Cancer

1. Milestones in Public Health: Chapter 5 Cancer Lectures for Medical and Clinical Education January 2011

2. Learning Objectives • Define cancer • Describe the public health impact of cancer • Describe cancer health disparities • Describe cancer milestones in public health • Describe the role of screening in the four most common cancers • Describe the role of media advocacy in raising cancer awareness

3. Lecture Outline Looking Back Biology of Cancer Cancer Prevention Cancer Screening Advocacy

4. Cancer Looking Back

5. Tumors are described as early as 1600 BC in ancient Egyptian writings such as the Smith papyrus Looking Back Source: Courtesy of the National Library of Medicine

6. Looking Back (Cont.) Source: Courtesy of the National Library of Medicine Hippocrates introduced the term “carcinoma,” derived from karkinos (crab) The ancients saw the disease as clawing its way, crab-like, through the body Hippocrates proposed that cancer was a disease caused by an excess of black bile

7. Looking Back (Cont.) Pfizer Inc. (2006). Chapter 5: Cancer. In Milestones in public health : Accomplishments in public health over the last 100 years (p. 83).New York, NY: Pfizer Inc. In 1800, Marie Francois Xavier Bichat proposed that cancer was an overgrowth of cellular tissue Cells were identified as the fundamental unit in tumor tissue in 1830, after the invention of the microscope Rudolph Virchow’s 1858 theory that every cell originates from another cell became the foundation for the present understanding of cancer

8. Cancer Biology of Cancer

9. What is Cancer? Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells If the spread is not controlled, cancer can result in death. Cancer affects almost every part of the human body Cancer arises from the same material, cells, used by the body to construct its own tissues Abnormal masses of tissue are called tumors. Tumors can be benign (non-cancerous) or malignant (cancerous) Cancerous tumor cells differ from normal cells in many respects

10. What is Cancer? Cancerous tumor cells are abnormal and divide without order or control Cancerous cells can damage nearby tissue, and invade other areas of the body (metastasize). Tumor grade is a system used to determine how quickly the tumor is likely to grow and spread, and how abnormal the cells look under a microscope In determining tumor grade the growth pattern and structure of the cells are taken into consideration

11. What Causes Cancer? Cancer is caused by both external factors and internal factors that occur from metabolism (chemical processes occurring within a living cell or organism that are necessary for the maintenance of life) These factors may act together or in sequence to initiate the formation of cancer

12. Cancer Cancer Prevention

13. Leading U.S. Causes of Death, 2006 Source: US Mortality Data 2005, National Center for Health Statistics, Centers for Disease Control and Prevention, LCWK 1. Deaths, percent of total deaths, and death rate for the 15 leading causes of death in 5-year age groups, by race and sex, United States, 2006, “Cause of death (Based on the Tenth Revision, International Classification of Diseases, Second Edition, 2004), race, sex, and age.” (All races, both sexes, all ages). Retrieved May 29, 2010 from http://www.cdc.gov/nchs/data/dvs/LCWK1_2006.pdf

14. Cancer Statistics American Cancer Society (2008) Cancer Facts and Figures 2008. Retrieved June 10, 2010 from http://www.cancer.org/downloads/STT/2008CAFFfinalsecured.pdf Some 1.3 million Americans are diagnosed with cancer each year Following heart disease, cancer is the second most common cause of death in the U.S. More than 550,000 Americans die from cancer annually The median age for the diagnosis of cancer in adults is age 67 Lung cancer is the leading cause of cancer death among men and women Cancer affects nearly one in every two men Cancer affects nearly one in every three women

15. Preventable Cancer Causes American Cancer Society (2009), Cancer Facts and Figures 2009. Retrieved May 28, 2010 from http://www.cancer.org/downloads/STT/500809web.pdf Cancers caused by cigarette smoking can be prevented. In 2009, the American Cancer Society estimated that 169,000 cancer deaths would be caused by tobacco use In 2009 scientific evidence indicated that one third of US cancer deaths of the estimated 562,340, would be related to overweight, obesity, physical inactivity, and nutrition

16. 2009 Estimated U.S. Cancer Deaths Lung & bronchus 30% Prostate 9% Colon & rectum 9% Pancreas 6% Leukemia 4% Liver & intrahepatic 4%bile duct Esophagus 4% Urinary bladder 3% Non-Hodgkin 3% lymphoma Kidney & renal pelvis 3% All other sites 25% • 26% Lung & bronchus • 15% Breast • 9% Colon & rectum • 6% Pancreas • 5% Ovary • 4% Non-Hodgkin lymphoma • 3% Leukemia • 3% Uterine corpus • 2% Liver & intrahepatic bile duct • 2% Brain/ONS* • 25% All other sites Men292,540 Women269,800 ONS=Other nervous system. Source: American Cancer Society, “Cancer Statistics 2009: A presentation from the American Cancer Society,” * Retrieved May 29, 2010 from http://www.cancer.org/downloads/PRO/Cancer_Statistic_2009_Slides_rev.ppt#397,2,2009 Estimated US Cancer Deaths

17. Cancer Death Rates* Among Men, U.S., 1930-2004 Rate Per 100,000 Lung & bronchus Stomach Colon & rectum Prostate Pancreas Leukemia Liver *Age-adjusted to the 2000 US standard population. From the Cancer Statistics 2008: A Presentation from the American Cancer Society. Retrieved May 28, 2010 from http://www.acsevents.org/downloads/STT/Cancer_Statistics_2008.ppt#426,7,Cancer Death Rates* Among Men, US,1930-2004 Source: US Mortality Data 1960-2004, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

18. Cancer Death Rates* Among Women, U.S.,1930-2004 Rate Per 100,000 Lung & bronchus Uterus Breast Colon & rectum Stomach Ovary Pancreas *Age-adjusted to the 2000 US standard population. From the Cancer Statistics 2008: A Presentation from the American Cancer Society. Retrieved May 28, 2010 from http://www.acsevents.org/downloads/STT/Cancer_Statistics_2008.ppt#427,8,Cancer Death Rates Among Women, US,1930-2004. Source: US Mortality Data 1960-2004, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

19. Health Disparities and Cancer LaVeist, T. (2005). Minority populations and health: An introduction to health disparities in the united states. San Francisco : Jossey-Bass. • “Differences in the incidence, prevalence, mortality, and burden of diseases and other health conditions that exist among specific population groups in the United States.” National Institutes of Health, US Department of Health and Human Services • “Differences in the incidence or prevalence of disease disability, or illness. These differences can be among racial/ethnic groups, socioeconomic groupings, gender groups, or other groupings.”

20. Cancer Incidence Rates* by Race and Ethnicity, 2000-2004 Rate Per 100,000 *Age-adjusted to the 2000 US standard population. †Person of Hispanic origin may be of any race. From the Cancer Statistics 2008: A Presentation from the American Cancer Society, Retrieved May 29, 2010 http://www.acsevents.org/downloads/STT/Cancer_Statistics_2008.ppt#412,17,Cancer Incidence Rates* by Race and Ethnicity, 2000-2004. Source: Surveillance, Epidemiology, and End Results Program, 1975-2004, Division of Cancer Control and Population Sciences, National Cancer Institute, 2007.

21. Cancer Death Rates* by Race and Ethnicity, U.S., 2000-2004 *Per 100,000, age-adjusted to the 2000 US standard population. † Persons of Hispanic origin may be of any race. From the Cancer Statistics 2008: A Presentation from the American Cancer Society, Retrieved May 28, 2010 http://www.acsevents.org/downloads/STT/Cancer_Statistics_2008.ppt#428,9,Cancer Death Rates* by Race and Ethnicity, US, 2000-2004 Source: Surveillance, Epidemiology, and End Results Program, 1975-2004, Division of Cancer Control and Population Sciences, National Cancer Institute, 2007.

22. Cancer Cancer Screening

23. Cancer Screening Screening involves looking for early signs of a particular disease in asymptomatic people Cancer screening seeks to find cancers as early as possible, when the chance of cure is highest

24. When is Screening Helpful? While there are several types of cancer, not all cancers have screening tests. A screening test should: • Detect the cancer early • Not give false negatives • Not give false positives • Not be unpleasant or dangerous • Be cost-effective

25. Cancer Screening • Screening is used in the detection of the following cancers: • Breast (Mammography) • Cervix (Papanicolau smear) • Colon (Colonoscopy, Sigmoidoscopy, Fecal Occult Blood) • Prostate (Prostate Specific Antigen) • Identifying the majority of cancers in their early stage leads to improved diagnosis, less radical treatment, decreased mortality, and lower health care costs

26. The United States Preventive Services Task Force (USPSTF) Agency for Health Care Research and Quality, US Department of Health and Human Services (n.d.). US Preventive Services Task Force, About USPSTF. Retrieved May 28, 2010 from http://www.ahrq.gov/clinic/uspstfab.htm Sponsored by the Agency for Healthcare Research and Quality, US Department of Health and Human Services, the United States Preventive Services Task Force (USPSTF) represents “the leading independent panel of private-sector experts in prevention and primary care.” “The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services.”

27. Screening Recommendations and the USPSTF Issues recommendation statements for use in the primary care setting, including cancer screening Provides clinicians with the evidence behind each recommendation, allowing providers to make informed decisions about screening

28. USPSTF Grade Definitions Agency for Health Care Research and Quality, US Department of Health and Human Services. (n.d.).US Preventive Services Task Force Grade Definitions. Retrieved June 9, 2010 from http://www.ahrq.gov/clinic/uspstfab.htm The USPSTF employs a grading system based on the certainty of the net benefit, and assigns one of five letter grades to each of its recommendation statements (A, B, C, D, and I).

29. USPSTF Grade Definitions Agency for Health Care Research and Quality, US Department of Health and Human Services. (n.d.). US Preventive Services Task Force Grade Definitions. Retrieved June 9, 2010 from http://www.ahrq.gov/clinic/uspstf/gradespost.htm

30. Example: 2003 Cervical CancerScreening Recommendation Summary Agency for Health Care Research and Quality, US Department of Health and Human Services. (n.d.). US Preventive Services Task Force Screening for Cervical Cancer. Retrieve May 28, 2010 from http://www.ahrq.gov/clinic/uspstf/uspscerv.htm The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix. Grade: A Recommendation The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer (go to Clinical Considerations).Grade: D Recommendation The USPSTF recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease. Grade: D Recommendation The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of new technologies to screen for cervical cancer. Grade: I Statement The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of human papillomavirus (HPV) testing as a primary screening test for cervical cancer. Grade: I recommendation

31. Milestones in Cancer Treatment Pfizer Inc. (2006). Chapter 5: Cancer. In Milestones in public health : Accomplishments in public health over the last 100 years (pp. 86-88). New York, NY: Pfizer Inc. Until the 20th century, few cancer patients had a chance for long-term survival; however, two notable interventions, radiation therapy and chemotherapy, have improved survival rates: • Professor Wilhelm C. Roentgen’s work provided the foundation for radiation therapy for cancer • Dr. Min Chiu Li demonstrated that systemic chemotherapy could result in the cure of a widely metastatic disease

32. Cancer Media Advocacy and Cancer

33. Advocacy and Cancer Pfizer Inc. (2006). Chapter 5: Cancer. In Milestones in public health : Accomplishments in public health over the last 100 years (pp. 83-85). New York, NY: Pfizer Inc. The scientific discoveries aimed at treating and curing cancer occurred in a historical context where efforts by health care advocates led to the founding of national organizations addressing these aspects of intervening against cancer and decreasing the stigma surrounding this disease: • 1913 American Society for Cancer Control (ASCC) • 1936 National Cancer Institute • 1945 ASCC became the American Cancer Society • 1971 National Cancer Act

34. Advocacy and Cancer: The 1971 National Cancer Act Pfizer Inc. (2006). Chapter 5: Cancer. In Milestones in public health : Accomplishments in public health over the last 100 years (p. 85). New York, NY: Pfizer Inc. Mary Lasker, a philanthropist, who advocated for medical research on cancer, and Texas Senator Ralph Yarborough fought together to increase government expenditures in cancer research and treatment that resulted in a successful lobbying effort that culminated in the National Cancer Act of 1971 “The National Cancer Act established as a national priority the goal of conquering cancer and strengthened the National Cancer Institute’s ability to lead the national cancer program.”

35. Advocacy and Cancer National Cancer Institute. (2010). FY 2011 budget. Retrieved June 10 2010 http://www.cancer.gov/aboutnci/servingpeople/budgetrequest Pfizer Inc. (2006). Chapter 5: Cancer. In Milestones in public health : Accomplishments in public health over the last 100 years (p. 85). New York, NY: Pfizer Inc. The National Cancer Act of 1971 was a turning point in an on-going battle to address cancer -- the purpose of the act was to support basic research and apply the results of basic research to reduce the incidence, mortality and morbidity from cancer. Since 1971 research funds have grown from less than $1 million to $5.1 billion for the National Cancer Institute.

36. Advocacy and Breast Cancer Pfizer Inc. (2006). Chapter 5: Cancer. In Milestones in public health : Accomplishments in public health over the last 100 years (p. 94). New York, NY: Pfizer Inc. “Some of the most important contributions toward awareness of breast cancer screening in the United States came in 1974. At that time, three women in the public eye were battling cancer at the same time: Betty Ford, Susan G. Komen and Rose Kushner.” When Betty Ford was first diagnosed, breast cancer was rarely discussed in public and little was known about the disease. The first lady was the first high-profile American woman to publicly discuss her breast cancer, and she gained legions of admirers for the candor with which she faced her disease, as well as for her support of breast cancer awareness, screening and research.”

37. Health care delivery system Community Assuring the Conditions for Population Health Public Health Infrastructure Employers and Business Academia The Media Presence of the Media in the Public Health System Institute of Medicine (U.S.). Committee on Assuring the Health of the Public in the 21st Century. (2003). The future of the public's health in the 21st century. Washington, D.C.: National Academies Press.

38. Media and Public Health “If you don’t exist in the media, for all practical purposes you don’t exist.” Daniel Schorr, National Public Radio

39. Media Advocacy and Public Health Wallack, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 293-317 “The purpose of media advocacy is to promote public health goals by using the media to strategically apply pressure for policy change.”

40. Media Advocacy Wallack, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 293-317 “Provides a framework for moving the public health discussion from a primary focus on the health behavior of individuals to policymakers whose decisions structure the environment in which people act.”

41. Media Advocacy (Cont.) U.S. Department of Health and Human Services. Media Strategies for Smoking Control: guidelines. Washington, DC, U.S. Government Printing Office, 1989. (NIH Pub. No 89-3013) Wallack, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health.Health Education Quarterly, 23(3), 293-317 • “The strategic use of mass media to apply pressure to advance healthy public policy” • Employs “authentic voices,” advocates who can legitimately speak from the perspective of those most affected by the issue • Focuses on public policy rather than on individual behavior and as such addresses the power gap between community and the policy environment • The desired outcome in media advocacy is for a community to exercise influence over the policy environment through the employment of the media

42. Media Advocacy (Cont.) Wallack, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 293-317 Addresses the power gap rather than the information gap and focuses on public policy rather than personal on personal behavior

43. Social Marketing Andreasen, A. R. (1995). Marketing social change :Changing behavior to promote health, social development, and the environment. San Francisco, CA : Jossey-Bass “The application of proven concepts and techniques drawn from the commercial sector to promote change in diverse socially important behaviors such as drug use, smoking, sexual behaviors…” • Addresses the information gap

44. Media Advocacy vs. Social Marketing Wallack, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 293-317 Media Advocacy • Individual as advocate • Advances health public policies • Decentralized and opportunistic • Changes the environment • News and paid advertising • Targets person(s) with the power to make changes • Addresses the power gap Soc. Mktg./ Public Education • Individual as audience • Develops health messages and products • Focused and systematic • Changes the individual • Relies on public service and PR • Targets the person with the problem or at-risk • Addresses the information gap

45. Goals of Media Advocacy Get your stories covered Shape HOW your stories are covered

46. Framing Gamson, W. A. (1989). News as framing: Comments on Graber. American BehavioralScientist , 33, 157-161 Iyengar, S. (1989). Is anyone responsible? : How television frames political issues. Chicago: University of Chicago Press. “The frame is the format in which the key feature of the story is understood, developed, and supported.”

47. Frames Wallack, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 293-317 • Framing for access • Goal: get health issue/topic covered in the media • What’s covered in the media may not affect what people think, but affects what people think about • Framing for content • Goal: get health topic covered in a particular way (from perspective of advocate)

48. Framing for Access Wallack, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 293-317 Shaping the story to get the journalist’s attention “Pitching” in PR industry jargon (“What’s the pitch?”) Creating events and recognizing anniversaries tied to advocacy Using celebrity spokespersons Find an individual’s story that makes it real for the journalist For television, what’s the visual element?

49. Framing for Content Wallack, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 293-317 Telling the story from the policy advocacy perspective Addressing root causes Pursuing social accountability (who or what is to blame and what changes will fix the problem?)

50. What Makes a Good Story? Wallack, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 293-317 • Content • Controversy/Conflict/Injustice • Local peg • Anniversary • Breakthrough/First • Celebrity • Compelling visuals and symbols • Authentic voices • “Media bites”