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25. Cancer Cancer is the second leading cause of death in the United States, constituting approximately 20 percent of all deaths. The leading killers are lung, colorectal, and breast cancers. Over 30 percent of Americans now living eventually will develop some form of cancer. Many cancer deaths are preventable, however. The American Cancer Society estimates that about 178,000 people died in 1989 from cancer, who might have been saved by earlier diagnosis and treatment. (#177) 'Cancer' is not a single disease, according to Michael Ske~els of the Oregon Department of Human Resources, abut rather a diverse set of clinical and epidemiological entities. Perhaps the only feature that cancers share in common is the underlying process, which involves a loss of control of normal cell growth." (~321) Although many approaches to preventing cancer were mentioned in the hearings, this chapter focuses primarily on cancer screening and on secondary prevention issues. It highlights two forms of cancer that affect women breast and cervical cancers-and a type of cancer that is increasing at a rapid pace, malignant melanoma. Many of the risk factors most often associated with prevention of cance~smoking, dietary habits, exposure to toxic substances, and other environmental causes are addressed at length in Chapters 10, 12, 17, and 18. Witnesses make the point that the people stricken by cancer are just as diverse as the disease itself, and efforts must be made to target screenings, prevention programs, and treatments to the needs of each specific group. Many testifiers express grave concern about the cancer morbidity and mortality rates among Blacks. Robert Rutman of the University of Pennsyl- vania says, "The excess cancer risk facing the Black population is not only a major moral and ethical problem, it also is a costly financial one." Hispanics, too, are singled out for special attention, as are women who need to be brought into screening programs, especially mammography screening. Harold Freeman of the American Cancer Society is concerned that the United States, as a nation, is not attending to the poor, minorities, and others who are not part of the mainstream. We have directed most of our attention to those who can understand our language and pay our price. Unfortunately, many 186 Healthy People 2000: citizens Chart the Course people are dying who are not in that category." (#443J Although only 12 witnesses focused their testimony specifically on cancer, 52 addressed it in discussions of other topics. SPECIFIC CANCERS During the course of the seven hearings, lung cancer the most common fatal cancer for both men and women received considerable attention. However, other cancers were not overlooked. According to Skeets. In males, the second and third most common primary sites for fatal cancer are the prostate and the large intestine (colorectal cancer). In 1987, breast cancer was the second, and colorec tal cancer the third leading type of fatal malig nancy in females.2 (#321) Recognizing the importance of colorectal cancer, Linda Randolph of the New York State Department of Health suggests an objective of Increasing the proportion of adults who have occult blood testing, sigmoidoscopy, and digital rectal examinations per- formed at regular integrals." (#177) Oral cancer, discussed at some length especially by dentists and dental hygienists, is covered in Chapters 10 and 26. Breast and Cervical Cancer Although effective screening techniques exist to detect breast and cervical cancer, many women are not taking advantage of them. Witnesses testifying about these cancers emphasized the importance of increasing the percentage of women who are screened. Until recently surpassed by lung cancer, breast cancer was the leading cause of mortality in women. According to American Cancer Society statistics cited by witnesses, approximately 142,000 cases of invasive breast cancer are diagnosed each year, and one third of the women who develop breast cancer in 1989 will die of it.3 Morbidity and mortality from this disease could be reduced, several witnesses emphasize, if more women used the three screening techniques: breast self-examination, physical exam, and mammography.

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(#256; #336; #452; #484) Similarly, inadequate use of screening is resulting in needless deaths from cervical cancer. Witnesses call for increases in the number of women who undergo Pap smears to check for cervical cancer. Ann Norman of the University of Washington focused on the need to get more older women screened: approximately one out of every ten women in this country will develop breast cancer, and 75 percent of those cancers will be detected among women 50 years of age or older.4 She notes that although older women are at greater risk of dying from breast or centrical cancer than younger women, they are less likely to participate in cancer screening.s Norman also cites research showing that older women are about as likely as younger women to survive these cancers if they are detected early.6 (#336) Norman and others note that the National Cancer Institute (NCI) Goals for the Year 2000: Cancer Con- trol for the Nation7 addresses screening of older wo- men, whereas the 1990 Objectives failed to target this group. She argues that NCI goals should be included in the Year 2000 Health Objectives. Those goals are (1) to increase the percentage of 50- to 70-year-old women who have an annual physical breast examina- tion combined with mammography to 80 percent (it is now 45 percent for physical examination alone and 15 percent for mammography), and (2) to increase the percentage of women 40 to 70 years old who have a Pap smear every three years from 57 to 80 percent. (#336) In addition to older women, witnesses suggest that low-income and non-White women be targeted in programs aimed at increasing screening utilization. (#020; #256; #452; #488; #615) Alvin Mauer and Mona Arreola of the University of Tennessee, Mem- phis, report that a year-long study of women admitted to a local hospital for treatment of breast or uterine cancer showed that poor women were coming in for breast cancer treatment at a later stage than others. Their study found that the reasons for the advanced stage at diagnosis could not be explained easily. The results of the study indicated that, unfor tunately, none of the simpler hypotheses were upheld. The women interviewed knew about cancer and its warning signs; they experienced no difficulties in gaining access to health care. The problem of delayed presentation appeared to be related to underlying psychosocial behavioral factors that confounded the iden tification of a simple solution.8 (#256) Jose Lopez of the San Antonio Tumor and Blood Clinic made similar observations about Hispanics. He cites figures from one study in New York on know- ledge and use of breast cancer detection among Hispanics: fewer Hispanic women did breast self- examination within the last year than non-Hispanic women; fewer Hispanic women have had a mam- mogram; and fewer have had a Pap smear. (~488) An important impediment to the use of mammog- raphy is cost, according to witnesses. Even with the recent addition of mammography coverage to Medi- care, gaps remain. Guy Newell and Charles LeMaistre of the University of Texas M.D. Anderson Hospital and Tumor Institute suggest a number of ways to reduce the cost of mammography screenings; for example, fewer films could be taken in routine screenings.9 Newell and LeMaistre emphasize that cost and other barriers must be overcome so that more women can undergo mammograms. Increased use of mammography depends on scientific consensus, policy making, marketing strategies, and cost reduction, among other factors. Endorsement of mammography screen- ing by the medical profession coupled with availability at reasonable costs for the individual will be required for the widespread application of mammography screening. Until screening for breast cancer becomes a routine preventive practice, deaths from breast cancer will continue to be an increasing public health problem. (#484) Addressing specifically the need to overcome barriers to testing among older women, Norman says that more research is needed on psychosocial factors, the role of physicians in assuring that older women are screened, and other areas. Innovative programs and approaches to the use of screening among older women should be tested as well. (~336J Malignant Melanoma Malignant melanoma was portrayed as an ideal candidate for an aggressive prevention program by William Robinson of the University of Colorado Health Sciences Center. He said that this type of skin cancer, which almost always affects Caucasians, has reached epidemic proportions. The incidence of malignant melanoma is increasing faster than any other cancer, yet the disease is largely preventable. (#708) Cancer 187

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The rising incidence of the disease is due to increased exposure to sunshine and ultraviolet light, caused by changes in clothing habits and migration to the sunbelt, Robinson explained. It is a disease of the upper middle class. Those affected typically have brown, light brown, or light reddish hair and non- brown eyes. "We know what causes it, and we know who to target for the educational campaigns that need to be carried out," he says. This is an area in which a concerted prevention campaign could greatly reduce morbidity and mortality. (#708) POOR AND MINORITIES The inadequate utilization of breast and cervical screening techniques among Blacks and Hispanics is part of a broader-based gap in cancer prevention in those communities, witnesses reported. Although limited national data on cancer rates among Hispanics indicate that they apparently have lower rates of some of the most common malignan- cies, several factors contribute to an increased risk of some types of cancer mortality, according to Lopez. He cites several factors to account for the increased risk, including later stage of cancer at diagnosis; lack of access to the health care delivery system; and certain knowledge, attitudes, and practices regarding cancer that are peculiar to Hispanics. (#488J Lopez says that Hispanics are more fearful of getting cancer than other people, but they show, at best, a moderate awareness of the major risk factors for the disease. It is necessary to overcome psycho- logical, cultural, and economic barriers to reach the Hispanic community with cancer programs, he added; "Hispanics tend to be fatalistic, feel there is a stigma attached to cancer, and have questions and concern about the treatment and the costs." (~488J Hispanics in California follow the national pattern of "substantially lower" cancer incidence than non- Hispanic Whites, but Lester Breslow of the University of California, Los Angeles is concerned that as Hispanics "adopt the culture and way of life" of the area, there will be a "very sharp Use" in their cancer rates. He calls for Year 2000 Health Objectives to give "explicit attention to minority problems." (#026) John Bruhn of the University of Texas Medical Branch at Galveston points out that in some areas of Texas and for some types of cancer (stomach, liver, and gallbladder for males; uterine and cervical cancer for females), Mexican-Americans already are more 188 Healthy People 2000: Citizens Chart the Course vulnerable than Whites. He says that "targeted edu- cation programs and readily available screening clinics should be of high priority. (#235) The picture is even bleaker for Blacks, who "still have the highest overall age-adjusted cancer rate for both incidence and mortality of any U.S. population," according to Osman Ahmed of Meharry Medical Col- lege. (~269) Judith Glazner of the Denver Depart- ment of Health and Hospitals quotes several statistics for Black women illustrating the gap: ~Nationally, the incidence rate for breast cancer has increased 1 per- cent per year; but while the mortality rate for White women has remained unchanged, for Black women it has increased 1 percent per year. For uterine cancer, the mortality rate among White women has declined 2.4 percent per year for the past five years, whereas for Black women, it has decreased by only 1.1 per- cent.~ f#377) Margaret Hargreaves, Osman Ahmed, and their coauthors from Meharry Medical College cite American Cancer Society figures indicating that in the last 30 years, cancer death rates for Blacks increased 40 percent, whereas the White rate increased only 10 percent; 30 years ago, Black and White rates were about the same. Data for 1967-1973 show that fewer Blacks than Whites had cancer diagnosed at an early stage when the chances of cure are greatest. Blacks are less knowledgeable than Whites about warning signs and cancer tests, they noted. (#615) The NCI recognizes the need to reach minority groups if its goal of reducing cancer mortality 50 percent by the year 2000 is to be met, according to testimony, and the NCI is beginning to address these issues. Minority representatives emphasized that cul- turally sensitive information about cancer and cancer detection tests is essential to any health education effort. Cancer in minority populations is discussed further in Chapter 6. Testimony from the American Cancer Society (ACS) underscores the increased risk of cancer among poor people. Harold Freeman, ACS spokesman, reports that there is a 10-15 percent lower survival rate among poor people in America, regardless of race. At least half of the difference in survival is due to late diagnosis. He says that the increased preva- lence of risk factors, such as smoking, poor nutrition, environmental exposures, and alcohol intakes also contribute to the variations. (#443) Primary prevention aimed at controlling risk factors could probably control two-thirds of the cancers,

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according to Freeman. However, efforts aimed at improving secondary prevention-primarily early diagnosis~re also important because the poor tend to seek care late. Instilling preventive habits is not easy, REFERENCES 1. American Cancer Society: Cancer Facts and Figures, 1989. Atlanta: 1989 Freeman acknowledges: "It is difficult to convince someone who is being shot at to have a rectal exam." (~443) 2. National Center for Health Statistics: Health United States, 1989. (DHHS Publication No. [PHS] 90-1232), 1990 3. American Canoer Society: op. cit., reference 1 4. Seidman H. Mishinski M, Gelb S. et al.: Probabilities of eventually developing or dying of cancer-United States, 1985. CA Cancer J Clin 35~1~:36-56, 1985 5. Gallup Organization: 1983 survey of public awareness and use of cancer detection tests for the American Cancer Society. New Jersey: The Gallup Organization, 1983 6. Baranovsky A, Myers MH: Cancer incidence and survival in patients 65 years of age and older. CA Cancer J Clin 36~1~:26-41, 1986 7. Greenwald P. Sondik EJ (Eds.~: Cancer Control Objectives for the Nation. 1985-2000. National Cancer Institute. NCI Monographs, No.2. (NCI Publication No. 86-2880), 1986 8. Mauer AM, Rosenthal T. Murphy J. et al.: Delayed Diagnosis in Breast and Uterine Cancer: A Study in Secondary Prevention. Unpublished study, Memphis: University of Tennessee, 1986-1987 9. American Cancer Society: Workshop on strategies to lower the cost of screening mammography, July 16-18, 1986. Executive Summary. Cancer 60:1700-1701, 1986 10. National Cancer Institute: Cancer Statistics Review, 1973-1986. (NIH Publication No. 89-2789), May 1989 11. American Cancer Society: Cancer Facts and Figures for Black Americans. New York: 1986 12. American Cancer Society: Cancer in the Economically Disadvantaged: A Special Report. Prepared by the Subcommittee on Cancer in the Economically Disadvantaged. June 1986 TESTIFIERS CITED IN CHAPTER 25 020 Bernstein, Robert; Texas Department of Health 026 Breslow, Lester; UCLA School of Public Health 177 Randolph, Linda; New York State Department of Health 235 Bruhn, John; University of Texas Medical Branch at Galveston 256 Mauer, Alvin and Arreola, Mona; University of Tennessee, Memphis 269 Ahmed, Osman; Diehard Medical College 321 Skeets, Michael; Oregon Department of Human Resources 336 Norman, Ann Deucy; University of Washington, School of Social Work 377 Glazner, Judith; Denver Department of Health and Hospitals 443 Freeman, Harold; State University of New York at Buffalo 452 Santee, Barbara and Alexander, Alpha; National Board of the YWCA of the United States Cancer 189

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484 Newell, Guy and LeMaistre, Charles; University of Texas M.D. Anderson Hospital 488 Lopez, Jose; San Antonio Tumor and Blood Clinic 615 Hargreaves, Margaret; Meharry Medical College 708 Robinson, William; University of Colorado Health Sciences Center ,, 190 Healthy People 2000: Citizens Chart the Course