Fulfilling the Potential of Cancer Prevention and Early Detection

Susan J. Curry, Tim Byers, and Maria Hewitt, Editors

National Cancer Policy Board

INSTITUTE OF MEDICINE

NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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Fulfilling the Potential of Cancer Prevention and Early Detection Fulfilling the Potential of Cancer Prevention and Early Detection Susan J. Curry, Tim Byers, and Maria Hewitt, Editors National Cancer Policy Board INSTITUTE OF MEDICINE NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Fulfilling the Potential of Cancer Prevention and Early Detection THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the National Cancer Institute; the Centers for Disease Control and Prevention; the American Cancer Society; Abbott Laboratories; the American Society of Clinical Oncology; Amgen, Inc.; Aventis; and the United Health Care Foundation. The views presented in this report are those of the Institute of Medicine and the National Research Council National Cancer Policy Board and are not necessarily those of the funding agencies. Library of Congress Cataloging-in-Publication Data Fulfilling the potential of cancer prevention and early detection / Susan J. Curry, Tim Byers, and Maria Hewitt, editors ; National Cancer Policy Board. p. ; cm. Includes bibliographical references and index. ISBN 0-309-08254-4 (hardcover) ISBN 0-309-50619-0 (PDF Full Book) 1. Cancer—United States—Prevention. [DNLM: 1. Neoplasms—prevention & control—United States. 2. Health Behavior—United States. 3. Health Policy—United States. 4. Health Promotion—methods—United States. 5. Mass Screening—United States. QZ 200 F962 2003] I. Curry, Susan J. II. Byers, Tim. III. Hewitt, Maria Elizabeth. IV. National Cancer Policy Board (U.S.) RC268.F85 2003 616.99’4052—dc21 2003000742 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America.

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Fulfilling the Potential of Cancer Prevention and Early Detection THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Fulfilling the Potential of Cancer Prevention and Early Detection NATIONAL CANCER POLICY BOARD JOSEPH SIMONE (Chair), Simone Consulting, Dunwoody, GA ELLEN STOVALL (Vice Chair), Executive Director, National Coalition for Cancer Survivorship, Silver Spring, MD DIANA PETITTI (Vice Chair), Director, Research & Evaluation, Kaiser Permanente of Southern California, Pasadena, CA BRUCE W. STILLMAN (Vice Chair), Director, Cold Spring Harbor Laboratory, Cold Spring Harbor, NY JILL BARGONETTI, Associate Professor, Department of Biological Sciences, Hunter College, New York, NY TIM BYERS, Professor of Epidemiology, Program Leader, Clinical Cancer Prevention & Control, University of Colorado Health Sciences Center, Denver, CO VIVIEN W. CHEN, Epidemiology Section Chief & Professor, Louisiana State University Medical Center, New Orleans, LA (member through March 2002) SUSAN CURRY, Professor, Health Policy and Administration, and Director, Health Research and Policy Centers, University of Illinois at Chicago, Chicago, IL (member through March 2002) TIMOTHY EBERLEIN, Bixby Professor and Chairman, Department of Surgery, Washington University School of Medicine, St. Louis, MO KAREN HERSEY, Senior Counsel, Massachusetts Institute of Technology, Cambridge, MA JIMMIE C. HOLLAND, Chair, Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY DANIEL J. KEVLES, Professor, Yale University, New Haven, CT WILLIAM MCGUIRE, Chief Executive Officer, UnitedHealth Group, Minnetonka, Minnesota JOHN MENDELSOHN, President, M.D. Anderson Cancer Center, University of Texas, Houston, TX KATHLEEN HARDIN MOONEY, Professor, University of Utah College of Nursing, Salt Lake City, UT MONICA MORROW, Professor of Surgery, Comprehensive Breast Program, Northwestern University, Chicago, IL (member through March 2002) NANCY MUELLER, Professor of Epidemiology, Harvard School of Public Health, Department of Epidemiology, Boston, MA PATRICIA NOLAN, Director, Rhode Island Department of Health, Providence, RI PILAR OSSORIO, Assistant Professor of Law & Medical Ethics, Associate Director for Programming, Center for the Study of Race and Ethnicity in Medicine, University of Wisconsin Law School, Madison, WI (member through March 2002)

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Fulfilling the Potential of Cancer Prevention and Early Detection CECIL B. PICKETT, Executive Vice President, Discovery Research, Schering-Plough Research Institute, Kenilworth, NJ LOUISE RUSSELL, Professor, Rutgers University, New Brunswick, NJ JOHN SEFFRIN, Chief Executive Officer, American Cancer Society, Atlanta, GA (member through March 2002) THOMAS J. SMITH, Professor, Virginia Commonwealth University, Richmond, VA SANDRA UNDERWOOD, ACS Oncology Nursing Professor, University of Wisconsin School of Nursing, Milwaukee, WI (member through March 2002) SUSAN WEINER, President, The Children’s Cause, Silver Spring, MD ROBERT C. YOUNG, President, American Cancer Society and the Fox Chase Cancer Center, Philadelphia, PA Consultants Graham A. Colditz, Catherine Tomeo Ryan, Charles H. Dart, III, Geetanjali Datta, Laurie Fisher, and Beverly Rockhill, Channing Laboratory, Boston, MA Steven H. Woolf, Department of Family Practice, Virginia Commonwealth University Parthiv J. Mahadevia, Farin Kamangar, and Jonathan M. Samet, Bloomberg School of Public Health, Johns Hopkins University Edwin B. Fisher and Mario Schootman, Washington University School of Medicine, and Ross C. Brownson, Amy A. Eyler, and Debra L. Haire-Joshu, St. Louis University Judith Ockene, Jane Zapka, Lori Pbert, Suzanne Brodney, and Stephenie Lemon, University of Massachusetts Medical School Suzanne Phelan and Rena R. Wing, Weight Control and Diabetes Research Center, Brown University Study Staff Maria Hewitt, Study Director Mary Joy Ballantyne, Research Assistant Gelsey Lynn, Research Assistant Timothy K. Brennan, Research Assistant Michael K. Hayes, Editor NCPB Staff Roger Herdman, Director, National Cancer Policy Board Nicci T. Dowd, Administrator Jennifer Cangco, Financial Associate Rosa Pommier, Financial Associate

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Fulfilling the Potential of Cancer Prevention and Early Detection REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Timothy B. Baker, University of Wisconsin, Madison Dileep G. Bal, Cancer Control Branch, California Department of Health, Sacramento, CA Moon S. Chen, Jr., Ohio State University, Dublin, OH Wendy Demark-Wahnefried, Duke University Medical Center, Durham, NC Paul Frame, Tri-County Family Medicine, Cohoctin, NY Carolyn Gotay, Cancer Research Center of Hawaii, Honolulu Kathy Helzlsouer, Bloomberg School of Public Health, Johns Hopkins University Arthur Levin, Center for Medical Consumers, New York, NY Anne McTiernan, Cancer Prevention Research Program, Fred Hutchinson Cancer Research Center, Seattle, WA Duncan B. Neuhauser, Department of Epidemiology & Biostatistics, Case Western Reserve University Medical School, Cleveland, OH Malcom C. Pike, USC/Norris Cancer Center, Los Angeles, CA Helen Halpin Schauffler, Center for Health and Public Policy Studies, University of California, Berkeley David Schottenfeld, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI Steve Taplin, Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, WA Beti Thompson, Cancer Prevention Research Program, Fred Hutchinson Cancer Research Center, Seattle, WA Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Maureen M. Henderson,

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Fulfilling the Potential of Cancer Prevention and Early Detection M.D., D.P.H., Professor Emeritus of Epidemiology and Medicine, University of Washington. Appointed by the National Research Council, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Fulfilling the Potential of Cancer Prevention and Early Detection Acknowledgments The National Cancer Policy Board first and foremost acknowledges the contribution of the Board’s prevention subgroup. These Board members provided leadership and spent many hours shaping the study plan, reviewing drafts, discussing recommendations, and offering assistance to staff throughout the report’s production. Board Prevention Subgroup Susan Curry, (Group leader), University of Illinois at Chicago Diana Petitti, (Board Vice Chair), Kaiser Permanente of Southern California Tim Byers, University of Colorado Health Sciences Center Vivien W. Chen, Louisiana State University Medical Center William McGuire, UnitedHealth Group Nancy Mueller, Harvard School of Public Health Louise Russell, Rutgers University John Seffrin, American Cancer Society Sandra Underwood, University of Wisconsin School of Nursing Former Board members Robert Day, Fred Hutchinson Cancer Research Center, and Ellen Gritz, M.D. Anderson Cancer Center, helped plan the report. The Board also acknowledges the tremendous contribution made by authors of background papers that formed the basis of several of the report’s chapters.

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Fulfilling the Potential of Cancer Prevention and Early Detection Graham A. Colditz and his colleagues Catherine Tomeo Ryan, Charles H. Dart, III, Geetanjali Datta, Laurie Fisher, and Beverly Rockhill wrote “Quantifying the Contribution of Risk Factors to Cancer Incidence and the Estimated Reduction in Cancer Burden Through Selected Risk Factor Modifications.” Edwin B. Fisher and his colleagues Ross C. Brownson, Amy A. Eyler, Debra L. Haire-Joshu, and Mario Schootman wrote “Interventions to Promote Key Behaviors in Cancer Prevention and Early Detection.” Parthiv J. Mahadevia, Farin Kamangar, and Jonathan M. Samet wrote “Fulfilling the Potential of Lung Cancer Prevention and Early Detection: What Are the Implications of Adopting New Technologies in the Face of Uncertain Science?” Judith Ockene and her colleagues Jane Zapka, Lori Pbert, Suzanne Brodney, and Stephenie Lemon wrote “Provider, System, and Policy Strategies to Enhance the Delivery of Cancer Prevention and Control Activities in Primary Care.” Suzanne Phelan and Rena R. Wing wrote “Interventions to Reduce Obesity and Maintain a Healthy Weight.” Steven H. Woolf wrote “The Effectiveness of Screening for Cancer and Its Unfulfilled Potential in the United States: A Review of the Evidence.” Several other individuals addressed the Board at their quarterly meetings providing important information and perspectives: Ralph Coates and Kevin Brady, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention Barbara Rimer and Robert Croyle, Division of Cancer Control and Population Sciences, National Cancer Institute (NCI) Several individuals met with or corresponded with Board staff to provide information about their programs and activities. Carol Ashton, Houston Veterans Administration Center for Quality of Care and Utilization Studies Kevin Brady, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention Mary Burdick, Veterans Administration National Center for Health Promotion and Disease Prevention (NCHPDP) Leslie Given, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention Peter Greenwald, Division of Cancer Prevention, NCI Brian Kimes, Office of Centers, Training, and Resources, NCI Wendy Perry, Office of the Director, Agency for Healthcare Research and Quality

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Fulfilling the Potential of Cancer Prevention and Early Detection Stacey Vandor, Office of the Director, Division of Cancer Control and Population Sciences, NCI Many individuals made important contributions by reviewing sections of the report for accuracy Jean K. Brown, University at Buffalo School of Nursing, State University of New York Sachiko St. Jeor, Nutrition Education and Research Program, University of Nevada Helen Meissner, Applied Cancer Screening Research Branch, Behavioral Research Program, DCCPS, NCI John D. Potter, Fred Hutchinson Cancer Research Center Linda Meyers and Paula Trumbo, Food and Nutrition Board, Institute of Medicine Nancy Riese Daly, American Society for Therapeutic Radiology and Oncology (ASTRO) William T. Sause, Department of Radiation Oncology, LDS Hospital, Salt Lake City, Utah Michael Whitcomb, Division of Medical Education, Association of American Medical Colleges The Board also wishes to thank David Berrigan, NCI Cancer Prevention Fellow, who followed the progress of the report and reviewed commissioned papers and report drafts. The Board thanks high school students Ben Markwell and Alex Del Pinal for their contribution in checking references.

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Fulfilling the Potential of Cancer Prevention and Early Detection Acronyms and Abbreviations AACE American Association for Cancer Education AAHP American Association of Health Plans AAMC Association of American Medical Colleges ACRIN American College of Radiology Imaging Network ACS American Cancer Society ACSM American College of Sports Medicine ACT Activity Counseling Trial AHCPR Agency for Health Care Policy and Research AHEC Area Health Education Center AHRQ Agency for Healthcare Research and Quality ALA American Lung Association ASPO American Society of Preventive Oncology ATBC Alpha-Tocopherol Beta-Carotene Cancer Prevention Study Group ATPM Association of Teachers of Preventive Medicine BED binge eating disorder BMI body mass index BPHC Bureau of Primary Health Care (HRSA) CAD computer-aided diagnosis CARET Beta-Carotene and Retinol Efficacy Trial CATCH Child and Adolescent Trial for Cardiovascular Health CDC Centers for Disease Control and Prevention CDMRP Congressionally Directed Medical Research Programs CHC Community Health Center Program

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Fulfilling the Potential of Cancer Prevention and Early Detection CI confidence interval CME continuing medical education CMS Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) CONQUEST Computerized Needs-Oriented Quality Measurement Evaluation System CQI continuous quality improvement CSP Cooperative Studies Program (VA) CT computed tomography DCCPS Division of Cancer Control and Population Sciences (NCI) DCIS ductal carcinoma in situ DHHS U.S. Department of Health and Human Services DoD U.S. Department of Defense ELCAP Early Lung Cancer Action Project FDA Food and Drug Administration FFS fee for service FOBT fecal occult blood test FQHC federally qualified health centers FY fiscal year GM General Motors HCFA Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) HEDIS Health Plan Employer Data and Information Set HMO health maintenance organization HPV human papillomavirus HRA health risk appraisal HRSA Health Resources and Services Administration IARC International Agency for Research on Cancer IHS Indian Health Service IOM Institute of Medicine kcal/day kilocalories per day kg kilogram kg/m2 kilogram per square meter lb pound (1 pound = 0.45 kilogram) LCD low-calorie diet mA milliangstroms MCO managed care organization mg milligram MHC Migrant Health Center Program

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Fulfilling the Potential of Cancer Prevention and Early Detection mm millimeter mrad millirad MTCP Massachusetts Tobacco Control Program NBCCEDP National Breast and Cervical Cancer Early Detection Program NCI National Cancer Institute NDC National Dialogue on Cancer ng/dl nanograms per deciliter NHANES National Health and Nutrition Examination Survey NHLBI National Heart, Lung, and Blood Institute NIH National Institutes of Health NNS number needed to screen NNT number needed to treat NRT nicotine replacement therapy NSAID nonsteroidal anti-inflammatory drug NTAO National Technical Assistance Office OTC over the counter (nonprescription) PACE Physician-Based Assessment and Counseling for Exercise PBGH Pacific Business Group on Health PCAP Prevention Curriculum Assistance Program PDQ Physician Data Query PLCO study Prostate, Lung, Colorectal, and Ovarian study PPIP Put Prevention into Practice PPV positive predictive value PSA prostate-specific antigen QALY quality-adjusted life year QUERI Quality Enhancement Research Initiative QuIC Quality Interagency Coordination RADIUS Research and Development in the United States (database) RWJF Robert Wood Johnson Foundation SCHIP State Children’s Health Insurance Program SEER Surveillance, Epidemiology, and End Results Program SPN Special Populations Networks for Cancer Awareness, Research, and Training TRCBSs Translational Research Centers in Behavioral Science TRIP Translating Research into Practice USPSTF U.S. Preventive Services Task Force VA U.S. Department of Veterans Affairs VANAC VA Nurses Against Cancer VBG vertical banded gastroplasty

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Fulfilling the Potential of Cancer Prevention and Early Detection VHA Veterans Health Administration VISN Veterans Integrated Service Networks VLCD very low-calorie diet WHO World Health Organization WIC Special Supplemental Food Program for Women, Infants, and Children

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Fulfilling the Potential of Cancer Prevention and Early Detection Contents     EXECUTIVE SUMMARY   1 1   Introduction   15 2   Potential to Reduce the Cancer Burden Through Cancer Prevention and Early Detection   30 3   Lifestyle Behaviors Contributing to the Burden of Cancer   41 4   Modifying Health Risk Behaviors   87 5   Potential of Screening to Reduce the Burden of Cancer   156 6   Improving Participation in Cancer Screening Programs   224 7   Adopting New Technology in the Face of Uncertain Science: The Case of Screening for Lung Cancer   259 8   Professional Education and Training   294 9   Federal Programs That Support Cancer Prevention and Early Detection   332 10   Research Trends and Opportunities   365 11   Findings, Policy Implications, and Recommendations   400     References   438     Glossary   521     Index   527

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Fulfilling the Potential of Cancer Prevention and Early Detection List of Boxes, Figures, and Tables BOXES 3.1   Definition of Levels of Evidence for Epidemiological Associations,   42 3.2   Frequently Referenced Prospective Cohort Studies,   43 4.1   Core Components of Skill-Training Interventions,   93 4.2   Selected State Tobacco Control Initiatives,   103 4.3   A Model Tobacco Control Program in an HMO,   154 5.1   Definitions of Screening Test Performance,   159 5.2   Hierarchy of Effectiveness of Study Designs,   164 5.3   Recommendations for Colorectal Cancer Screening in Average-Risk Persons,   184 5.4   Recommendations for Screening for Breast Cancer,   203 5.5   Recommendations for Screening for Prostate Cancer,   216 5.6   Recommendations for Screening for Cervical Cancer,   221 6.1   Challenges to Providers in Improving Rates of Screening for Colorectal Cancer,   234 6.2   Cancer Screening at Worksites and Places of Worship,   247 8.1   Selected Healthy People 2010 Cancer Objectives,   298 8.2   Professional Organizations with a Focus on Health Promotion and Disease Prevention,   302

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Fulfilling the Potential of Cancer Prevention and Early Detection 8.3   Recommended Content Areas for a Smoking and Tobacco Use Cessation Intervention Curriculum,   308 8.4   Examples of State Efforts to Train Smoking and Tobacco Use Treatment Providers,   318 9.1   Cancer-Related Healthy People 2010 Objectives,   333 9.2   Surgeon General’s Reports on Tobacco Control,   337 9.3   Selected Examples of Cancer Prevention and Early Detection Surveillance Tools,   337 9.4   State-Level Variations in Cancer Risk Factors,   339 9.5   VHA National Cancer Strategy Policy Objectives,   345 10.1   Evolving Definition of Cancer Control Research,   366 10.2   Objectives of NCI Strategic Plan to Reduce Health Disparities,   378 10.3   Cochrane Reviews Related to Cancer Prevention and Early Detection,   397 11.1   Interventions Recognized as Effective Against Smoking and Promoted by National Organizations,   408 11.2   Summary of Objectives to Reduce Illness, Disability, and Death Related to Tobacco Use and Exposure to Secondhand Smoke Outlined in Healthy People 2010,   413 11.3   Recommendations for Public Health Action on Weight Control and Physical Activity to Promote Cancer Prevention, IARC, WHO,   414 11.4   Public Health’s Mission and Services,   419 FIGURES 1.1   Age-Adjusted Cancer Death Rates,* for Males by Site, U.S. 1930– 1997,   19 1.2   Age-Adjusted Cancer Death Rates,* for Females by Site, U.S. 1930– 1997,   20 3.1   Age-Adjusted Prevalence of Overweight (BMI 25–29 kg/m2) and Obesity (BMI = 30 kg/m2) in U.S. Adults Aged 20–74,   64 3.2   Age-Adjusted Prevalence of Overweight or Obesity (BMI = 25 kg/ m2) by Sex and Race/Ethnicity,   65 9.1   Comprehensive Cancer Control Plans, 2001,   340 10.1   PubMed Citations for Cancer-Related Prevention and Control Research, 1985–2000,   369

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Fulfilling the Potential of Cancer Prevention and Early Detection 10.2   PubMed Citations for Cancer-Related Prevention and Control Research as a Percentage of All Cancer-Related Citations, 1985– 2000,   369 10.3   Organizational Chart for NCI’s DCCPS,   376 10.4   Distribution of Research Dollars (not the number of grants) Spent in DCCPS Behavioral Research Portfolio, FY 2001 (total amount, $113.5 million),   377 11.1   Cigarette Smoking, United States, 1990–1999,   404 11.2   Prevalence of Overweight Among Children and Adolescents: United States, 1963–1970 to 1999–2000,   406 TABLES 1.1   Deaths and Percent of Total Deaths for Leading Causes of Death by Sex: United States, 1999,   18 1.2   Estimated Number of New Cancer Cases and Cancer Deaths in the United States, 2002,   21 1.3   Incidence and Mortality Rates by Site, Race, and Ethnicity, United States, 1992–1998,   23 1.4   Five-Year Relative Survival Rates, by Racial or Ethnic Group and Stage at Diagnosis, United States, 1989–1996,   24 2.1   Risk Factors, Goals, and Assumptions Used by NCI Working Group and ACS in Predictions for the United States,   34 3.1   Increase in Risk of Incident Cancer Associated with Smoking,   44 3.2   Current Cigarette Use, Adults 18 Years or Older, United States, 1999,   55 3.3   Tobacco Use, High School Students, United States, 1999,   56 3.4   Reduction in Risk of Incident Cancer Associated with Physical Activity,   58 3.5   Increase in Risk of Incident Cancer Associated with Obesity,   61 3.6   Reduction in Risk of Incident Cancer Associated with Fruit and Vegetable Intake,   67 3.7   Increase in Risk of Incident Cancer Associated with High Intakes of Red Meat,   73 3.8   Risk of Incident Cancer Associated with Selected Macronutrients,   78 3.9   Risk of Incident Cancer Associated with Selected Micronutrients,   79

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Fulfilling the Potential of Cancer Prevention and Early Detection 3.10   Increase in Risk of Incident Cancer Associated with Alcohol Use,   83 4.1   Summary of Treating Tobacco Uses and Dependence (TTUD) Meta-Analysis Assessing the Impact of Various Elements of Treatment Structure,   95 4.2   Summary of TTUD Meta-Analyses Evaluating First-Line Pharmacotherapies,   100 4.3   Access to Wellness Programs and Fitness Centers Among U.S. Full-Time Employees, by Type of Employer,   116 4.4   Summary of AHRQ Analyses of the Efficacy of Interventions to Modify Dietary Behavior Related to Cancer Risk: Fruit and Vegetable Intake,   140 4.5   Summary of AHRQ Analyses of the Efficacy of Interventions to Modify Dietary Behavior Related to Cancer Risk: Dietary Fat Intake (percentage of energy from fat),   141 5.1   Illustration of Influence of Prevalence on Positive Predictive Value,   160 5.2   Randomized Controlled Trials of Fecal Occult Blood Testing,   177 5.3   Results of the Randomized Clinical Trials of Screening Mammography,   189 7.1   Summary of Nonrandomized Prospective Trials of Lung Cancer Screening (1950s to 1970s),   262 7.2   First Screening (Prevalence) Results from NCI-Sponsored Randomized Controlled Trials of Lung Cancer Screening Using Chest Radiographs and Sputum Cytology,   266 7.3   Incidence Screening Results from Randomized Controlled Trials of Lung Cancer Screening Using Chest Radiographs and Sputum Cytology,   268 7.4   Spiral CT Lung Cancer Screening Trials: Prevalence Data,   278 7.5   Spiral CT Lung Cancer Screening Trials: Incidence Data,   280 8.1   National Cancer Institute Research Training and Career Development Opportunities for Prevention, Control, Behavioral, and Population Scientists,   323 8.2   Training and Career Development Opportunities, American Cancer Society,   329 9.1   VHA Cancer-Related Behavioral Risk Factor Counseling Recommendations,   345

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Fulfilling the Potential of Cancer Prevention and Early Detection 9.2   VHA Cancer Screening Recommendations,   346 9.3   Preventive Health Practices, Veterans Health Survey, 1997– 1999,   347 9.4   Preventive Health Practices, Results of Chart Audit, External Peer Review Program, 1999,   348 9.5   Percentage (95% confidence interval) of Reproductive-Age Women Reporting Pap Testing in the Past Year, by Location of Test and Health Insurance Coverage, National Survey of Family Growth, 1995,   353 9.6   Coverage for Cancer Screening Tests Under Original Medicare Plan, Centers for Medicare and Medicaid Services,   356 9.7   Mammography Use Within Past 2 Years,   357 9.8   Medicare Beneficiaries’ Rates of Use (Percent) of Tests for Colorectal Cancer Screening and Diagnostic Services, 1995–1999,   359 9.9   Medicaid Program Coverage of Pharmacotherapy and Counseling, United States, 2000,   362 10.1   Types of Research Necessary to Improve the Application of Evidence-Based Cancer Prevention and Early Detection Interventions,   367 10.2   Distribution of Cancer Control and Population Sciences Grants Funded in FY 2001, by Program,   377 10.3   Centers for Disease Control and Prevention FY 2001 Appropriation,   382 10.4   AHRQ-Supported Research Grants, FYs 1999 to 2001,   385 10.5   Congressionally Directed Medical Research Programs of the U.S. Department of Defense,   390 10.6   VA-Supported Cancer Prevention and Early Detection Research at VA Centers of Excellence,   392 10.7   ACS Research Funding (Intramural and Extramural), FYs 1999 to 2000,   393 10.8   Other Selected Foundations Supporting Cancer Prevention and Early Detection Research,   395

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