Showing papers in "CA: A Cancer Journal for Clinicians in 2004"

Cancer Statistics, 2004

Abstract: Each year, the American Cancer Society estimates the number of new cancer cases and deaths expected in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival rates based on incidence data from the National Cancer Institute and mortality data from the National Center for Health Statistics. Incidence and mortality rates are age standardized to the 2000 US standard million population. A total of 1,368,030 new cancer cases and 563,700 deaths are expected in the United States in 2004. Incidence rates stabilized among men from 1995 through 2000 but continued to increase among females by 0.4% per year from 1987 through 2000. Mortality rates have decreased by 1.5% per year since 1992 among men, but have stabilized from 1998 through 2000 among women. Cancer death rates continued to decrease from the three major cancer sites in men (lung and bronchus, colon and rectum, and prostate) and from female breast and colorectal cancers in women. In analyses by race and ethnicity, African-American men and women have 40% and 20% higher death rates from all cancers combined compared with White men and women, respectively. Cancer incidence and mortality rates are lower in other racial and ethnic groups than in Whites and African Americans for all sites combined and for the four major cancer sites. However, these groups generally have higher rates for stomach, liver, and cervical cancers than do Whites. Furthermore, minority populations are more likely to be diagnosed with advanced stage disease than are Whites. Progress in reducing the burden from cancer can be accelerated by applying existing cancer control knowledge into practice among all segments of the population.

Cancer disparities by race/ethnicity and socioeconomic status

Abstract: This article highlights disparities in cancer incidence, mortality, and survival in relation to race/ethnicity, and census data on poverty in the county or census tract of residence. The incidence and survival data derive from the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) Program; mortality data are from the National Center for Health Statistics (NCHS); data on the prevalence of major cancer risk factors and cancer screening are from the National Health Interview Survey (NHIS) conducted by NCHS. For all cancer sites combined, residents of poorer counties (those with greater than or equal to 20% of the population below the poverty line) have 13% higher death rates from cancer in men and 3% higher rates in women compared with more affluent counties (less than 10% below the poverty line). Differences in cancer survival account for part of this disparity. Among both men and women, five-year survival for all cancers combined is 10 percentage points lower among persons who live in poorer than in more affluent census tracts. Even when census tract poverty rate is accounted for, however, African American, American Indian/Alaskan Native, and Asian/Pacific Islander men and African American and American Indian/Alaskan Native women have lower five-year survival than non-Hispanic Whites. More detailed analyses of selected cancers show large variations in cancer survival by race and ethnicity. Opportunities to reduce cancer disparities exist in prevention (reductions in tobacco use, physical inactivity, and obesity), early detection (mammography, colorectal screening, Pap tests), treatment, and palliative care.

Soft Tissue Sarcomas

Abstract: Sarcomas are a heterogeneous group of rare tumors that arise predominantly from the embryonic mesoderm. They present most commonly as an asymptomatic mass originating in an extremity but can occur anywhere in the body, particularly the trunk, retroperitoneum, or the head and neck. Pretreatment radiologic imaging is critical for defining the local extent of a tumor, staging the disease, guiding biopsies, and aiding in diagnosis. Core-needle biopsy is the preferred biopsy technique for diagnosing soft tissue sarcomas. The American Joint Committee on Cancer (AJCC) staging system for soft tissue sarcomas is based on histologic grade, the tumor size and depth, and the presence of distant or nodal metastases. Despite improvements in local control rates with wide local resections and radiation therapy, metastasis and death remain a significant problem in 50% of patients who present with high-risk soft tissue sarcomas. The most common site of metastasis is the lungs, and metastasis generally occurs within two to three years after the completion of therapy. Progress in the molecular characteristics of these tumors should in the near future translate into molecularly based therapies that can be incorporated into standard treatment strategies.

The staging of colorectal cancer: 2004 and beyond.

Abstract: Stage is the strongest predictor of survival for patients with colorectal cancer Accurate staging also is critical for appropriate patient management and meaningful clinical research Uniform staging criteria applied in a uniform manner are essential for accurate evaluation of therapies and outcomes Historically, numerous different staging systems for colorectal cancer have been employed, but a single internationally recognized system is required to ensure a common language for cancer that is understood by clinicians in all specialties For the tumor, node, metastasis system to remain relevant, it has to continuously undergo critical evaluation and change when clinically indicated

An Evidence‐based Staging System for Cutaneous Melanoma

Abstract: A completely revised staging system for cutaneous melanoma was implemented in 2003 The changes were validated with a prognostic factors analysis involving 17,600 melanoma patients from prospective databases This major collaborative study of predicting melanoma outcome was conducted specifically for this project, and the results were used to finalize the criteria for this evidence-based staging system In fact, this was the largest prognostic factors analysis of prospectively followed melanoma patients ever conducted Important results that shaped the staging criteria involved both the tumor-node-metastasis (TNM) criteria and stage grouping for all four stages of melanoma Major changes in the staging include: (1) melanoma thickness and ulceration are the dominant predictors of survival in patients with localized melanoma (Stages I and II); deeper level of invasion (ie, IV and V) was independently associated with reduced survival only in patients with thin or T1 melanomas (2) The number of metastatic lymph nodes and the tumor burden were the most dominant predictors of survival in patients with Stage III melanoma; patients with metastatic nodes detected by palpation had a shorter survival compared with patients whose nodal metastases were first detected by sentinel node excision of clinically occult or "microscopic" metastases (3) The site of distant metastases (nonvisceral versus lung versus all other visceral metastatic sites) and the presence of elevated serum lactate dehydrogenase (LDH) were the dominant predictors of outcome in patients with Stage IV or distant metastases (4) An upstaging was implemented for all patients with Stage I, II, and III disease when a primary melanoma is ulcerated by histopathological criteria (5) Satellite metastases around a primary melanoma and in-transit metastases were merged into a single staging entity that is grouped into Stage III disease (6) A new convention was implemented for defining clinical and pathological staging so as to take into account the new staging information gained from lymphatic mapping and sentinel node biopsy

Long-term Complications Following Childhood and Adolescent Cancer: Foundations for Providing Risk-based Health Care for Survivors

Abstract: Survivors of childhood and adolescent cancer are one of the higher risk populations seen by health care professionals. The curative therapy administered for the cancer also affects growing and developing tissues. Following chemotherapy, radiation therapy, and surgery, many survivors will experience chronic or late-occurring health problems, often not becoming clinically apparent until decades after therapy. Survivors face an increased risk of morbidity, mortality, and diminished quality of life associated with their previous cancer therapy. Risk is further modified by the survivor's genetics, lifestyle habits, and comorbid health conditions. Over their lifetime, survivors will see health care professionals from an array of specialties and disciplines. The aim of this review is threefold: (1) to convey a sense of the risk faced by survivors to clinicians unfamiliar with the population; (2) to provide an up-to-date tool for clinicians, regardless of specialty or discipline, when providing care for a survivor; and (3) to complement the recently completed recommendations for screening, prevention, and management of childhood cancer survivors.

Chemoprevention of Cancer

Abstract: Cancer chemoprevention is defined as the use of natural, synthetic, or biologic chemical agents to reverse, suppress, or prevent carcinogenic progression to invasive cancer. The success of several recent clinical trials in preventing cancer in high-risk populations suggests that chemoprevention is a rational and appealing strategy. This review will highlight current clinical research in chemoprevention, the biologic effects of chemopreventive agents on epithelial carcinogenesis, and the usefulness of intermediate biomarkers as markers of premalignancy. Selected chemoprevention trials are discussed with a focus on strategies of trial design and clinical outcome. Future directions in the field of chemoprevention will be proposed that are based on recently acquired mechanistic insight into carcinogenesis.

Poverty, culture, and social injustice: determinants of cancer disparities.

Abstract: In 1971, President Richard Nixon signed the National Cancer Act and declared a “War Against Cancer.” In the more than 30 years since this declaration of war, the nation has made extraordinary progress in our understanding of the causes of cancer, especially at the molecular level. We have also witnessed a dramatic evolution in the development of various therapeutic modalities resulting in more effective, more targeted, and less destructive cancer treatments. From a public health perspective, we have a seen a decline in the percentage of adults who smoke cigarettes. Note that tobacco is the cause of more than one third of cancer deaths. Related to this progress, an overall decline in cancer mortality has occurred in the last several years. However, some Americans have not fully benefited from this progress as evidenced by their higher cancer incidence, mortality, and lower survival. Stating this another way, there is a critical disconnect between what we discover and what we deliver, between what we know and what we do for all people (Figure 1). It is critical to accurately define which groups of Americans suffer a heavier burden of cancer, determine the causes, and apply interventions to eliminate the disparities. In this issue of CA, Ward and others highlight disparities in cancer incidence, mortality, and survival in relation to race/ethnicity and socioeconomic status. They conclude that for all cancer sites combined, residents of poorer counties have a higher cancer death rate than residents in more affluent counties. Ward further concludes that even when poverty rates are accounted for, some racial groups (eg, African Americans and American Indians/Alaskan Natives have a lower five-year survival rate than non-Hispanic Whites. Note also that within each racial/ethnic group, looked at separately, those living in poorer counties have the lowest survival rates according to Surveillance, Epidemiology, and End Results (SEER) Program data. For a better understanding of the issues raised by Ward et al., it is important to review the background of our current knowledge of cancer disparities. In 1973, Henschke noted an “alarming increase” in the cancer mortality in African Americans in the preceding 25 years. After the publication of this study, the National Cancer Institute (NCI) increased its focus on racial differences in cancer incidence, mortality, and survival. In 1986, based on a subcommittee’s findings, the American Cancer Society (ACS) issued a “Special Report on Cancer in the Economically Disadvantaged.” The report concluded that the poorer cancer outcome in African Americans compared with White Americans is primarily related to lower socioeconomic status in African Americans. The study concluded further that poor Americans, irrespective of race, have a 10% to 15% lower five-year survival. A pivotal report by Freeman in 1989 provided an analysis and broad overview of these findings. In 1989, the ACS issued its report “Cancer in the Poor: A Report to the Nation.” This report was the culmination of a series of fact-finding hearings held throughout the nation in collaboration with the NCI and Centers for Disease Control (CDC). Poor people with cancer of all racial and ethnic groups testified. The key findings were: Y Poor people lack access to quality health care and are more likely than others to die of cancer. Y Poor people endure greater pain and suffering from cancer than most Americans. Y Poor people face substantial obstacles to obtaining and using health insurance and often do not seek needed care if they cannot pay for it. Y Poor people and their families must make extraordinary personal sacrifices to obtain and pay for health care. Y Cancer education and outreach efforts are insensitive and irrelevant to many poor people. Y Fatalism about cancer prevails among the poor and prevents them from gaining quality health care. Dr. Freeman is Director, Center to Reduce Cancer Health Disparities, National Cancer Institute, Rockville, MD.

Preventing Cancer, Cardiovascular Disease, and Diabetes: A Common Agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association*†

Abstract: Collectively, cardiovascular disease (including stroke), cancer, and diabetes account for approximately two-thirds of all deaths in the United States and about 700 billion US dollars in direct and indirect economic costs each year. Current approaches to health promotion and prevention of cardiovascular disease, cancer, and diabetes do not approach the potential of the existing state of knowledge. A concerted effort to increase application of public health and clinical interventions of known efficacy to reduce prevalence of tobacco use, poor diet, and insufficient physical activity-the major risk factors for these diseases-and to increase utilization of screening tests for their early detection could substantially reduce the human and economic cost of these diseases. In this article, the American Cancer Society, the American Diabetes Association, and the American Heart Association review strategies for the prevention and early detection of cancer, cardiovascular disease, and diabetes, as the beginning of a new collaboration among the three organizations. The goal of this joint venture is to stimulate substantial improvements in primary prevention and early detection through collaboration between key organizations, greater public awareness about healthy lifestyles, legislative action that results in more funding for and access to primary prevention programs and research, and reconsideration of the concept of the periodic medical checkup as an effective platform for prevention, early detection, and treatment.

American Cancer Society guidelines for the early detection of cancer, 2004.

Abstract: Each January, the American Cancer Society (ACS) publishes a summary of its recommendations for early cancer detection, including updates, emerging issues that are relevant to screening for cancer, or both. In the spring of 2003, the ACS announced updated guidelines for breast cancer screening, and several other organizations released updated guidelines that we compare with recent ACS updates. Finally, the most recent data pertaining to participation rates in cancer screening are presented by age and sex from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System, as are U.S. maps profiling states based on the proportion of the age-eligible population not recently screened for breast cancer or colorectal cancer.

Clinical Breast Examination: Practical Recommendations for Optimizing Performance and Reporting

Abstract: Clinical breast examination (CBE) seeks to detect breast abnormalities or evaluate patient reports of symptoms to find palpable breast cancers at an earlier stage of progression. Treatment options for earlier-stage cancers are generally more numerous, include less toxic alternatives, and are usually more effective than treatments for later-stage cancers. For average-risk women aged 40 and younger, earlier detection of palpable tumors identified by CBE can lead to earlier therapy. After age 40, when mammography is recommended, CBE is regarded as an adjunct to mammography. Recent debate, however, has questioned the contributions of CBE to the detection of breast cancer in asymptomatic women and particularly to improved survival and reduced mortality rates. Clinicians remain widely divided about the level of evidence supporting CBE and their confidence in the examination. Yet, CBE is practiced extensively in the United States and continues to be recommended by many leading health organizations. It is in this context that this report provides a brief review of evidence for CBE's role in the earlier detection of breast cancer, highlights current practice issues, and presents recommendations that, when implemented, could contribute to greater standardization of the practice and reporting of CBE. These recommendations may also lead to improved evidence of the nature and extent of CBE's contribution to the earlier detection of breast cancer.

HPV Communication: Review of Existing Research and Recommendations for Patient Education†

Abstract: The potential for human papillomavirus (HPV) DNA testing in cervical cancer prevention programs has been a topic at the forefront of cervical cancer policy discussions in recent years. To prevent some of the anxiety and psychological distress often experienced on HPV diagnosis and during the period of management, mass patient education must accompany the incorporation of HPV DNA testing into screening protocols. To contribute to a growing body of work that provides an empiric basis for development of effective counseling messages about HPV and HPV testing, this paper highlights women's most common information gaps and psychosocial concerns and describes the different perspectives offered by women's usual sources of information about HPV, including the crucial role of the clinical community in creating a shared decision making environment in which screening decisions and results can be discussed.

Performance and reporting of clinical breast examination: a review of the literature.

Abstract: Clinical breast examination (CBE) seeks to detect breast abnormalities or evaluate patient reports of symptoms to find palpable breast cancers at an earlier stage of progression, when treatment is more effective and treatment options are greater than for later stage disease. Evidence suggests that, for some women, CBE can be an important complement to mammography in the earlier detection of breast cancer; CBE identifies some cancers missed by mammography and provides an important screening tool among women for whom mammography is not recommended or women who do not receive high-quality screening mammography according to recommended guidelines. But CBE performance and reporting approaches are inconsistent. Health care providers indicate that they are not confident in their CBE skills and would welcome training. Studies demonstrate that training can enhance CBE performance, measured in terms of execution of CBE components and accuracy. This literature review provides evidence to the extent that it is available, to support the specific recommendations of Saslow, et al. for optimizing CBE performance and reporting and to guide further research on CBE performance characteristics, reporting systems, barriers to high-quality CBE performance, and training.

A new method of predicting US and state-level cancer mortality counts for the current calendar year.

Abstract: Every January for more than 40 years, the American Cancer Society (ACS) has estimated the total number of cancer deaths that are expected to occur in the United States and individual states in the upcoming year. In a collaborative effort to improve the accuracy of the predictions, investigators from the National Cancer Institute and the ACS have developed and tested a new prediction method. The new method was used to create the mortality predictions for the first time in Cancer Statistics, 2004 and Cancer Facts & Figures 2004. The authors present a conceptual overview of the previous ACS method and the new state-space method (SSM), and they review the results of rigorous testing to determine which method provides more accurate predictions of the observed number of cancer deaths from the years 1997 to 1999. The accuracy of the methods was compared using squared deviations (the square of the predicted minus observed values) for each of the cancer sites for which predictions are published as well as for all cancer sites combined. At the national level, the squared deviations were not consistently lower for every cancer site for either method, but the average squared deviations (averaged across cancer sites, years, and sex) was substantially lower for the SSM than for the ACS method. During the period 1997 to 1999, the ACS estimates of deaths were usually greater than the observed numbers for all cancer sites combined and for several major individual cancer sites, probably because the ACS method was less sensitive to recent changes in cancer mortality rates (and associated counts) that occurred for several major cancer sites in the early and mid 1990s. The improved accuracy of the new method was particularly evident for prostate cancer, for which mortality rates changed dramatically in the late 1980s and early 1990s. At the state level, the accuracy of the two methods was comparable. Based on these results, the ACS has elected to use the new method for the annual prediction of the number of cancer deaths at the national and state levels.

Understanding cancer clusters.

Abstract: Each year, state and local health departments respond to more than 1,000 inquiries about suspected cancer clusters. Three quarters of these reports involve situations that are clearly not clusters and can be resolved by telephone. For the remainder, follow-up is needed, first to confirm the number of persons affected, their age, type of cancer, dates of diagnosis, and other factors, and then to compare cancer incidence in the affected population with background rates in state tumor registries. In approximately 5% to 15% of the reported situations, formal statistical testing confirms that the number of observed cases exceeds the number expected in a specific area, given the age, sex, and size of the affected population. Even in these instances, however, chance remains a plausible explanation for many clusters, and further epidemiologic investigation almost never identifies the underlying cause of disease with confidence. The few exceptions have involved clusters of extremely rare cancers occurring in well-defined occupational or medical settings, generally involving intense and sustained exposure to an unusual chemical, occupation, infection, or drug. This article discusses the resources and scientific tools currently available to investigate cancer clusters. It also provides a framework for understanding cancer clusters and a realistic appraisal of what cluster investigations can and cannot provide in the context of community expectations.

Alternative cancer cures: "unproven" or "disproven"?

Abstract: Oncology has always coexisted with therapies offered outside of conventional cancer treatment centers and based on theories not found in biomedicine. These alternative cancer cures have often been described as "unproven," suggesting that appropriate clinical trials have not been conducted and that the therapeutic value of the treatment is unknown. Contrary to much popular and scientific writing, many alternative cancer treatments have been investigated in good quality clinical trials, and they have been shown to be ineffective. In this article, clinical trial data on a number of alternative cancer cures including Livingston-Wheeler, Di Bella Multitherapy, antineoplastons, vitamin C, hydrazine sulfate, Laetrile, and psychotherapy are reviewed. The label "unproven" is inappropriate for such therapies; it is time to assert that many alternative cancer therapies have been "disproven."

Identifying and Testing for Hereditary Susceptibility to Common Cancers

Abstract: Hereditary cancer syndromes account for an estimated 5% of breast, ovarian, and colon cancers. The rapid discovery of cancer-related genes in the last 15 years has propelled the field of cancer genetic risk assessment forward. With patients becoming increasingly aware of available genetic testing options, it is important that various health professionals become knowledgeable in identifying and advising patients at increased risk for a hereditary cancer syndrome. This article will outline the components of providing a hereditary cancer risk assessment with a focus on hereditary breast and ovarian cancer syndrome and hereditary colon cancer.

Why am I scared of HPV

Abstract: As a physician community, we must develop proven educational methods to explain human papillomavirus (HPV) so that we do not invoke patients’ confusion, guilt, anxiety and psychological distress. Patient participation in any type of medical care is dependent on their understanding of the problem, confidence in their knowledge and choice of medical options, and the cost of care relative to other important aspects of their life. HPV education should address the sexually transmitted nature of HPV, the natural history and outcomes of HPV infection, the medical nomenclature encompassing HPV, and where HPV testing fits within current cervical cancer screening guidelines.

What is new in lymphoma

Abstract: The lymphomas are a diverse group of malignant disorders that vary with respect to their molecular features, genetics, clinical presentation, treatment approaches, and outcome. Over the past few years, there have been major advances in our understanding of the biology of these diseases, leading to a universally adopted World Health Organization classification system. New therapies are now available with the potential to improve patient outcome, and the International Prognostic Index and standardized response criteria help make clinical trials interpretable. Most notably, the chimeric antiCD20 monoclonal antibody rituximab has altered our therapeutic paradigms for B-cell disorders. Combinations of this antibody with chemotherapy and other biologic agents have shown promise in treating lymphoma. Other antibodies, radioimmunoconjugates (such as Y-90 ibritumomab tiuxetan and I-131 tositumomab), and oblimerson sodium (a BCL-2 antisense oligonucleotide) have all shown promise. New chemotherapy regimens such as bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP), agents such as gemcitabine, and monoclonal antibodies directed against CD30 are also being studied in Hodgkin Lymphoma. The challenge of clinical research is to optimize the use of these agents, select patients most likely to respond, and develop multitargeted strategies based on sound scientific rational, with the potential to increase the cure rate of patients with lymphomas.

TNM: Our Language of Cancer

Abstract: For more than four decades, the American Joint Committee on Cancer (AJCC) has played a leadership role in the United States as the collective organization that provides oversight of cancer staging for most solid tumors seen in clinical practice. From the inception of this coordinated effort, the American Cancer Society (ACS) has played a vital role in the development and the ongoing activities of the AJCC. As a founding member, the ACS has worked with the AJCC to ensure that the tumor-node-metastasis (TNM) system as a prognostic factor in cancer is perpetuated and improved through rigorous scientific evaluation. It is quite appropriate, therefore, that a series of articles dedicated to TNM staging appear in CA, a scientific publication of the ACS. This series of articles is designed to review the changes that have been made to the TNM staging system, which have appeared in the sixth edition of the AJCC Cancer Staging Manual. The review published in this edition of CA is the first in this series and is dedicated to the staging issues relative to the management of melanoma. Over the next 18 to 24 months, additional publications will appear that are directed to the staging strategies and management of other major cancers, and they will be authored by experts who lead our AJCC Task Forces in their respective oncologic areas. It is imperative that all of us who care for the cancer patient embrace a common language that allows us to give appropriate prognoses to our patients and enhances the dialogue among personnel in specialties caring for patients with neoplastic disease. It is especially important that we emphasize adequate staging in the future as we develop new clinical trials to assess multimodality treatment, including the molecular management of cancer. The AJCC, along with the International Union Against Cancer/Union Internationale Contre le Cancer (UICC), is committed to carrying on the tradition of TNM that was developed by Pierre Denoix, a surgeon, while working in France in the 1940s and 1950s. In the mid-1980s, a unique worldwide agreement was forged to assure that TNM staging of cancer would become the common language for cancer staging and would be utilized by clinicians throughout the world. Although this goal has yet to be reached, the AJCC and UICC are committed to continuing this effort. This series of articles will also highlight the introduction of newer and more specific methods of diagnosis and elucidation of even the minutest cellular characteristics of cancer. While changes in the TNM staging taxonomy do not affect all tumors, there are important newly identified global issues that do have a bearing on all cancers. These include molecular identification of metastases and the continued effort by pathologists to uncover smaller and smaller cell clusters that may ultimately have a bearing on the multimodality management of our patients. These issues will be discussed, and the concepts will be outlined for future evolution of this important topic. Similarly, diagnostic strategies such as positron emission tomography scans are extending the envelope in diagnosis and staging of many tumors such as colorectal cancer, melanoma, lymphoma, and lung cancer. The importance of these newer imaging studies and their effect on the clinical TNM stage will be emphasized in our ongoing series. The roles of both the AJCC and the ACS go well beyond creation and maintenance of a common language for cancer care. Our organizations are also dedicated to the education and promotion of a dialogue using TNM that includes physicians, nurses, and all members of the health care team who care for patients with cancer. An additional important benefactor of the system in the United States is our cancer registrar community. Registrars work diligently at many hospitals as well as state and national registries to ensure that clinical and pathologic information are recorded properly and that this information is maintained in a consistent format to be used for patient care, clinical research, and the accumulation of important epidemiologic data. Certified tumor registrars are on the front line to adapt to any changes in our cancer vernacular. The AJCC, ACS, and ultimately the cancer patients are the direct benefactors of their outstanding contributions. Dr. Greene is Chair, Department of General Surgery, Carolinas Medical Center, Charlotte, NC.

The "Welcome to Medicare" physical: a great opportunity for our seniors.

Abstract: Beginning January 1, 2005, Medicare will cover an initial preventive physical examination for all Medicare beneficiaries within 6 months of enrolling in Medicare. The “Welcome to Medicare” physical includes measurement of height, weight, and blood pressure, and an electrocardiogram “with the goal of health promotion and disease detection.” The visit will also include education, counseling, and referrals for the other preventive services already covered under Medicare including breast, cervical, colorectal, and prostate cancer screening tests. Medicare beneficiaries will also be eligible for cardiovascular blood screening tests, bone mass measurements, and counseling on nutrition. Beneficiaries at risk for diabetes will be eligible for diabetes screening tests, glaucoma screenings, and diabetes outpatient management training. The “Welcome to Medicare” prevention visit is a historic and very important step in the prevention and early detection of cancer. When the Medicare Program was first created in 1965, it was designed to fit the traditional insurance model of the time—it was designed to treat acute or chronic illnesses. (Medicare was also first created to provide health coverage for Americans 65 years of age and older, but coverage was later extended to some individuals with disabilities and permanent kidney failure.) At Medicare’s inception, little was known about the benefits of early detection and prevention methods—and we had few effective tools with which to detect cancer early and prevent it. Insurance models discouraged coverage for “broad and ill-defined” services, such as routine physicals and health education or counseling. Nevertheless, research has shown nearly 40 years later that many diseases, including cancer, can be prevented and successfully treated if detected early. Fundamentally, Medicare has been a program for the sick. Services that are not medically “reasonable and necessary” and not provided to specifically treat illness are not covered by Medicare, unless otherwise specifically added by Congress through the legislative process (Section 1862(a)(1)(A) of the Social Security Act; 42 USC 1395y(a)(1)(A)). Thus, in large part because of the efforts of the American Cancer Society, Congress passed legislation in the 1990s that allowed Medicare to begin covering breast, colorectal, prostate, and cervical cancer screening tests. Currently, Medicare beneficiaries only have coverage for physicians’ visits when they are sick or when they have signs or symptoms of an illness. Because Medicare does not cover any preventive visits such as a health checkup or examination, providers have to do risk factor counseling and promote screening during sporadic encounters related to treatment of acute and chronic diseases. Therefore, Medicare beneficiaries have to pay out-of-pocket for visits with their providers that include a prevention-oriented physical examination and discussion of general health, disease risks, and other preventive measures. The American Cancer Society has long recognized that making coverage available for an initial physical for each individual entering the Medicare program is an important first step to improving screening rates and health outcomes for people aged 65 and older. The Society appreciated the value of a one-time visit that would be dedicated to prevention and early detection. The new initial preventive physical will allow patients and providers to spend time emphasizing prevention and screening during a visit when the Medicare patient is not preoccupied with symptoms or treatment plans for another health problem. The one-time preventive checkup will provide Medicare beneficiaries with the opportunity to talk with their health care providers about health risk factors, personal health and family history, screening and other cancer prevention strategies (such as smoking cessation), as well as discuss the important role nutrition and physical activity play in staying healthy. The American Cancer Society fought vigorously to get this “Welcome to Medicare” prevention benefit included under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) passed last year. It was one of the Society’s highest priority issues under the Ms. DeWilde is Senior Policy Analyst, National Government Relations Department, American Cancer Society, Washington, DC.

Common Interests and Common Goals: Achieving Greater Progress in Preventive Health Through Strategic Collaborations

Abstract: In this issue of CA, and concurrently in Diabetes Care (American Diabetes Association [ADA]), Circulation (American Heart Association [AHA]), and Stroke (AHA), the American Cancer Society (ACS), the ADA, and the AHA are announcing a new strategic partnership to reduce disability and premature death from cancer, cardiovascular disease, and diabetes. In my judgment, the potential for this collaboration is far reaching and, if successful, will contribute to far greater and faster progress in chronic disease control than the total of our individual organizational efforts. As a medical oncologist and President of the ACS, my overriding focus in both roles is on cancer. The ACS’ stated mission is “eliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and service.” However, as a physician, I also recognize that other chronic conditions, such as cardiovascular disease and diabetes, account for even more disability and death. The ADA and the AHA have mission statements that are similar to the ACS, and they also support broad agendas focused on prevention, early detection, and therapy. Each organization is making headway against some aspects of their respective diseases, but each also faces enduring as well as new challenges. Some challenges are the result of broad, long-term societal trends, such as the annual toll of tobacco-related illness and the worsening epidemic of childhood and adult obesity. However, other challenges are inherently due to the absence of a system for delivery of preventive care and counseling. In this respect, it is quite clear that much of the current disease burden from cancer, cardiovascular disease, and diabetes is preventable if we were able to systematically apply present knowledge about risk reduction and disease prevention. Furthermore, it is increasingly evident that the common causes of these chronic illnesses are not unique to any one of these conditions but, in fact, are shared by each of them. Physical inactivity, poor diet, and obesity are each risk factors for cancer, cardiovascular disease, and diabetes. Smoking is responsible for more deaths from cancer and cardiovascular disease than any other single risk factor and substantially worsens the complications of and mortality from diabetes. Recent studies suggest that that smoking may also be a risk factor for type 2 diabetes. Each of these chronic diseases is, to a great degree, preventable. Each also has a long developmental period during which secondary prevention could reduce risk, and each has a preclinical period where early interventions could alter the natural history of the disease and its complications. It is also the case that a significant percentage of the population steadily accumulates risk without guidance or intervention and that a significant percentage of the adult population has undiagnosed disease. The glaring reality is that current approaches to prevention and early detection are fractionated and sporadic for those with access to care and largely nonexistent for those without health insurance. Patients largely depend on a coincidence of interests and opportunity during doctor-patient encounters for illness. We establish goals for prevention and early detection, but health care delivery focuses far more on treatment than prevention. Indeed, we are seemingly helpless in the face of a growing epidemic of obesity. Mokdad and colleagues estimate that physical inactivity and poor diet will soon account for more annual deaths in the United States than smoking. It is time for a new approach. Cancer, cardiovascular disease, and diabetes account for nearly two out of three deaths each year in the United States. These three major chronic diseases should not be competing for the Dr. Vance is President, American Cancer Society, Atlanta, GA, and Professor of Medicine, University of Mississippi School of Medicine, Jackson, MS.

The marriage of cancer control and advocacy.

Abstract: Cancer is the nation’s leading health concern and its second leading cause of death. During the next 12 months, approximately 1.3 million Americans will hear the words, “You have cancer,” and more than 550,000 will die of the disease. Although cancer continues to take an enormous toll on our country, we have an unparalleled opportunity to reduce suffering and death from malignant diseases, as reflected in the article by Jemal and colleagues in this issue of CA. For progress in research to have a substantial impact on this cancer burden, it must be translated to public health and clinical interventions that reach all members of our society. This will require continued federal and state support of cancer research and control programs, as well as sustained efforts to ensure that the health care system provides access to diagnosis and treatment for all. Thus, we must wed cancer control to advocacy to achieve our mission of diminishing suffering and saving lives. The American Cancer Society (ACS) has established necessarily ambitious goals to advance the nation’s progress against cancer by 2015. In collaboration with the federal government and other public, private, and voluntary health organizations, we hope to achieve a 50% reduction in the age-adjusted cancer mortality rate, a 25% reduction in the age-adjusted cancer incidence rate, and a measurable improvement in quality of life (in physical, psychological, social, and spiritual domains) from the time of diagnosis throughout cancer survivors’ lives. To achieve these ambitious goals, the nation must reaffirm its commitment to the fight against cancer. By applying our existing knowledge of cancer control more fully—including effective prevention and early detection programs—we can make significant strides toward the 2015 goals. The last decade has seen major advances in comprehensive cancer control efforts at the state level. Federal efforts are also making a difference, such as the recently completed doubling of the National Institutes of Health (NIH) budget. However, cuts in federal funding, diversion of state tobacco settlement funds, increasing poverty, and declining health insurance coverage impede states’ efforts and pose new challenges. Many believe that recent advances in biotechnology will help us surmount these challenges. We may be on the brink of being able to interrupt or reverse the biological processes by which cancer occurs. According to Dr. Andrew von Eschenbach, Director of the National Cancer Institute, “Today, we still may not be able to ‘cure’ cancer, but we can now implement a comprehensive strategy to preempt the onset and progression of the disease. The exponential advances in cancer research are defining with ever-greater specificity the many genetic, molecular, and cellular events that determine the disease process of susceptibility, disease initiation, and fatal progression. And this new knowledge can be translated into innovative and more effective strategies of prevention, elimination, and modulation.” We have indeed made significant advances in cancer prevention, but we can fully realize this potential only with continued support of basic, clinical, and applied research. This support will continue only through the successful marriage of cancer control and advocacy. Many people tend to think of cancer as a purely medical or scientific issue, but it is also a political one. Every day legislators introduce bills, pass laws, and allocate funds that profoundly affect persons with cancer and their families. Health insurance coverage, clinical trial participation, the development of new treatments, and the delivery of quality care all involve legislation. I share the belief of many Society volunteers and staff that advocacy on behalf of cancer control is critical to reaching our 2015 goals. It is a force multiplier in the fight against cancer. One example of the synergy between cancer control and advocacy is tobacco control. Cigarette smoking alone causes approximately 30% of cancer deaths in the United States and a total of 440,000 premature deaths annually. Most of the deaths are from lung and other cancers, ischemic heart disease, stroke, and chronic obstructive pulmonary disease. An estimated $157 billion in annual health-related economic losses are also attributed to smoking. Advocacy can accelerate the goal of ending the epidemic of deaths caused by tobacco. At the federal level, we can work to enact legislation supported by the public health community that grants the Food and Drug Administration Dr. Vance is President, American Cancer Society, and Professor of Medicine, University of Mississippi School of Medicine, Jackson, MS.