Transcript Community Based Strategies for Cancer Control and Prevention

Community Based Strategies for
Cancer Control and Prevention
Elaine Puleo, Ph.D.
Associate Dean of Research
School of Public Health and Health Sciences
University of Massachusetts
Amherst, MA
Leading Causes of Death in US for
2007 (number of deaths reported)

Heart disease: (616,067)

Cancer: (562,875)

Stroke (cerebrovascular diseases): (135,952)

Chronic lower respiratory diseases: (127,924)

Accidents (unintentional injuries): (123,706)

Alzheimer's disease: (74,632)

Diabetes: (71,382)

Influenza and Pneumonia: (52,717)
Estimated numbers of new cases and deaths
for 5 leading cancer types:
Cancer Type
Estimated New
Cases
Estimated Deaths
Lung
222,520
157,300
Colon and Rectal
(Combined)
142,570
51,370
Breast (Female- Male)
207,090 – 1,970
39,840 – 390
Pancreatic
43,140
36,800
Prostate
217,730
32,050
Risk Factor Analysis
Current scientific evidence suggests that
the risk associated with a majority of
health conditions are attributable to
lifestyles and health behaviors that are
modifiable given the right opportunity
structure, access to health care, and
information.
Behavioral Risk Factors
Physical/environmental risk factors
Social-structural factors
Behavioral Risk Factors:
There is solid epidemiological evidence for
red meat, folate, physical activity, and
smoking as part of cancer prevention
efforts.
Smoking accounts for 30 percent of all
cancer deaths and is the leading
preventable cause of cancer in the
United States.
Specifically, smoking has been linked to cancers
of the lung, oral cavity, digestive tract, and
colon.
An additional 30 percent of cancer deaths
can be attributed to adult diet.
Higher intake of red meat is a risk factor for
colon cancer, and recent evidence links red
meat to risk for prostate cancer.
The relationship between physical activity
and cancer risk has been widely studied.
A strong and consistent relationship is found with
risk for colon cancer.
Some studies have also shown a protective
effect of physical activity on breast cancer,
although results are less consistent than for
colon cancer.
Folate is protective against colon cancer.
Long-term multi-vitamin use, in particular has
been found to reduce risk for colon cancer, likely
because of its folate content.
Physical/Environmental Risk Factors specific to Low
Income populations
1.
Internet Access:
While approximately 76% of Americans age 18+ have access to the
internet, there exists a “digital divide,” with people from higher
income and education demonstrating greater access and usage
compared to those who are from lower SES groups.
Even if access is improved, fewer websites in health information
seeking are designed to cater to the needs of those in the lower
SES groups, who are more likely to have lower literacy skills.
Online use for health is influenced by broadband access and
experience in usage and those with less education, income and
who are older are less likely to have Broadband connections at
home.
2. Barriers to successful dissemination of
evidence-based interventions

Often these are costly and time consuming intensive interventions that
could limit generalizability

Limited resources, staff time, and expertise in the community to capitalize
on the availability of evidence-based interventions

Competing demands for limited resources, especially among those groups
serving underserved populations

Failure to address outcomes that are of relevance, interest and importance
to community leaders, policy makers and practitioners

Inadequate training of practitioners

Complexity and difficulty in use of the interventions

Lack of an effective engagement of the community in promoting the
adoption of interventions
Social-structural Factors
Across multiple health behaviors, patterns of risk by
socioeconomic position (SEP) and race/ethnicity remain
constant:
1.
Persons of higher SEP engage in fewer high risk behaviors than persons of
lower SEP, and there have been greater improvements over time in the
health behaviors of higher income groups vs. lower income groups. Risk
patterns also differ by ethnicity.
2. Meat consumption in the US has declined over the last 10 years, but greater
declines have been seen in high-income households than in low income
households. Similar patterns have been observed by race/ethnicity.
3. Although sedentary behavior is pervasive in the US population at large,
minority populations are consistently found to be less active than whites.
Lower income populations less active than higher income groups.
4. Whites are more likely to use vitamin supplements than minorities, a positive
relationship has been found between SEP and supplement use.
5. Disparities in smoking rates by SEP and race/ethnicity are well-documented.
Three Current NIH Funded
Research Projects
Open Doors to Health
1.
•
•
A randomized control trial designed to
address colorectal cancer prevention
through low income housing sites.
Conducted in 12 diverse low income housing
sites; eligible residents were enrolled. The
housing site was the unit of randomization.
Open Doors to Health (cont. 1)
•
The delivered Intervention – a social
contextual, housing site based
intervention that included
•
•
•
•
Increased access to screening
Increased development of social norms and
social support
Addressed social and environmental barriers
to participation
Brought sustainable resources for prevention
to the housing site through involvement of
peer leaders.
Open Doors to Health (cont. 2)
Successes:
•
•
•
•
Enrolled and retained 1554 subjects across 12 low
income housing sites.
Increased social networks and social capital among
intervention group.
Established walking maps for all sites
Sustained peer leaders in all sites
Open Doors to Health (cont. 3)

Barriers
•
•
High rate of colon cancer screening (over
66%) at baseline was a barrier to seeing any
but modest effects of the intervention
Low participation rate in on-site intervention
activities decreased their effectiveness
2. Click to Connect
•
•
A randomized controlled trial focused on
underserved people’s capacity to obtain and
process health information by developing their
capacity to seek and use health information
by providing them access to and training in
the use of the Internet.
Recruitment based in adult literacy classes
across the metro-Boston area.
Click to Connect (cont. 1)

Intervention:
•
•
Free computers and high-speed Internet
access for one year
A web-portal with links to health information
websites at appropriate literacy levels
•
Training classes in computer and Internet use
•
Free technical support for one year
Click to Connect (cont. 2)

Primary outcomes include several factors that
contribute to health literacy – operationalized as
media use and exposure to health:
 Internet use,
 health information seeking
 information efficacy.
Participants complete a telephone survey at baseline
and one month after intervention ends
Currently approximately 350 participants have enrolled
3. Project PLANET
To facilitate the dissemination of evidence-based cancer prevention
interventions, the National Cancer Institute (NCI) and partners have
developed the Cancer Control P.L.A.N.E.T., a state-of-the-art webbased resource for community groups, program planners and
researchers, intended to help them design, implement and adopt
evidence-based cancer control interventions
(http://cancercontrolplanet.cancer.gov/), .
The website is maintained by NCI and is a product of a governmentprivate sector partnership including NCI, the Centers for Disease
Control and Prevention (CDC) and the American Cancer Society
(ACS) among others. While much effort has been devoted to
envisioning and creating PLANET, to date, there is virtually no
literature or information on the adoption of it and the
efficacy of its dissemination approaches.
Project PLANET (cont. 1)
The goal of our project is to develop and test a
community participatory model for dissemination of
evidence-based cancer prevention interventions, building
off of the resources provided through PLANET.
Community-based participatory research (CBPR) methods
are an appropriate vehicle for working with communities
that are considering adoption of evidence-based
interventions and may enhance the probability of
successful adoption of the interventions.
Drawing on principles of CBPR, we promote the adoption
of PLANET in three underserved Massachusetts
communities: Boston, Lawrence & Worcester.
Project PLANET (cont. 2)
Components of the intervention:



Use mixed methods to conduct formative research to understand
the barriers and facilitators to successful adoption of evidence-based
cancer control interventions.
Create a web portal, that will: (a) provide the necessary communityspecific information on cancer control topics, access to Cancer
Control PLANET and other web links, and (b) improve collective
efficacy and social capital among local partners by providing a forum
for exchanging information on health program issues and for
communicating with each other. Training on the portal’s use will be
provided.
Test if the new PLANET MassCONECT web portal, and training of
community members will lead to increases in: a) collective efficacy
for adopting evidence-based interventions; b) use of the PLANET;
(c) PLANET Reach, and (d) Program planning and program
adoption.
Implications


Reaching an underserved population has
great benefit in reducing cancer burden.
Positive aspects of involving community
members in development of such
interventions:



The intervention is culturally sensitive
More participation by the community
Longer lasting effects and continued programs
References:









American Cancer Society: Cancer Facts and Figures 2010. Atlanta, Ga: American Cancer
Society, 2010.
National Vital Statistics Report of the Center for Disease Control
http://www.cdc.gov/NCHS/data/nvsr/nvsr58/nvsr58_19.pdf
Anonymous. Harvard Report on Cancer Prevention. Volume 1: Causes of human cancer.
Cancer Causes & Control. 1996;7(Suppl 1):S3-59.
Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years'
observations on male British doctors. British Medical Journal. 1994;309:901-911.
Giovannucci E. An updated review of the epidemiological evidence that cigarette smoking
increases risk of colorectal cancer. Cancer Epidemiology Biomarkers and Prevention.
2001;10(7):725-731.
Chao A, Thun M, Jacobs E, Henley S, Rodriguez C, Calle E. Cigarette smoking and colorectal
cancer mortality in the cancer prevention study II. Journal of the National Cancer Institute.
2000;92(23):1888-1896.
Heineman E, Zahm S, McLaughlin J, Vaught J. Increased risk of colorectal cancer among
smokers: results of a 26-year follow-up of US veterans and a review. International Journal of
Cancer. 1994;59(6):728-738.
Terry P, Ekbom A, Lichtenstein P, Feychting M, Wolk A. Long-term tobacco smoking and
colorectal cancer in a prospective cohort study. International Journal of Cancer.
2001;91(4):585-587.
Hsing A, McLaughlin J, Chow W, et al. Risk factors for colorectal cancer in a prospective study
among U.S. white men. International Journal of Cancer. 1998;77(4):549-553.












Sandhu M, White I, McPherson K. Systematic review of the prospective cohort studies on meat
consumption and colorectal cancer risk: A meta-analytic approach. Cancer Epidemiology,
Biomarkers, and Prevention. 2001;10(5):439-446.
Michaud D, Augustsson K, Rimm E, Stampfer M, Willet W, Giovannucci E. A prospective study on
intake of animal products and risk of prostate cancer. Cancer Causes & Control. 2001;12(6):557567.
United States Department of Health and Human Services. Physical activity and health: A report of
the Surgeon General. Atlanta, GA: US Department of Health and Human Services; Center for
Disease Control and Prevention, National Center for Disease Prevention and Health Promotion;
1996.
Thune I, Furberg AS. Physical activity and cancer risk: Dose-response and cancer, all sites and
site-specific. Medicine & Science in Sports & Exercise. 2001;33(6 Suppl):S530-550.
Gerhardsson M, Floderus B, Norell S. Physical activity and colon cancer risk. International Journal
of Epidemiology. 1988;17(4):743-746.
Severson R, Nomura A, Grove J, Stemmermann G. A prospective analysis of physical activity and
cancer. American Journal of Epidemiology. 1989;13(3):522-529.
Lee I, Paffenbarger R, Hsieh C. Physical activity and risk of developing colorectal cancer among
college alumni. Journal of the National Cancer Institute. 1991;83(18):1324-1329.
Lee IM, Paffenbarger RS. Physical activity and its relation to cancer risk: A prospective study of
college alumni. Medicine and Science in Sports and Exercise. 1994;26(7):831-836.
Giovannucci E, Ascherio A, Rimm E. Physical activity, obesity, and risk of colon cancer and
adenoma in men. Annals of Internal Medicine. 1995;122(5):327-334.
Thune I, Lund E. Physical activity and risk of colorectal cancer in men and women. British Journal
of Cancer. 1996;73(9):1134-1140.
Martinez ME, Giovannucci E, Spiegelman D, Hunter DJ, Willett WC, Colditz GA. Leisure-time
physical activity, body size, and colon cancer in women. Nurses' Health Study Research Group.
Journal of the National Cancer Institute. 1997;89(13):948-955.
Colditz GA, Cannuscio CC, Frazier AL. Physical activity and reduced risk of colon cancer:
Implications for prevention. Cancer Causes and Control. 1997;8:649-667.











Rockhill B, Willett W, Hunter D, Manson J, Hankinson S, Colditz G. A prospective study of
recreational physical activity and breast cancer risk. Archives of Internal Medicine.
1999;159(19):2290-2296.
Fraser G, Shavlik D. Risk factors, lifetime risk, and age at onset of breast cancer. Annals of
Epidemiology. 1997;7:375-382.
Wyshak G, Frisch R. Breast cancer among former college athletes compared to non-athletes: A
15-year follow-up. British Journal of Cancer. 2000;82(3):726-730.
Giovannucci E, Stampfer MJ, Colditz G, et al. Multivitamin use, folate, and colon cancer in women
in the Nurse's Health Study. Annals of Internal Medicine. 1998;129:517-524.
Jacobs E, Connell C, Patel A, et al. Multivitamin use and colon cancer mortality in the Cancer
Prevention Study II cohort (United States). Cancer Causes & Control. 2002;12:927-934.
White E, Shannon J, RE. P. Relationship between vitamin and calcium supplement use and colon
cancer. Cancer Epidemiology, Biomarkers & Prevention. 1997;6:769-774.
McTiernan A, Ulrich C, Slate S, Potter J. Physical activity and cancer etiology: Associations and
mechanisms. Cancer Causes and Control. 1998;9:487-509.
Colbert L, Hartman T, Malila N, et al. Physical activity in relation to cancer of the colon and
rectum in the cohort of male smokers. Cancer Epidemiology, Biomarkers, and Prevention.
2001;10(3):265-268.
Slattery ML, Edwards SL, Boucher KM, Anderson K, Caan BJ. Lifestyle and colon cancer: An
assessment of factors associated with risk. American Journal of Epidemiology. 1999;150(8):869877.
Tomeo CA, Colditz GA, Willett WC, et al. Harvard Report on Cancer Prevention. Volume 3:
prevention of colon cancer in the United States. Cancer Causes & Control. 1999;10(3):167-180.
Robinson L, Mertens A, Boice J, et al. Study design and cohort characteristics of the childhood
cancer survivor study: A multi-institutional collaborative project. Medical Pediatrics Oncology.