives being met by 2010 or earlier (cervical, prostate, breast, and melanoma), but shortfalls occurring for three (lung, colorectal, and all sites combined), based on the most current estimated annual percentage change. The target for mortality from oropharyngeal cancer has been met for the overall total population, but not by some population groups.

Addressing the objectives for cancer prevention, Dr. Sondik stated that the rate of cigarette smoking by adults aged 18 and older decreased very slightly in most of the years between 1990 and 2000, but that the pattern of use by students in grades 9-12 was variable over that decade. The percentage of students who reported current cigarette use increased significantly from 1991 to 1997 and then decreased significantly from 1997 to 2001. In 2000, use of early cancer detection procedures (mammograms, Pap tests, fecal occult blood tests [FOBT], and endoscopic exams) showed clear gradients by family income levels. Regardless of income level, blacks scored highest in 2000 in having had a recent Pap test and Hispanics lowest. The pattern was similar in 2000 for mammograms, except that whites with middle/high income were most likely to have had a mammogram. The rate of use of FOBT in 2000 was lowest in Hispanics. Overall, females in grades 9-12 used sunscreen at higher rates than did males in 2001.

Discussion

In the presentations by lead agency representatives, Dr. Nancy Lee, Director, Division of Cancer Prevention and Control, discussed CDC’s activities, focusing principally on the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), the National Program of Cancer Registries (NPCR), and Comprehensive Cancer Control (CCC). She described the NBCCEDP as a flagship program now operative in all States, the District of Columbia, six U.S. territories, and 14 tribal organizations. Among the purposes of the NPCR are to determine cancer patterns in various population groups; provide information for a national database of cancer incidence; advance clinical, epidemiological, and health services research; and help set State and national priorities for planning and evaluation. As of January 2002, 29 NPCR-funded States had a registry with information on at least 95 percent of the expected number of cancers diagnosed within their borders in 1999. The Healthy People 2010 target is for the 45 NPCR States to capture case information on at least 95 percent of the expected number of reportable cancers in a diagnosis year. NPCR is working closely with the National Cancer Institute’s (NCI’s) Surveillance, Epidemiology and End Results (SEER) Program to coordinate the collection and reporting of cancer data meeting high standards of quality.

The mission of CCC, Dr. Lee said, is to provide an integrated and coordinated approach to reducing cancer incidence, morbidity, and mortality through prevention, early detection, treatment, rehabilitation, and palliation. CCC seeks to bring a public health perspective to such cancer issues as: care for the underserved, reform of State laws regarding insurance and access, improvement of infrastructure, public education and outreach, and the quality of life of cancer survivors. The CCC Leadership Institutes for States is a collaboration between CDC, NCI, and the American Cancer Society (ACS) to provide workshops for leaders in the States taking part in the program. Dr. Lee also spoke about the National Colorectal Cancer Action Campaign, a collaborative effort of CDC, NCI, and the Centers for Medicare and Medicaid Services (CMS), with the slogan “Screen for Life.” (For additional information about CDC’s cancer prevention and control activities, refer to www.cdc.gov/cancer.)

Dr. Jon Kerner, Assistant Deputy Director for Research Dissemination and Diffusion at NCI’s Division of Cancer Control and Population Sciences, emphasized that cancer control should function across a seamless continuum from prevention, detection, diagnosis, treatment, to survivorship. This in turn should be coordinated across the discovery-delivery continuum: Discovery (research) arrow pointing right Development arrow pointing right Delivery arrow on top pointing left and arrow on bottom pointing right Policy. NCI’s principal program for closing the gap between research discovery and program delivery is Translating Research into Improved Outcomes (TRIO). TRIO has three aims: employ cancer and behavioral surveillance data to identify needs, track progress and motivate action; collaborate with other national public and private organizations (e.g., ACS, the Agency for Healthcare Research and Quality, CDC, CMS, the Health Resources and Services Administration, The Robert Wood Johnson Foundation, and the U.S. Department of Agriculture) to develop tools for accessing and promoting adoption of evidence-based cancer control interventions; and support regional and local partnerships to expand local capacity and integrate science into comprehensive cancer control planning and implementation.

As an example of the combined and coordinated effort required for optimal impact, Dr. Kerner cited the collaboration between NCI, CDC, ACS and the Substance Abuse and Mental Health Services Administration to develop Web-based research/practice tools for cancer control. The universal Web-portal that is being developed to link these Web-based tools is the Cancer Control PLANET (Plan, Link, Act, Network with Evidence-based Tools) program. PLANET will help cancer control planners, program staff, and researchers design and implement evidence-based prevention and intervention programs. PLANET can be used to plan a comprehensive cancer control program or can be used to search for specific cancer control tools, such as programs to promote the early detection of breast, cervical, and colorectal cancer; informed decisionmaking in prostate cancer; and prevention of cancer through tobacco use cessation, dietary change, increased physical activity and sun safety practices.

One example of how PLANET can be used is its application to address cervical cancer disparities. Thus, NCI and CDC are collaborating with USDA to train NBCCEDP outreach staff and USDA cooperative extension agents to examine incidence, mortality and screening behavior data to identify high-risk communities in high mortality counties. With this, they seek out and implement evidence-based interventions to promote breast and cervical cancer screening among high-risk women who have never been screened or have not been screened in the preceding 5 years. In addition, NCI sponsors CISNET, an activity in which a cooperative group of 17 grantees is modeling the impact of different intervention approaches on incidence and mortality for breast, prostate, lung and colorectal cancers. NCI will supplement these grantees in fiscal year 2003 to specifically model the most effective pathways to achieving the Healthy People 2010 objectives and include these recommendations in the 2004/05 midcourse review. (For additional information about NCI activities, go to www.nci.nih.gov.)

Approaches for Consideration

From the foregoing presentations and in comments elicited by Dr. Slater from other HHS staff present, the following suggestions for strategies emerged:

  • Promote increased smoking prevention and cessation activities, given that tobacco use continues to be the single largest cause of preventable premature mortality in the United States, most notably from lung cancer.
  • Strive to close disparities in use of evidence-based cancer screening modalities that impact hardest on those who lack health insurance or a usual source of care, or who are recent immigrants.
  • Seek to close the gap between research discovery and program delivery, one of the key determinants of the unequal burden of cancer.
  • Expand mathematical modeling to express mortality as a function of cancer control interventions.
  • Adapt models of cancer intervention to particular areas of the country using evidence-based best practices that have proven most effective for the circumstances.
  • Ensure that treatment capability is available and adequate to followup on cancer control interventions.
  • Stimulate partnering with other Federal and State agencies and nongovernment organizations to better serve health care consumers at the community level.
  • Make greater use of community and migrant health centers as sources of cancer prevention and treatment services.
  • Expand the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which presently is able to serve only 15 percent of the population.
  • Encourage communities to use cancer control interventions that are evidence-based and not merely customary or traditional.
  • Strengthen data sources to make them robust enough to yield cancer data at the county level nationwide.
  • Accelerate efforts to reach the Healthy People 2010 target of 45 States that have a population-based cancer registry that captures case information on at least 95 percent of the expected number of reportable cancers.
  • In the interest of increasing access to care, explore strategies to overcome infrastructure barriers to adjustment of reimbursement levels.
  • Increase research on cancer in children that may be environmentally mediated.
  • Use the Mammography Quality Standards Act as a guideline for developing similar standards for colorectal cancer screening.
  • Give greater attention to the availability of interventions used for colorectal cancer screening.

Contacts for information about Healthy People 2010 focus area 3 – Cancer

  • Centers for Disease Control and Prevention—Karen Richard-Lee, kmr4@cdc.gov
  • Office of Disease Prevention and Health Promotion (coordinator of the Progress Reviews)—Nancy Stanisic, nstanisic@osophs.dhhs.gov (liaison to the focus area 3 workgroup)

Richard H. Carmona
Richard H. Carmona, M.D., M.P.H., F.A.C.S.
VADM, USPHS
Surgeon General and Acting Assistant Secretary for Health

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