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Public health and cancer prevention: Success and future challenges in cancer policy

PHILADELPHIA Medical research has revealed much about cancer prevention, but is the information reaching all Americans, and are they acting on it" Today, at the American Association for Cancer Researchs Sixth Annual International Conference on Frontiers in Cancer Prevention Research, being held from December 5 to 8 in Philadelphia, Pennsylvania, researchers explore the question of how best to translate cancer prevention science into public health policy.

Quitting smoking and inoculation with the human papillomavirus (HPV) vaccine are two ways that major segments of the general population can drastically lower their risk of developing certain cancers, yet researchers have found that these messages are not necessarily translating into action by the public. Likewise, researchers found that minority women fare worse between time of breast cancer diagnosis and treatment, then do Caucasian women, highlighting a worrisome gap in health care among racial and ethnic minorities.

Policies to reduce tobacco harm: What works? Abstract no. A29

To discourage cigarette use, the strategies that are working best on a global basis are to use large graphic package warning labels, ban cigarette advertising, institute smoke-free policies, increase cigarette prices and implement methods to prevent smuggling and counterfeiting of tobacco products, say researchers at Roswell Park Cancer Institute involved in an International Tobacco Control (ITC) Policy Evaluation study. What hasnt worked as well as hoped is mandating tar and nicotine levels in cigarettes, they add.

The researchers have been investigating progress on controlling tobacco use from the ongoing Framework Convention on Tobacco Control (FCTC), the treaty devoted to improving public health put forth by the World Health Organization.

The FCTC was adopted by WHOs member states in May, 2003, and became legally binding for those countries that ratified the treaty in 2005. To date, 151 countries have done so, and are thus required to implement the policies within three years.

For the first time ever, we are beginning to scientifically assess which governmental tobacco control policies are working and which ones are not, said K. Michael Cummings, Ph.D., MPH, chair of the Department of Health Behavior at Roswell Park Cancer Institute. In the same way that evidence-based medicine has been built from rigorous evaluation of treatment options, our goal is to contribute to the development of a sound science base for tobacco control policies.

The ITC serves to study which policies are working best in countries that have imposed restrictions, says Cummings. Cummings started the study in four countries in 2002 with a $1.5 million grant from the Robert Woods Johnson Foundation, and to date, $35 million has been raised to expand the research into 15 countries, utilizing the aid of 60 investigators from 17 research institutes.

Because randomized clinical trials cant be used to evaluate government policies, the ITC study uses as controls those countries that have implemented tobacco control policies and compares the effects on tobacco use behaviors in countries that have not, such as the United States. It is tracking tobacco use behaviors of 1,000 to 2,000 participants in each of the countries, Cummings says. This is a new model for global public health research that can be used to evaluate other public health policies such as HIV, diet, and cancer screening, he said.

It made sense for WHO to start off with tobacco as a focal point for action since tobacco use is the leading cause of preventable death in the world today and is a growing epidemic in the developing world, he said. Tobacco use was responsible for 100 million deaths in the 20th century, and that number is expected to grow to 1 billion in the 21st century, he says.

ITC researchers have found that boosting tobacco taxes, comprehensive advertising bans, smoke-free laws, and strengthening cigarette package warnings is an effective recipe for reducing tobacco consumption. Our research on package warnings has revealed that these warnings, especially if they are large and graphic, are more effective than anyone realized, especially in poorer countries that cant afford expensive counter-marketing campaigns, he said.

An example of a policy that hasnt worked, Cummings says, is the European Unions (EU) establishment of maximum emission standards for tar and nicotine. The goal was to make cigarettes less toxic, but the testing method adopted by the EU was flawed and cigarette makers increased filter ventilation to get around the new rules. Actual exposure to toxins didnt change. The well intentioned, but flawed EU policy has given smokers the false illusion that their cigarettes deliver less tar and nicotine, when they dont, he said.

The ITC has also established the first international cigarette repository, which currently holds 10,000 cigarette pack varieties from 15 different countries. This research shows that tobacco manufacturers alter their products frequently without revealing that they are doing so, he says. Foods and drugs are regulated so that consumers are informed when the products are altered. The same should be true for tobacco products, Cummings said.

Physician Intentions and HPV Vaccination: The First Year. Abstract no. A104

Before last summer, when the FDA approved use of the first vaccine developed to prevent cervical cancer, 92 percent of several hundred family care physicians surveyed in the poorer urban areas of metropolitan New York City said they would recommend the vaccine to their young female patients. But over a year later, only 10 percent of these same physicians had actually vaccinated some of their patients, report researchers at Columbia University.

While vaccines usually take time to come into widespread use, a delay in use of this proven cancer preventative will result in lost opportunity for many young women, says the studys lead investigator. Sherri Sheinfeld Gorin, Ph.D., a senior member of the Herbert Irving Comprehensive Cancer Center and Associate Professor of Health Behavior.

Routine use of the vaccine will play out over time, but how many women will be deprived in the intervening years" she said. Physician recommendation is key to vaccination, and these findings suggest there is a critical need for strategies that encourage physicians to follow through on their own good intentions.

The study first sampled 235 multi-ethnic/racial urban primary care physicians with a questionnaire in early 2006 to see if these doctors intended to discuss use of the human papilloma virus (HPV) vaccine, when approved, with their young female patients. Its important to know if physicians plan to educate their patients about HPV prevention, because fewer than one-third of the population has heard of HPV, Sheinfeld Gorin said.

They found that 92 percent of the physicians were extremely or somewhat likely to use the vaccine and that doctors who routinely offer pelvic examinations for their female patients, who are more familiar with the professional guidelines for cervical cancer screening, and who are female, were most likely to offer the vaccine.

But a follow-up audit of a proportion of patient charts in these practices, conducted between 12-18 months after the vaccine was approved, found that only 10 percent had vaccinated eligible young patients. By contextual comparison, 14 percent of patients received the hepatitis B vaccine in 1991, about one year after it was approved for universal use among infants.

Sheinfeld Gorin says she has some clues as to why so few physicians actually used the vaccine once it was approved. One is cost: even though the vaccines $360 price tag is usually reimbursed by insurance, physicians have to pay for their vaccine stocks up front, they have to store them and make sure they dont expire. That is a financial burden some physicians dont want to have until use of the vaccine becomes more commonplace, she said.

Another is that physicians may not have had a chance yet to discuss the vaccine with their young patients. But the most likely scenario, based on other studies, is that physicians presume patients will not be accepting of an HPV vaccine, Sheinfeld Gorin says. So they dont talk about it yet, and expect that social acceptance will improve in the future, she said. But, in fact, research has shown that patients are quite responsive to the vaccine. Thats why we need a strategy now to help physicians discuss HPV vaccines with their patients.

Time interval from diagnosis to treatment of breast cancer at an NCI Comprehensive Cancer Center: Survival and associated demographic factors. Abstract no. A9

Race and age appear to play a role in how quickly a woman newly diagnosed with breast cancer is surgically treated, with a lengthy delay potentially impacting overall survival, report researchers at Johns Hopkins Medical Institutions. Factors such as socioeconomic status and the cumulative effects of a patient's other illnesses likely contribute to these delays, they say.

Preliminary results of their study of 1,477 patients show that the average interval from breast cancer diagnosis to surgery was six days longer for African-American women than for Caucasian women. Women who were older than age 70 had an average interval of 12 more days than women younger than 40.

The researchers also observed that the women who experienced an interval of more than 60 days between diagnosis and treatment were 1.8 times more likely to have died from any cause when compared to women who had their surgery within 60 days of diagnosis. In this study, the average interval from diagnosis to surgery for all patients was 29 days.

We think that timely treatment could make difference in patient care, said Hae Seong Park, M.D., M.P.H., a research coordinator in the Department of Oncology at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins.

As the study is based on the registry data from a single institution, further research is necessary to confirm the findings and to generalize the results. All of the patients had surgery either a lumpectomy or mastectomy between 2000 and 2005 at Johns Hopkins Hospital, including those who had a diagnostic biopsy at a different institution.

The researchers found that on average, Caucasian women were treated 28 days from diagnosis, compared to 34 days for African-American women. On average, women younger than 40 were treated within 21 days; patients 40-50 were treated within 28 days; women in their 50s were treated within 31 days; patients 60-70 were treated by 29.5 days after diagnosis; and women over age 70 had an average treatment interval of more than 33 days.

Investigators also looked at the place and year of diagnosis and found that the shortest interval, 24 days on average, occurred during 2000-2001; and the longest was 2002-2003 when the average interval was 34 days. Intervals were less in 2004-2005 (almost 30 days).

There were no significant differences in time to treatment based on the stage of cancer that a woman was diagnosed with, Park says. Although this is one factor that one might expect a time differential, we did not observe much difference, she said.

Worrisome to the researchers, however, was the finding that almost 24 percent of patients did not receive adjuvant therapy, such as chemotherapy or hormone therapy following surgery. Preliminary findings suggested that patients who had surgery more than 60 days from diagnosis received adjuvant therapy less frequently. This might be of greater importance, since we know that receiving adjuvant therapy does improve survival, Park says. Most patients should have received such treatment, but it may be that the cancer registry data did not reflect all of this information, she said.

The investigators also did not have information on the patients insurance status or any other data that could explain some of the time lags. We plan to review individual patient records and collect more information to confirm what we observed, and perhaps to think about interventions to provide more timely and complete care, Park said.


Contact: Greg Lester
American Association for Cancer Research

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