Fulfilling the Potential of Cancer Prevention and Early Detection An American Cancer Society and Institute of Medicine Symposium (2004) / Chapter Skim
Currently Skimming:
3 Group Discussions
3 Group Discussions
Pages 66-114
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From page 66... ...
I just want us to think for a moment about the behavior change that the company was aiming for. You are a shopper.
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From page 67... ...
Therefore, in obesity and physical activity, given so much of the research effort is focused on obesity and weight loss at a clinical level as opposed to the public health effort, we, in collaboration with CDC and others,
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From page 68... ...
Dr. Dietz has talked about the number of venues in the area of physical activity.
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From page 69... ...
Here we are talking about cancer prevention and early detection, but I think it really does make sense in terms of planning and coordination to talk about chronic disease prevention. Therefore the disease groups, both public, private, non-profit advocacy, all of us government and non-government, still have a way to go in terms of putting our forces together.
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From page 70... ...
At the federal level we have got huge deficits. At the state level, you have all been reading about unprecedented levels of deficits in many states.
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From page 71... ...
We are again going to have to fight hard to keep people using evidence-based solutions for public health purposes. Many states, New York, Delaware, Connecticut, Florida, have all passed statewide clean indoor air laws.
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From page 72... ...
Dr. William Dietz, Director of the Division of Nutrition and Physical Activity, CDC: What opportunities are there to link and create synergy between policy initiatives for tobacco and obesity?
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From page 73... ...
We do have some strategies, like promotion of breast feeding, control of television time in children, and physical activity, but we don't yet have a food-related strategy.
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From page 74... ...
There is an imbalance between the motivation of the food industry that depends on increasing food consumption for its products and the desire to shrink portion sizes and slim down the population. This conflict has to be resolved through incentives or disincentives because that is the only thing that really seems to work in a free society.
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From page 75... ...
I don't think there is an adequate evidence base that justifies calorie taxation, anymore than you could justify taxation on the other side of the energy balance equation. I suspect that incentives may work better.
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From page 76... ...
One of the points I make in the quit smoking program where I work is that if people can exercise or increase physical activity as they are going through a quit attempt, it will help them avoid that post-cessation weight gain, and secondly, it will help them deal with the stress of nicotine withdrawal. There are powerful ways in which we can combine these two interventions (quitting smoking and increasing physical activity)
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From page 77... ...
The closest we come to a national plan for tobacco control is Healthy People 2010. As I have argued previously (Davis, 1998)
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From page 78... ...
Every advocate or lobbyist on Capitol Hill is pushing a policy of some sort. So, back to the point about the food industry, the trick is to identify policies that have the usual benefits to as many possible constituents and still achieve the goal that you are trying to achieve.
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From page 79... ...
There are about 20 states that now have comprehensive cancer plans, and by this time next year all 50 states will have them. States are going to be implementing those plans mainly in the community, and this provides an opportunity for us to begin to put together tobacco, obesity, diet, physical activity and all of the rest of the early detection and research continuum.
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From page 80... ...
Dr. William Dietz: CDC is funding 20 states this year for nutrition, physical activity, and obesity programs, and the mandate that those programs have is to integrate across current state programs which include the cancer, cardiovascular disease, and diabetes programs as well as across agencies.
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From page 81... ...
Perhaps, experts could give us one large table that lists interventions that are definitely effective, smoking cessation being the best example. Employers in America could let their employees know, through posters and other communication methods, that there is scientific evidence from the National Cancer Institute, American Cancer Society, and other authoritative sources: a)
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From page 82... ...
Medicare is structurally a defined benefit program which means that categories of benefits are defined in the statute, so getting patient care is a defined benefit; durable medical equivalent is a defined benefit. The things that are not defined in the statute as categories of benefits are not covetable no mat
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From page 83... ...
It is not prevention, diagnosis and treatment; it is diagnosis and treatment of illness and injury. The absence of the prevention language has meant that it is not possible to add preventive services in the Medicare program except from time to time through individual statutory changes.
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From page 84... ...
The only ones I am aware of are payment for the initial preventive examination, waiving the deductible for colorectal cancer screening, increased payment for mammography, and diabetes screening. In the House bill these are, I think, the four items that deal with prevention, and there is nothing in the Senate bill that I'm aware of.
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From page 85... ...
So, in terms of disparities, and particularly focusing on how low income adults receive preventive services, this seems to be a major area that currently has, and will have an even greater gap as we move forward. That gets to issues of support for CDC in breast and cervical cancer prevention and screening and extending that to colorectal cancer.
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From page 86... ...
Dr. Susan Curry: The biggest risk factor for smoking initiation is parents smoking.
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From page 87... ...
When you think about evidence-based, you need to think for whom, because if you work in a specific population and you are talking about weight loss intervention or other sorts of physical activity programs, one program is not going to be effective for everybody.
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From page 88... ...
I'll share with you a document that RTI prepared for our board at the American Legacy Foundation, where we do spend a great deal of our resources on primary prevention of smoking for the youth campaign, a media and grass roots campaign called the Truth Campaign. What they concluded was that they were roughly equivalent.
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From page 89... ...
I think the massive decline in smoking that has occurred in California is almost entirely attributable to the mass media campaign activating peoples' thinking about smoking. It resulted in the change in the clean indoor air laws; it resulted in many more people seeking cessation services; it resulted in many adults quitting, and children didn't start because they didn't see their parents smoking.
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From page 90... ...
Dr. Len Lichtenfeld: I was really impressed with the data from Group Health that showed that only two percent of subscribers were getting PSA testing, especially in relation to the comment that shared decision making may be an excuse for making no decision.
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From page 91... ...
Clement Bezold, President, Institute for Alternative Futures, Moderator: In this discussion we hope to look at the average time for innovation and focus in particular on, first, how we can change the current process of funding, reporting, and disseminating research results in cancer prevention to decrease the time it takes to get information on effective strategies into clinical practice and public awareness and, second, on what new research funding or shared funding initiatives are needed to increase the number of studies that apply rigorous scientific methods to evaluate dissemination strategies.
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From page 92... ...
With regard to publication and reporting, in the work the Division of Cancer Prevention and Control is doing with the NCI and others on the Community Guide, one of the challenges has been to adequately evaluate the published community intervention research and to summarize findings across studies because of the way information is reported. Frequently, information that would allow us to say how generalizable findings are in the different populations is missing.
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From page 93... ...
Perhaps the American Cancer Society should be considering doing dissemination of research through the ACS divisions. I think CDC should take a leadership role in doing dissemination research through state health departments.
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From page 94... ...
There are two general approaches to cancer prevention, a public health approach and more recently, a medical approach. On the public health side, state health agencies could be funded to address this, but I am afraid that has collapsed in the past few years.
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From page 95... ...
I would say the biggest area that needs support with funding is training. Nobody is trained to do what we do in cancer prevention.
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From page 96... ...
The report focuses on things like smoking cessation, diet, and physical activity counseling, the delivery or the recommendation for screening interventions. There is not much profit in those, and, of course, profit drives what the drug companies are doing to get the adoption of a product.
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From page 97... ...
But a survey of primary care practitioners and ob-gyns that we did at SloanKettering in the mid-1980s showed that the number one predictor of counseling in smoking cessation was whether the doctor had quit smoking. The number one predictor on counseling in physical activity was whether doctors had changed their physical activity, and the number one predictor on counseling on nutrition was whether they had changed their diets to lose weight.
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From page 98... ...
What we did was we had 52 locales, community practices with their hospitals, taking part in clinical trials. Part of the result is the information, like the recent prostate prevention trial, but another part is the motivation for cancer control.
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From page 99... ...
I know that Health Canada says that there is a possible relationship, and the World Cancer Research Fund says that there is a probable relationship. What is confusing for people doing comprehensive cancer control planning or wanting to do community interventions on risk factors is identification of what those risk factors are.
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From page 100... ...
The Robert Wood Johnson Foundation and the American Cancer Society and a lot of other agencies could go out and do some of that audience work for us and with us so that we have a better idea, and we can stop assuming that simply because we produced something that summarized the evidence anybody actually cared to look at it, read it, and then presumably did something about it.
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From page 101... ...
It is competing priorities. How much attention can you devote to any particular health issue at any moment?
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From page 102... ...
Group Discussion IV Prevention Through Education and Primary Care Dr. Len Lichtenfeld, Moderator: In this discussion, we hope to explore who is accountable for ensuring education in prevention and early detection, what leverage points there are for monitoring delivery of evidencebased prevention interventions, and how state health departments and federal agencies, like CMS, can advance prevention as a priority Dr.
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From page 103... ...
We hope that all of these educational inputs for the physician are generally going to be framed around evidence-based practice guidelines, such as those of the U.S. Preventive Services Task Force.
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From page 104... ...
are the bodies that accredit graduate medical education, so those are additional points at which we can influence national educational policies. Beyond that, we can work with individual medical schools, with individual residency programs, to try to ensure that they address cancer prevention and early detection.
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From page 105... ...
The IOM report on cancer prevention and early detection didn't get anywhere near the attention that the one on medical errors did. The impact of the patient safety report (and the publicity surrounding it)
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From page 106... ...
Dr. Robert Smith, Director of Cancer Screening, American Cancer Society: As I looked at this report, I thought, we've got this critical need for undergraduate and graduate medical education.
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From page 107... ...
We have an opportunity to build in cancer prevention and detection as part of routine primary care.
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From page 108... ...
What opportunities do we have to partner with managed care organizations? What are they doing now in anticipation of HEDIS and colon cancer screening down the road in 2004?
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From page 109... ...
The problem is the people that don't walk in the office, that is where we fail. We were not delivering preventive services then that we knew people should have.
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From page 110... ...
Dr. Robert Smith: When you look at commonly recommended preventive health behaviors and guidance related to physical activity, maintaining a healthy weight, and nutrition, these recommendations are associated with lower risk for a number of chronic conditions, and therefore organizations focused on cancer, heart disease, and diabetes clearly have an opportunity to promote a broader benefit than may be apparent to the public if we focus on just one disease at a time.
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From page 111... ...
So the more patients start asking for something, the more physicians are revising their standard of care, the more they start initiating care they perceive patients desire. We are seeing this in colorectal cancer, a very good example.
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From page 112... ...
I think there are four critical elements in the disease care system effectiveness, efficacy, bias, and system change. We don't have proven effective strategies in primary care to counsel on nutrition, physical activity, and some other clinical preventive services.
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From page 113... ...
To me, those systems are not too much different than what we have already got in place for breast and cervical cancer screening, but we've got really different systems that you are going to need for primary prevention.
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From page 114... ...
We can't ask for accountability to administer all the services recommended by the U.S. Preventive Services Task Force guidelines, because that could take seven hours a day of a physician's time (Yarnell et al., 2003~.
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