Fulfilling the Potential of Cancer Prevention and Early Detection An American Cancer Society and Institute of Medicine Symposium (2004) / Chapter Skim
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2 Plenary Session
2 Plenary Session
Pages 6-65
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From page 6... ...
We will have the opportunity through the course of this day to engage in discussion of ways that we can move forward. I am also very pleased that this program was sponsored jointly with the American Cancer Society (ACS)
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From page 7... ...
Dr. von Eschenbach, prior to the time that he was scheduled to become the Director of the National Cancer Institute, was poised to take over at the American Cancer Society as president-elect, so he has been detoured from that duty but, I understand from Dr.
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From page 8... ...
In that regard, the idea of the strategic inflection simply is the realization that with regard to diseases like cancer, for the first time we are really understanding cancer as a disease process, and understanding it at the very fundamental genetic, molecular, and cellular mechanisms. This strategic inflection, this new paradigm, is really creating for us extraordinary opportunities that enable us to begin to approach the burden of disease in fundamentally different ways.
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From page 9... ...
If we now begin to think about the product of our investment in research as giving us an understanding of cancer as a disease process, we begin to see that there are multiple steps within that process that make cancer vulnerable. We can think about it as a process in which even before malignant transformation, there is a stage of the process in which we are susceptible to disease, susceptible because of exposure to things like tobacco, or susceptible just because of aging.
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From page 10... ...
But there can be a significant strategy of integration of these interventions to enable us to bring about the outcome of modulation and elimination of suffering and death. We have chosen to approach this at the National Cancer Institute in the context of a portfolio of investment in three areas: discovery; development; and delivery.
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From page 11... ...
One of the important aspects of the launch of this study was a collaboration with the American Cancer Society to work in the community around the 30 centers that are carrying out this study to promote education, awareness, and recruitment to this study. So, again, it is a collaborative effort to achieve success.
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From page 12... ...
And we have opportunities with regard to risk identification and the important role that the human papilloma virus plays, especially in cancer of the cervix. We have an opportunity through the development of cancer vaccines and the cervical cancer vaccine trials that are underway to be able to eliminate disease by a preventative interventional strategy.
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From page 13... ...
Working together, we can bring about the objectives and realize the opportunities to accomplish this goal. View from the ACS: Fulfillment of the Potential of Cancer Prevention John Seffrin, Ph.D., CEO, American Cancer Society It is a privilege for me to be here and to represent the American Cancer Society, the world's largest voluntary health organization and the largest notfor-profit in America today that receives over 90 percent of its total support from private contributions.
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From page 14... ...
The ten leading causes of death in the United States. SOURCE: Mortality Public Use Data Tape 2000, National Cancer Center for Health Statistics, Centers for Disease Control and Prevention, 2002.
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From page 15... ...
That is impressive, although you might say it is not a free fall. But from roughly 1991 to 2000, that represents in the aggregate 200,000 deaths that didn't occur if the cancer mortality rates had remained the same.
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From page 16... ...
We have turned the corner on this disease, and while there is a great deal yet to be done, we are no longer simply trying to stem the ever-increasing tide of higher cancer incidence and mortality rates. Second, we have discovered that prevention works.
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From page 17... ...
The prevalence of women reporting a recent mammogram has increased almost 40 percent, from 45 percent in 1990 to 63 percent in the year 2000. As you know, we have seen a decade of decline in breast cancer mortality in women in the United States.
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Obesity trends among adults in the United States (1985~. me, ~ ~~ ~0 ~ 0%-1 4% 15%-19% 20%-25% Figure 5.
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From page 19... ...
Among them is our increasingly sedentary lifestyle. Let me share some data with you from the American Cancer Society's Cancer Prevention Study II (CPS II)
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From page 20... ...
When we look at tobacco use combined with exercise patterns, just two risk factors, the impact is predictable, and it is still shocking. Women who exercise regularly and don't smoke are less than a third as likely to die in mid-life than women who smoke and lead a sedentary life.
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From page 21... ...
I was in town over the weekend for the meeting of the National Dialogue on Cancer, which the American Cancer Society is proud to be a part of with 150 other collaborating partners. The Dialogue's CEO roundtable has developed something called "The Gold Standard," which is evidence-based, state-of-the-art cancer screening and prevention guidelines in employee benefits.
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From page 22... ...
I am an epidemiologist, and I have a problem remembering numbers. People ask me, what is the breast cancer incidence rate?
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From page 23... ...
We can't reverse the epidemic of obesity or start screening everybody tomorrow. It is based on the premise that with additional efforts doing things that we know work proven behavioral programs and other policies with achievable, reasonable efforts, we could foresee improvements of about that order of magnitude, that is, about a ten percent further reduction.
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From page 24... ...
I got a letter last week from a woman in Colorado that reminded me about the value of single lives. We are doing a mass mailing campaign in Colorado to Medicare beneficiaries to ask them to ask their physicians to give colon cancer screening, which is a Medicare benefit.
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From page 25... ...
The Cancer Information Service has been leveraged to include participation in cancer screening and for the adoption of healthy eating behaviors. There is no reason why the infrastructure that is in place for these programs at the state and national levels could not be expanded.
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From page 26... ...
For example, NCQA does this for tobacco cessation assistance, mammography, and cervical cancer screening. These efforts can be built upon.
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From page 27... ...
First, revenues from taxes can be used to pay for what is needed to increase access to, and demand for individual programs, such as health lines and mass media campaigns. Second, we know from careful research with tobacco that when taxes increase prices, there is a direct and significant effect on tobacco use.
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From page 28... ...
Wouldn't it be nice if it was an anachronism in 2013? Comments, Questions, and Answers Leonard Lichienfeld, M.D., Deputy Chief Medical Officer, American Cancer Society, Moderator Participant: On September 18 and 19 of this year, the National Dialogue on Cancer will convene a prevention summit to which they are inviting key leaders from around the nation, including state and local officials, community-based organization leaders, and others.
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From page 29... ...
The bottom line is, we went to any number of human resource directors and chief medical officers with things we thought made sense, and never could get to first base. But we began moving when we got CEOs around the table and thinking who was their ~ The costs of getting from current coverage to 100% compliance with ACS screening guidelines for breast, cervical, prostate, and colorectal cancer over about five years, not including costs of treatment of cancers, the benefits including disability, life insurance, and employee replacement cost avoidance, among others.
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From page 30... ...
I would also agree with Peter Greenwald that CMS coverage for clinical preventive services is important; in fact, coverage for preventive services across all the federal programs from the Indian Health Service to prisons to Medicare and Medicaid is important. Also employer, employee, insurance company relationships with regard to clinical preventive services are important.
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From page 31... ...
Ms. Mulhauser, Clinical Social Worker, Children's Medical Center: Several years ago there was an effort to increase internist reimbursement for preventive services, but it was not a real successful effort.
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From page 32... ...
For those here from the American Cancer Society, the academic community, it's a moral imperative. Who is going to take this imperative into the future beyond these well established people?
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From page 33... ...
Dr. von Eschenbach: Maybe there is an opportunity here.
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From page 34... ...
Superimposed on that experience, I have had the opportunity to advance to national positions that have allowed me to look at the entire nation. For example, as the national president of the American Cancer Society in 19881989, or for a number of years as chairman of the President's Cancer Panel, I could look both ways, big, broad, but probably always through the lens of
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From page 35... ...
Over the years, there have been important reports that have dealt with the issue of disparities. In 1989, the American Cancer Society report on cancer in the poor (American Cancer Society, 1989)
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From page 36... ...
The discovery-delivery continuum, which Dr. von Eschenbach speaks about a lot, needs a lot of attention.
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From page 37... ...
Social position, economic status, culture, and environment are critical determinants of who is born healthy, who grows up healthy, who sustains health throughout the life span, who survives disease, and who maintains a good quality of life after diagnosis and treatment. It is not just the medical disease, the molecular manifestations, that we must learn to understand.
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From page 38... ...
Prostate cancer national incidence and mortality by race and ethnicity (1 992-1 999~.
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From page 39... ...
Female breast cancer national incidence and mortality by race and ethnicity (1992-1 999)
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From page 40... ...
But in examining who smokes among adults in America, the highest percentage is in Native Americans. According to National Center for Health Statistics surveys and SEER data, they are smoking more than anyone else.
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From page 41... ...
So we thought of the concept of navigation, which actually came out of the 1989 American Cancer Society report on cancer and the poor. In that report, the people said to us that they had difficulty in negotiating the health care system.
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From page 42... ...
42 AMERICAN CANCER SOCIElrY & IOM SYMPOSIUM Intervention Research PATIENT WAVIGAT10N ~ o £3 .= C, ~ Cal Z Figure 13. Patient navigation helps patients transition from an abnormal finding to a resolution by assisting in their journey through the health care system.
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From page 43... ...
The stages of the people who were in the study in Harlem were eight percent of them in stage one compared to 38 percent in the national SEER data and 61.8 percent in stage three and four compared to 23 percent in the SEER statistics. So, people are coming in very late with colorectal cancer, just as they did for breast cancer.
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From page 44... ...
In this group, in 128 biopsies, we found five early colorectal cancers, six tubulovillous adenomas, and 32 adenomatous polyps of other kinds. We think that if we have success in getting people in for one thing, whatever it might be, and breast cancer screening is popular with women, why not see if we can take them to the next step?
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From page 45... ...
Wanting is not enough. We must do." Delivering Quality Cancer Prevention Hugh Staley, M.D., Medical Director for Quality and Research, Group Health Cooperative, Seattle, Washington I am very pleased to have been asked to speak here today and privileged to be among such distinguished speakers and panelists.
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From page 46... ...
Although we are making huge investments in clinical information systems, we are decreasing the number of people we have building content and building guidelines. We have to become more efficient.
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From page 47... ...
That is why we have prevention programs and screening programs for breast cancer, colorectal cancer, and recommendations for prostate cancer which I will speak about, but our primary prevention strategy is in cessation of tobacco use. Our current care model as illustrated in Figure 14 is the paradigm upon which we organize the systems of care, both for prevention and for disease management.
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From page 48... ...
As tools for implementation, we use patient-based registries that are available for our primary care practitioners, clinical guidelines, patient education materials, case management strategies for chronic care, as well as case management for certain prevention strategies, referral guidelines and most importantly, clinical information systems. The business of health care is really in transmitting information, and the clinical information system is Group Health's one capital investment that we have been making over the last five years.
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From page 49... ...
Colorectal cancer screening is still one of the most cost effective screening programs, as is breast cancer screening. Those are built into our system.
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From page 50... ...
If you don't join the program, you pay for the nicotine replacement therapy. Identification of smoking status, brief, repetitive positive advice, assistance offered to those wanting to quit, and, of course, coverage, are some of the things that need to be systematically put into the system.
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From page 51... ...
We have multidisciplinary steering committees, coordinating groups, and information systems. Letters go out to women that are enrolled in our breast cancer screening program to remind them when it is time for their regular screening.
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From page 52... ...
This was the controversy of the mid 1990s with the American Cancer Society, American Urologic Society, American College of Radiology, among others, recommending mass population-based screening and the National Cancer Institute, the U.S. Preventive Services Task Force, among others, more cautiously not recommending mass screening or recommending a shared decision making model.
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From page 53... ...
In answer to the question, what can we focus on, I believe that tobacco cessation remains the number one preventive goal that all of our systems must take on, although we are now learning about the obesity epidemic and what we can do to stop that. As the IOM report says, "Helping the 23.5 percent of adults who smoke cigarettes discontinue their habit and preventing youth from adopting the habit will save more lives than the sum of all the incremental benefits of improving cancer screening rates or cancer treatments." That is my quick run-through of how Group Health Cooperative is trying to close the gap in hopes that others may learn something from our efforts and experiences.
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From page 54... ...
First, I want to commend the National Cancer Policy Board, the Institute of Medicine, the American Cancer Society and particularly Drs. Byers and Curry for their report.
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From page 55... ...
The evidence-based screening services, those represented in the IOM report as meeting a consensus about what ought to be covered, are covered as part of our basic benefit package. A report that is under development through the Partnership for Prevention, funded by the Robert Wood Johnson Foundation, examines an active set of initiatives to try and better understand and encourage the role of employers and their perspectives on the delivery of preventive services (http://www.prevent.org/publications/Preventive_Services_Helping_Employers_Expand_Coverage.pdf)
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From page 56... ...
The compound annual growth rate of per-employee revenue, what companies are bringing in, is growing about three percent annually, whereas health care costs are going up about ten percent annually. The response by the employer community has been to pick up some of those costs, but also to have more employee cost sharing.
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From page 57... ...
An example is prohibition of"drive-through delivery," or, in particular, the example of autologous bone marrow transplant that was pushed as a mandate in the absence of evidence these seemed like attractive approaches, but they had some real problems. A second structural issue is the temporal problem for preventive services.
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From page 58... ...
Another innovation is the use of reminder programs, pioneered by the health insurance industry with leadership from NCQA. I mention these not because you haven't heard about them, but just to show you some of the scale that insurance companies are capable of that is, 430,140 reminders for mammography screening sent out last year and 537,913 reminders for cervical cancer screening in the form of attractive and thoughtful Hallmark cards with the result that screening is driven from 50 to 69 percent and from 70 to 78 percent for breast and cervical cancer screening, respectively.
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From page 59... ...
Some of you may have seen the article in the Wall Street Journal, "Skyrocketing Health Care Costs Pit Worker against Worker. Employees gripe that those with bad habits drive up insurance charges for all." The more you push a preventive medicine
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From page 60... ...
I think each one of these sectors has a role in that redirection. The American Cancer Society has a tremendously important role as the lead voluntary organization in this field, to raise the issue not only of advances in research at the basic level, at the translational level, but also to encourage the effective delivery of services to the entire nation, to all of our population, particularly those who are most
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From page 61... ...
The public sector clearly has a role in ensuring that evidencebased medicine becomes the standard and proven evidence-based preventive services are in place, and the private sector role is to support innovation, to go to scale, to continue to support evidence-based prevention and screening, and to work with the other sectors to make all this happen. Comments, Questions, and Answers Len Lichienfeld, M.D., Moderator William Dietz, M.D., Ph.D., CDC: My question comes from a book called Epidemic of Care by Halvorson and Isham (Halvorson and Isham, 2003)
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From page 62... ...
If you look through the guidelines for clinical preventive services from the U.S. Preventive Services Task Force, over and over again you see there is insufficient evidence to recommend for or against.
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From page 63... ...
A very good example of this might be colonoscopy for colorectal cancer screening. It is very expensive up front.
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From page 64... ...
Our successful programs are those that were carved out of primary care. Our breast cancer screening program, our tobacco cessation programs were integrated; information was transferred back and forth.
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From page 65... ...
Then you also have to overcome the anecdotal experience of physicians themselves, about having that one hysterectomized patient on whom you didn't do the Pap smear, who gets a vaginal carcinoma, so you have a lot of factors that you have to overcome as far as educating the physician. Plus, physicians are dinosaurs; we tend to practice what we were taught in residency.
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