Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium (2004)

Dr. Clement Bezold, President, Institute for Alternative Futures, Moderator: There is a paragraph in the agenda that outlines some of the questions about tobacco and obesity. We want to address those and think about what needs to be done to implement Recommendations 1, 2 and 3 from the report.

Dr. Harvey Fineberg, President, Institute of Medicine: I’d like to begin by telling you a story about New Liquid Tide. I don’t know how many people use this product. It was introduced about 20 years ago by Procter & Gamble at a time when they already had the leading washing detergent in the country, which was—guess what? Tide. But it was the powdered Tide. They developed a new, liquid product that they wanted to promote. This was a company that already had the market leader by the same name, so the consumer didn’t have to learn a new name.

I just want us to think for a moment about the behavior change that the company was aiming for. You are a shopper. You wash clothes. You are in the supermarket. Picture yourself going down the aisle with your shopping basket, and you come to the detergent section. As you pass the detergents, you come to a detergent you used to buy, and there is next to it New Liquid Tide. This is the behavior change that the company was seeking. Instead of reaching like this, you had to reach like that. You were already prepared to buy. You already needed the product. You already knew the name. You just had to reach to another neighboring spot. That is the entire behavior change they were aiming for. In the early 1980s over the first six months of new product introduction, they spent $38 million to educate the American public, to promote this product, and accomplish the change.

Now, I tell that story so you can think about that behavior change, that investment, that prior predisposition compared to the challenge of tobacco or obesity. I think a moment’s reflection will persuade any of us that we are really not yet serious about the investment needed to make significant changes in smoking, eating, and activity behaviors, although we have had significant success in reducing tobacco use. The 50 million people who are former smokers is an extraordinary success, but one fact that wasn’t mentioned this morning is that, on average, the remaining smokers smoke more than the people who quit smoked before they quit. We are getting down to a harder core than in the previous smokers, and we still have the problem of new beginning smokers.

Now, to our question about policy for tobacco and obesity, I think first there are meaningful lessons to be learned from the tobacco story thus far, because it is a tremendous partial success. The lessons to be learned and to be translated include the scale of investment subsequent to the tobacco settlement that has been deployed and, in public health terms, lavished on the problem, the degree of success yet with still more to do, and how far we are from similar progress in obesity. If we had done a color chart of the country’s smoking rates like the color chart of obesity rates we saw this morning, it would have gotten progressively lighter but there would still be plenty there to work on. The main message is that the scale of commitment required is orders of magnitude beyond where we are accustomed to thinking in preventive programs aimed at fundamental behavior change.

For obesity and for tobacco, the amount of investment is still not where it needs to be. The reason for that is simply that there isn’t any one entity with the resources that has an interest in making the changes in the right direction. It is a social good for which social investment is required, and that is hard to mobilize. Part of our task is thinking together about how we can and will be successful in mobilizing the necessary investment. I am eager to hear what stimulating thoughts others here have and what we can discuss together.

Dr. Robert Croyle, Director, Division of Cancer Control and Population Sciences, NCI: One of the lessons of the tobacco control movement from a science perspective is that there were a lot of programmatic activities that we tried out early on in school-based prevention and other domains that were not terribly informed or effective. One of the reasons was that we grossly underestimated the importance of addiction and that we were dealing with an addictive drug. Once that was more clearly recognized, we were able to bring to bear pharmacological agents to help deal with the addiction, and we were able to double cessation rates.

Therefore, in obesity and physical activity, given so much of the research effort is focused on obesity and weight loss at a clinical level as opposed to the public health effort, we, in collaboration with CDC and others,

have got a big public health research agenda. I am concerned that NIH hasn’t quite gotten that yet. When we talk to colleagues across NIH, public health relevant research is always a bit of a struggle and is always a fairly small slice of the pie. Therefore, the speed of responsiveness to something like the obesity epidemic which is changing so rapidly is going to be tough to achieve. This kind of group, this report, and these collaborations can help each of us to get our own broader organizational entities involved, although that is difficult because being organized around diseases, not risk factors, makes it hard to marshal rapid coordinated efforts targeted towards public health issues and risk factors.

Another lesson is the importance of changing social norms and social climate. Part of turning the corner in terms of tobacco, even as we lose ground with the cutting of state programs, is the changing social norm about tobacco use and its acceptability. This has been reflected in clean indoor air laws and other policy efforts.

For tobacco, policy changes have been important in addition to individual level efforts and have been enabled by the shifting of attitudes and social norms. Also important for tobacco control has been understanding the industry. You have got to understand the product that the industry is marketing. Clearly, it is easier in the case of tobacco than it is in the case of food, nutrition, and diet, but I think we need to get more folks in the public health program health research world learning more about and understanding more about the food industry, how it operates, how it functions. People in public health education and promotion need to understand how to work on obesity and diet, sometimes around but sometimes with industry. It will be harder than for tobacco in the sense that it is more complex. It is more varied. It is much harder to determine who the good guys and the bad guys are, because with large industries there are good and bad elements and products and sectors throughout.

Another lesson was the ineffectiveness of the use of single isolated channels for behavior change and public health change. School programs sound great, but they are not enough on their own. Communication campaigns are great but not terribly effective on their own. A lot of the debate emerging in obesity and diet is the same debate we had 15 or 20 years ago in tobacco; people were arguing over whether we should we do school prevention, or media campaigns, or should we focus on policy, or is it just all about taxation, or is it all about drug development for nicotine replacement. Of course, the answer is that it is all of those. The effect size of each one of those is greater when used in conjunction with others. The interaction effects make for synergy.

Another lesson is looking to simple things that can be done with big impact. Dr. Dietz has talked about the number of venues in the area of physical activity. It took a while with tobacco. It took too long to figure out

that sometimes you could do something that didn’t cost a whole lot but would have a big impact. Some of those things were in the policy domain. When I addressed the committee for the IOM report as they were first talking about this report, I spoke about what I labeled as MINC, minimal intervention necessary for change. When dollars are tight, one of our focuses should involve trying to identify those things that have a big bang for a little buck.

Finally, in communication and campaigns which was Recommendation 10, we have had a real struggle trying to get other Institutes at the NIH talking about how to synergize all the fragmented health promotion campaigns that are scattered about, the National Cholesterol Education Program, National High Blood Pressure Education Program, the Obesity Initiative, our Five-a-Day Initiative, and on and on. There are bits and pieces of health communication campaigns all focused on chronic disease prevention, most of them focusing on similar risk factors. The effectiveness of these is undermined by the fact that they are scattered. They are independent. They are not synergistic or coordinated. How do we avoid the diffusion of responsibility that occurs once we are not talking about disease specific problems? Here we are talking about cancer prevention and early detection, but I think it really does make sense in terms of planning and coordination to talk about chronic disease prevention. Therefore the disease groups, both public, private, non-profit advocacy, all of us government and non-government, still have a way to go in terms of putting our forces together.

Bill Corr, Esq Executive Director, National Center for Tobacco-Free Kids: I am very pleased to be here and hope that I can try to adapt what I was going to say given the very thoughtful comments that have already been made so we can get to the discussion. There are three big lessons that have been learned from tobacco that still need to be applied in tobacco and maybe have a good deal of relevance for obesity.

First, with all the attention that is being paid to tobacco reduction, with all the money, and resources that are available, with all of the study that has been done on the impact of tobacco and how to address it, there are still a number of major misunderstandings. I say this not based on a scientific sample but on my own personal experience as I have gone around the country talking to state legislators and city council people and members of Congress. You would be amazed at how many people think the tobacco problem is fixed. I think that is because they are part of the 75 percent that don’t smoke, and they don’t see it very much anymore. They hear things like a 27 year low in high school seniors smoking. Although 26.5 percent or so of high school seniors are smoking. They hear the first half of that and not the second. They hear adult consumption is declining overall, but we still have 25 percent of adults smoking, and, as has been said, this may be the tougher group. They hear about all the people who want to quit, but they don’t hear about the

small percent that succeed. They understand that there is lots and lots of money—would you believe that over $20 billion a year is generated by the master settlement agreement and by tobacco excise taxes. But of that $20 billion, only about 3.5 percent this year is being spent on tobacco prevention. Unfortunately, much of the rest is going into deficit reduction.

Many people think that the effort that we are making now will suffice, that we just have to keep doing what we are doing. What they don’t realize is that the industry, in the three years since the national settlement agreement, has increased its promotion and marketing expenditures by 66 percent. The industry is not letting go of this issue by any means, which makes it all the harder to succeed with prevention and cessation programs. All of these misunderstandings lead to the possibility that we will actually undercut, not succeed with, our current efforts in tobacco. Many people think there is enough tobacco money so that we can share some of it for this other major public health crisis we have got in obesity. We would undermine our tobacco efforts. We would underfund our obesity intervention efforts. We simply cannot allow those kinds of misunderstandings to continue which is why this report is so valuable.

We have to find some new ways to overcome these misunderstandings. I know that it is daunting to think in terms of new resources for public health. At the federal level we have got huge deficits. At the state level, you have all been reading about unprecedented levels of deficits in many states. However, I can tell you personally from over 20 years of experience in Washington, on the Hill, in the Executive Branch, that if we in the public health community are shy about raising our voices for what is needed in public health, we will get nothing. A long time ago a fellow Hill staffer was pushing very hard for money at a time when there were limited dollars and I said, Brian, don’t you think you ought to take into consideration all these other needs?” and he said, Somebody else who is advocating for those needs has got to speak for them, but if we don’t speak up for our needs we are not going to get any money,” and it is true about public health. We simply cannot be intimidated by the difficult budget situations.

We have to take a crystal clear message to our elected officials and to our policy makers that we must spend more money on public health. We need to spend more money on obesity, and we have got to use the money that we have for tobacco prevention and cessation. We are an advocacy organization so we can speak out. I know that there are many organizations, including the IOM, that have some limits on what they can do in terms of being advocates as opposed to providing objective advice, but the public health community is going to have to be more aggressive if we are going to get the additional resources that we need.

Second, I mentioned this morning that elected officials, as a general rule, do not know about the evidence-based solutions that have already been

developed and that are being used. I was in the State of Maine talking to a legislator. Maine is one of the most progressive states in terms of its tobacco prevention efforts—36 percent reduction in high school smoking in three years. They have got a state-wide clean indoor air law. They just amended it to strengthen it. They have taken all their master settlement agreement money and put it into the Fund for a Healthy Maine. Part of it goes to tobacco prevention and cessation. Part of it goes to other health care. They are exercising leadership across the board; both parties are dedicated to creating a healthier Maine because they think it is going to be a more economically advanced Maine, and they have just done a spectacular job. But even in Maine, talking to a legislator, you hear comments such as: If I take a dollar and put it into expanding one of our research centers, we will get $8 from the NIH. That is a lot of research funding. So, I know a dollar spent there will get me $8. What will a dollar spent on tobacco control get me? I will feel better, but will it get me anything?” It is a very important question, one that we have to be able to answer with legislators across the country.

There is a strong evidence base for raising excise taxes; a 10 percent increase in tobacco prices causes a 7 percent reduction in the number of kids who use tobacco, 3 to 5 percent reduction in the amount that adults smoke. Since, January 2002, 30 states have raised their tobacco taxes, some to very high levels that no one ever dreamed possible. The problem is, as soon as these state deficits are solved you will see the end of tobacco tax increases. They use health rhetoric now, that it is good to stop kids from smoking. However, what they are really trying to do is solve the deficit problem. We are again going to have to fight hard to keep people using evidence-based solutions for public health purposes. Many states, New York, Delaware, Connecticut, Florida, have all passed statewide clean indoor air laws. Yet you still hear many, many legislators espousing the industry’s line that this is going to hurt business. All the evidence is that it either has no effect, or it actually improves business.

The third big issue is that we have to have an implementation plan. I know everyone is committed to seeing the report implemented, but you have got to have an action plan and that means that organizations have really got to pull together to figure out how are we going to get legislators better educated; how are we going to get the provider community, the health insurance and health plan community, and employers better educated about the value of cessation. We have got to get down to concrete steps if we are going to make progress. I think it will be all the tougher with obesity. As was said, so much time and energy has been spent on tobacco, a great deal has been learned. Now that same learning curve is going to occur with obesity. Hopefully, it will be faster, but organizations have got to be assigned responsibilities. They have got to take responsibilities and be coordinated and really push the implementation of these kinds of recommendations. Too often these

excellent objective recommendations based on good science and good evidence are articulated, are sent around the country, and they go on some-body’s shelf, and there just isn’t any follow through. So, we have got to become much more proactive and determined to implement these recommendations.

Dr. William Dietz, Director of the Division of Nutrition and Physical Activity, CDC: What opportunities are there to link and create synergy between policy initiatives for tobacco and obesity? We have to be quite clear that there are two intersections of obesity and tobacco use. One is the co-variance of tobacco use with obesity and other risk-taking behaviors, and that suggests to me that there may be a core of individuals who are in both camps for whom much more intensive and perhaps non-public health approaches might be merited. The second is that increasingly, particularly among adolescent girls, smoking is used as a weight control measure, and concern about weight gain is one of the barriers to smoking cessation. So, I think that there is an opportunity for thinking about combined strategies that address these two overlaps.

With regard to tobacco policy successes and the implementation of obesity related policies, it is very important to recognize that we are in a much more primitive state with respect to obesity control than we are with respect to tobacco control. Some of that has to do with a lack of evidence, or the lack of understanding I should say, because, although the public perceives it as a cosmetic issue, the evidence is that obesity is a health issue. In contrast, tobacco is widely perceived as a health issue. This difference was brought home to me by an African-American physician who started a weight control program in an African-American community in Kansas. She found as a result of her focus group work that African-American men and women did not understand the linkage between obesity and type 2 diabetes and its complications. In contrast, an extensive series of reports has identified tobacco as a health issue and made it possible to move forward into policy.

In contrast to tobacco use, stigmatization does not work for obesity. There is no group in the United States that is as stigmatized as those who are overweight. Despite that, the prevalence of obesity is increasing. In contrast, a reasonable argument could be made that stigmatization of smoking has been quite effective at reducing smoking rates. Stigmatization has been one of the consequences of the non-smokers’ rights campaign. One of the conclusions that is quite clear from the tobacco experience and should hold true also for obesity is that the medical approach has a role that can’t exist in isolation from the public health approach, as others have said.

A fourth important point is that, in contrast to tobacco use, obesity is much more complex. Tobacco is a single product, and there is no evidence that any tobacco use is beneficial, whereas you can’t survive without eating. Fifth, vilification of the industry, which has been so wide spread in the to-

bacco wars, is probably not going to be effective in the food arena despite what the tobacco lawyers would have us believe.

Food industry groups are responding to consumer demand, and they do what they do very well. They produce an inexpensive product that is readily available, tasty, and quick, and we haven’t developed food alternatives that meet those same criteria. One of the risks that we face is that if we begin with opposition to the food industry, we lose the opportunity for alliances that I believe are going to be necessary to move this issue forward. House-wives, who 20 years ago spent an hour preparing dinner, are not going to go back to the old days. Quick service products are with us for the foreseeable future. Under those circumstances, the strategy needs to be to change the product and change the demand for the product. In contrast to the tobacco issue, the role of public health in the obesity epidemic is to help create a demand for those products if industry moves in that direction. I think there is every indication that that movement has started; the decision of PepsiCo to eliminate trans fat which has nothing to do with obesity and to lower the total fat in their products is one of the examples of industry’s responsiveness to consumer needs.

Now, another reason for partnering with business is that we are not going to have the resources that business has to promote healthier alternatives. I think there are opportunities for partnership and understanding how to develop campaigns that meet needs from the public health or governmental perspective as well as the industry perspective. The other important point about industry is that we tend to think of industry only in terms of the fast food industry, when, in fact, other industries are potential allies. There may be very strong vested interests in the business community that are willing to support strategies to reduce the prevalence of obesity because so much of their income goes for paying the disease costs associated with obesity in their employees.

Finally, in contrast to state tobacco programs which have been free standing, the obesity program, that we are beginning to initiate within 20 states this year, has to connect with the other chronic disease efforts. Partnerships in that respect are crucial. There is an emergent broad alliance. The American Cancer Society, the American Heart Association, and the American Diabetes Association, the American Dietetic Association, and the American Academy of Pediatrics have all initiated activities in this area, and the Washington Business Group on Health has established an institute on obesity. However, we do not yet have a clear focus on the strategy. There is a consensus that a problem exists, but there is no consensus yet about what to do about it. In contrast to tobacco where it was quite easy to say we must stop smoking, what do we do about obesity? We do have some strategies, like promotion of breast feeding, control of television time in children, and physical activity, but we don’t yet have a food-related strategy.

I should finish with a word on disparities. I don’t have a clear idea yet about how we craft the strategy specific for the groups that are most affected, but I think we have moved towards identifying the most vulnerable populations that may contribute a disproportionate share to the burden of disease associated with obesity. The first of these is children and adolescents. Despite the fact that they only account for 25 percent of adult obesity, obesity which has its onset in youth and persists into adulthood is much more severe in adulthood than obesity which has its onset then. The second group includes African-Americans and Mexican-American children and adults; both males and females have a higher prevalence of obesity than Caucasian youth or adults. A particular problem is the group that has a body mass index (BMI) greater than or equal to 40—roughly 100 pounds overweight. Five percent of the U.S. population have a BMI over 40, but 15 percent of African-American women have a BMI over 40. This suggests to me that African-American females are another very important and vulnerable population group for whom very specific strategies that address culture, socioeconomic status, and social justice become very important.

Dr. Clement Bezold, moderator: You mentioned the PepsiCo issue. As a futurist, I read the press about this. It has been getting a lot of attention, front page of the Wall Street Journal and in Forbes. Pepsi is in effect trying to make its product line, its portfolio across the board, healthier. Do you consider them as an ally? Would you interpret that as an opportunity?

Dr. William Dietz: I think it is a very important opportunity. I think their market research is telling them that this is an issue whose time has come, and they need to position their products to capitalize on what they see as a shift in consumption patterns. A couple of months ago, someone from the advertising industry commented that 15 years ago products had to begin to address diversity. That was clearly an issue whose time had come and required a response in Grafting messages from the industry. He went on to say that today we need to do the same thing for obesity. This is an issue that is going to be with us, that is going to be pervasive, and the impact of obesity on products needs to be addressed or their will be marketplace consequences. I think that reflects a growing sensitivity on the part of both industry and advertising to the importance and relevance of obesity.

Participant: I am a clinical professor at George Washington University and CEO of a new company called Diet Fit, Incorporated. I find the comments very interesting, and I have a proposal regarding nutrition strategy. There is an imbalance between the motivation of the food industry that depends on increasing food consumption for its products and the desire to shrink portion sizes and slim down the population. This conflict has to be resolved through incentives or disincentives because that is the only thing that really seems to work in a free society. It is difficult to persuade people to give up food addiction or habits which have been instilled in childhood

and which they have lived with all their lives. I have seen that in different cultures that live in the United States which follow their dietary patterns faithfully from childhood.

Could we consider a tax on calories? Calories obviously come more from fat than from protein and carbohydrates, so a tax would be a disincentive to include fat because you would be raising the price of your product. It would encourage the creation of lower calorie products. As fat has decreased in some products, sugars have gone up to compensate for loss of taste. The result is that people who think they are consuming fewer calories because they choose low-fat products actually are consuming more calories because of the fundamental change in the formulation. That would also be overcome by a tax on calories. This could in effect subsidize healthful food but that might introduce a higher level of complexity, and I think most healthier foods can be lower in calories anyway.

Dr. Tim Byers: If the goal is simply raising money with a tax on calories, we can do that, and we can raise money. Many small taxes on soft drinks currently raise a lot of money. If our strategy is to begin to tax and manipulate the prices of foods enough to affect healthy eating behaviors, I just can’t imagine that that will be successful. That is too complex and would not get broad public support. I don’t support it, and I am a nutritional public health person. Given the wide range of foods, imposing a tax in order to affect prices that would then in turn affect behavior I think is a losing strategy.

Dr. William Dietz: I think that a tax requires several elements that are not in place for obesity in contrast to what is in place for cigarettes. The first is a clear linkage between what you are taxing and its consequences. You can tax tobacco because you know there is a disease consequence. I don’t think there is an adequate evidence base that justifies calorie taxation, anymore than you could justify taxation on the other side of the energy balance equation. I suspect that incentives may work better. Secondly, the one survey I’m familiar with of attitudes of Americans about various steps that could be taken in the obesity epidemic ranked taxes extraordinarily low. On the other hand, we are willing to pay for improvements in school lunches or more parks and recreation facilities. So, although you may think taxes are a good idea, I am not sure that we have an evidence base that supports them or the political will to pass them.

Dr. Harvey Fineberg: You made the observation that there is the consensus more on the problem than on the solution or strategy for the obesity problem. We have been talking so far mainly about the food side, the nutrition side, not much about the activity side. From a strategic point of view, is it wise to be thinking about the obesity problem as a kind of energy balance problem which has intake and expenditure simultaneously in mind? If so what strategic implications does that have from your vantage point?

Dr. William Dietz: It absolutely is a problem of energy imbalance. One can think about it in terms of increased intake or reduced expenditure. I think there are two distinct strategies here. There is a nutritional strategy, but there is an equally important physical activity strategy. Ironically, even though we know much more about the changes in the food supply that have accompanied the epidemic, we have better evidence about the importance of physical activity to address it. Even though physical activity doesn’t help people reduce weight very much, once their weight has increased it does appear to have a very substantial effect on co-morbidities associated with obesity. So, although we desperately need a food strategy that we can emphasize as much as the physical activity strategy, I think we can say for sure that we need to be promoting physical activity.

Participant: I am not oblivious to all the difficulties of doing this, but it seems to me price is used to control purchasing in this society constantly. Small adjustments in fuel prices for example produce hysterical reactions from the public who suddenly find the price goes up at the gas pump. It doesn’t stop them buying the gas, but it does certainly affect them. I think you have to think how we make a choice in buying food, because right now we have a disincentive. Low-fat milk or skim milk is more expensive than whole milk, and so-called “health foods,” or healthier foods, tend to be more expensive. That is working against what we are trying to do. A final point, portion sizes have pretty much doubled during the last 20 years which is the period of the epidemic because food is so cheap and because fast food joints offer, for example, two hamburgers for the price of one in a special deal. Everything is done to encourage over consumption, and very little is done to discourage it. That is really what I am searching for ways to discourage.

Dr. Ron Davis: I wanted to make a couple of comments and ask for reactions from the speakers. First, on the point about synergy between tobacco and obesity (including the relationship between smoking and body weight)—one of the biggest problems we deal with in smoking cessation is that people are discouraged by the tendency to gain weight after they quit. One of the points I make in the quit smoking program where I work is that if people can exercise or increase physical activity as they are going through a quit attempt, it will help them avoid that post-cessation weight gain, and secondly, it will help them deal with the stress of nicotine withdrawal.

There are powerful ways in which we can combine these two interventions (quitting smoking and increasing physical activity), and I think that this is particularly important because our DHHS guideline on smoking cessation actually states that you are better off not dealing with the weight gain situation with people who are quitting smoking, because they have all they can do to stay off cigarettes without worrying about another major behavioral change. That was the one thing that came out of our DHHS guideline on smoking cessation published in 2000, to which I took exception.

My second point follows up on what Bill Corr said about the need for a national action plan. We don’t have a national plan for tobacco control as amazing as that may seem. The closest we come to a national plan for tobacco control is Healthy People 2010. As I have argued previously (Davis, 1998), the fact that Healthy People 2010 (and Healthy People 2000 before it) was controlled by the Federal government and was cleared through the White House and OMB makes it something short of a national consensus plan. In addition, most of the goals in Healthy People 2010 are not actionable. Michael Stoto, when he was with IOM, talked about how the goals need to be actionable so that you can have accountability for them. So, I would like to reinforce that we need to have a national plan for tobacco control. This needs to be a consensus plan. It should not be controlled by a federal clearance process, and it needs to be actionable with accountability.

Dr. Jon Kerner: That statement actually was the second point I was going to make about a national action plan. We actually do have a national action plan for tobacco control; it has to be cleared. It was a partnership effort made by Robert Wood Johnson, Legacy, NCI, CDC, and AHRQ. It spent like 12 months in development, and it has been 10 months in clearance.

Dr. Ron Davis: That plan you are talking about is the Blueprint document (A National Blueprint for Disseminating and Implementing Evidence-Based Clinical and Community Strategies to Promote Tobacco-Use Cessation, 2002)? It’s just cessation though.

Dr. Jon Kerner: Yes, but it is a consensus plan addressing smoking cessation. It doesn’t cover the whole waterfront, and your point on clearance is well taken. It takes a long time, and it really brings me to the question I have for the group which is that throughout the report, there is an implied assumption that we are all in agreement. That we know policy works, and everybody supports policy. I would like to suggest that we have a competitor for policy. That is the individual responsibility philosophy which is challenging the policy approach and makes it somewhat difficult to actually address these issues of tobacco and diet selectively. If we conceptualize, and I think many do, that this is about individual responsibility, it is sometimes harder to make the case for policy. Is there a strong and compelling demand for policy approaches outside this room?

Dr. Harvey Fineberg: There is demand, and there is controversy, just as you are pointing out. For those who argue for individual choice, I would point out that there are also powerful cultural determinants, the context in which we might think we are making choices. For example, look around this room. Look how we are dressed. Just take that obvious example. Look how many of the men in the room are wearing ties, how many women are wearing the kind of clothing we are accustomed to wearing. We don’t even think about those decisions when we get up in the morning. We dress the way we

dress because that is the way we dress, but there is nothing obvious or ordained about it. We might think we have made a big personal choice by what tie we take out of the closet this morning, but that is individual choice within such a cultural constraint that the argument that these choices are devoid of powerful cultural determinants is, I think, flying in the face of everyday overwhelming experience.

Dr. Jon Kerner: Someone made the comment that very few policy makers understand what the options are. I would argue that they don’t care. It is not a question of understanding. I would argue that their focus is on certain choices. Probably the most important choice is the choice at election time, but that is then followed by what choices are going to be made in terms of supporting an issue. So, it is more than the science; that isn’t the argument. It is the willingness, interest, the political will to take this on, and I think there are lots of people in this country who still believe today that people are addicted to tobacco because they choose to be. People are obese because they choose to be and that we shouldn’t be spending all this money on this. People are just making bad choices, and if they could just get it right they would be fine. I am curious whether you agree that that is an issue we have to address because I didn’t really see it well addressed in the report.

Dr. Tim Byers: I think absolutely it is an issue we need to address in the way we project this. If we project that it is individual decision or the heavy hand of government through policy, that is the wrong paradigm. As you were saying, we all make choices in the social context, and in the area of tobacco, for instance, you lose your free choice when you get addicted. So, what is free choice about that? So, I think it is important not to frame these as either/or but how policy enables free choice and individual decisions.

Dr. Robert Croyle: Everybody loves policies that benefit themselves or their constituencies. Every advocate or lobbyist on Capitol Hill is pushing a policy of some sort. So, back to the point about the food industry, the trick is to identify policies that have the usual benefits to as many possible constituents and still achieve the goal that you are trying to achieve. Just as you would with any legislative political policy issues, you try to characterize this so that it not only achieves the goal we want to achieve, a public health goal for healthy eating for example, but also enables and empowers an allied constituency which it also benefits. One area where we work with CDC is with the produce industry about the five-a-day program. That is a large industry that is chronically stressed by changes in the weather, many commodities’ oversupply, but one where we have a very strong alliance. We want to promote fruit and vegetable consumption, and so do they, and the amount of resources that that industry sector puts towards that campaign far outstrips the federal investment.

Returning to my earlier comments about MINC, minimal investment needed for change, I don’t think we know what such investments are yet for

energy balance. I propose that as a major scientific question that we need answers to pretty rapidly, because I think there is still a lot of difficulty in terms of the small size of the evidence base regarding energy balance. In terms of tobacco, this report and many others run through the options, excise taxes are an example, a clean indoor air law is another example; one of the appeals of policy actions is their relatively low cost. In the areas of cancer screening and other cancer early detection technologies, a lot of evidence supports reminder systems as an example of a MINC, and that is oftentimes using the tools we have now in terms of information systems. Informatics and health technology provide us with a much longer list of potential MINCs than we used to have.

Participant: I feel that it is important to try to create some coordinated way of educating youth and the public about moderation, because it’s hard to get a radical policy change. Can we try to make all these things we have been discussing attractive? We need to make healthy alternatives attractive and gradually change attitudes.

Dr. Robert Croyle: The food example is a good one. Efforts of USDA, most recently with support from Congress, to change the nature of the food supply in school lunch programs reflect the importance of behavior. In that case, modification of food preferences through exposure is essential at an early age, not targeting individuals and haranguing them. The five-a-day demonstration project partnership with four states and the USDA around the country provides some pretty good evidence that simply providing for the availability of fruit as a snack in school settings had a significant impact on behavior.

Once you move to adults and changing long-term behavior patterns, part of the challenge is that many of the environmental changes that may work more effectively in kids are tougher with adults. The IOM report, for example, talked about work site interventions. The evidence there is mixed, and it is a small effect. The major barrier for so many people now is the time barrier. Even if you have access, even if you have a trail, even if you have a health club membership, many people never go. We discussed the role of employers and insurers and payers in terms of screening and treatment of sick people, but a huge untapped, uncharted territory is employer support for time for physical activity.

Dr. Bruce Black, American Cancer Society: Regarding a national tobacco plan, I believe that there is an opportunity right now with state cancer plans. There are about 20 states that now have comprehensive cancer plans, and by this time next year all 50 states will have them. States are going to be implementing those plans mainly in the community, and this provides an opportunity for us to begin to put together tobacco, obesity, diet, physical activity and all of the rest of the early detection and research continuum. It would be wonderful to have a national kind of strategy; otherwise

these states are going to be floundering. You know in the states all of these programs are fragmented. So, we are trying to develop a comprehensive cancer control approach and in chronic disease as well. If we could come up with some actionable objectives, a national plan with ideas about how to integrate these pieces, so that they can, by leveraging each other, increase the power of the whole cancer community at the state and local level, this would be really fabulous. I think it is really a nice way of taking this IOM document that talks about the need for multilevel interventions and implementing them into the real world through this framework.

Dr. William Dietz: CDC is funding 20 states this year for nutrition, physical activity, and obesity programs, and the mandate that those programs have is to integrate across current state programs which include the cancer, cardiovascular disease, and diabetes programs as well as across agencies. Programs like WIC, for example, need to be part of the state plans for nutrition and physical activity programs directed at obesity. We are also asking those states to link to non-governmental organizations. I am still ambivalent about whether we should take the best of those programs and incorporate them into a national plan, or whether a national plan should be created which feeds down into those state programs. I think that the place where change is most likely to happen is at the community level through the state programs, and there is benefit in looking at those to identify the best practices that then go forward into a national plan.

The other program that is very relevant to this discussion is the Steps to a Healthier U.S. program which carries with it this year $15 million for communities to work on asthma, diabetes, and obesity through tobacco, nutrition, and physical activity strategies. Next year in the President’s budget there is $100 million for those efforts. That provides an opportunity to give the kind of funding communities need to begin to implement these more comprehensive strategies, and in STEPS just as in our state programs, partnerships are mandated and expected. Hopefully some innovative and potentially effective strategies will emerge from those activities.

Len Lichtenfeld, Moderator; One of the key items for the symposium and for the group discussion is to try to develop actionable items, a list of things to focus on that would be beneficial in moving forward.

Ms. Helen Darling, President, Washington Business Group on Health: I’m happy to comment on what employers can do, because there are a lot of misconceptions or misinformation about this sector. The Washington

Business Group on Health is a membership organization of about 175 large employers who are forward thinking and dedicated to finding innovative solutions to the health care cost and quality crisis. The organization has existed for nearly 30 years, and it is made up of companies that provide comprehensive benefit packages and have innovative human resource practices. Employers can play a very important role in providing information to their employees. The evidence, much of which is summarized in IOM reports, is that a little over 50 percent nationwide of health care is what it should be, which means that a little over 40 percent is not. Part of the concern of the employers is that we are paying for a lot of care that isn’t doing anything useful and possibly is harmful. So, when the business community is asked for more money, the response is, wait a minute, we will give you all the funding we are giving you now, but stop doing the things that are either ineffective or downright harmful, and do the things that are effective with the current investment.

Of course, the question is also how we reallocate these resources. But the payers are not going to spend any more. The average family coverage in this country in January 2004 nationwide will be $12,000. The average pay package in this country is $27,000. Health care costs went up 14 percent, but pay rose only 1.7 percent. So at the rate we are inflating, we will be giving the average American worker more benefits in health care than we give in wages, which by the way are taxed (at least FICA and Medicare tax). So, actual take-home pay would be a minority of the total compensation package.

Before employers spend more money, they need more evidence. We need the health industry to provide short, crisp messages about what is truly effective. Perhaps, experts could give us one large table that lists interventions that are definitely effective, smoking cessation being the best example. Employers in America could let their employees know, through posters and other communication methods, that there is scientific evidence from the National Cancer Institute, American Cancer Society, and other authoritative sources: a) that these things work; b) that this is what they do for you; and c) that this is all you have to do to realize the benefits. Those very simple messages should be in bullet form, citing the authoritative sources.

I learned recently from CDC officials, that we should not tie the nicotine patch to a requirement that the patient receive counseling. The reason according to CDC is that you will pick up additional people if you don’t force them to do both. I had always believed, based on earlier evidence, that the patch and counseling produced the best results. I was glad to learn that on a net basis, an employer would do better to not have the linked requirement because that writes off a group. So, this is something that is a big problem, that is preventable, that is a killer, and yet there isn’t clarity on what to do. It would also be important to have the actual evidence, since real expenditures

with such a change could grow rapidly with concomitant success, which could alarm employers again.

So if the most knowledgeable people who are designing programs don’t have it down pat, the average person out there trying to make Ford Motor cars, or pay claims, is not likely to be able to act on the information. It will be very powerful when we get targeted evidence-based treatment plans, options in the simplest form and clearest language, with the sharpest distinctions and with the easiest communications.

We had a program on smoking cessation that brought companies together with CDC and researchers and knowledgeable people, and they gave us advice. So, we are making the information available online to members. The aim is for employers to be able to download instructions on how to change behavior, and what information might make a difference. Employers could also provide the information to employees through their intranet. The IOM’s report is very good about talking about options, but there is still a need for more clarity. There are two or three screening or diagnostic tests where there is relative agreement. But there are also two or three really big ones like PSA testing where there is a mixed message made even more complicated by the recent evidence about the test’s accuracy.

One of the things that confuses my members is shared decision making. Shared decision making is offered when there is little or no certainty, or there are mostly negative messages. Nobody seems to have the answer, but we know that most of the male health officials are getting the PSA test for themselves. The public can see through this, so it’s no surprise when people say I don’t know what to do so I’ll do nothing, and that may not be the right course. Physicians should understand that shared decision making is a way to deal with the fact(s) when there are no simple solutions and somewhat unsatisfactory options about which patients should be informed. Patients should be given an opportunity to decide whether they want the treatment or the test, but I think that if professionals would say that there isn’t a definite answer, but other things being equal I would do this, that might provide some welcome certainty. Shared decision making tends to get thrown in when providers don’t know with certainty what to do, but it should always be an objective of clinical practice, not just when there are no easy answers. For now, we will push those preventions that have certainty, smoking cessation and colorectal cancer being examples.

Dr. Sean Tunis, Chief Medical Officer, CMS: What I have to say is straightforward; it is just a problem of missing one word in the statute. Medicare is structurally a defined benefit program which means that categories of benefits are defined in the statute, so getting patient care is a defined benefit; durable medical equivalent is a defined benefit. The things that are not defined in the statute as categories of benefits are not coverable no mat-

ter how good they are, or how valuable they are, or how cost effective they are.

As an example, outpatient prescription drugs is a missing benefit category at the moment, and preventive care services is currently a missing benefit category, unmentioned in the statute. Not being explicitly defined in the statue means that the only way of extending services is a statutory change. The other part of the statute that is important to know about that goes along with this is the critical line in law [1862(a)(1)] that Medicare may only pay for services that are reasonable and necessary for diagnosis and treatment of illness and injury. It is not pevention, diagnosis and treatment; it is diagnosis and treatment of illness and injury.

The absence of the prevention language has meant that it is not possible to add preventive services in the Medicare program except from time to time through individual statutory changes. So, mammography screening, cervical cancer screening, osteoporosis screening, all were added to Medicare one at a time by congressional action and are therefore paid for by Medicare. Colorectal screening was added to the program in 1997, so that is now covered.

There is an interesting nuance and subtlety in that a lot of screening tests are also used as diagnostic tests. For example, fasting blood glucose or glucose tolerance testing for diagnosis of diabetes are also potential screening tests. The differentiation is that something is considered diagnostic and therefore coverable if it is done in the presence of signs or symptoms of disease. In other words, if somebody has weight loss, polyuria, fatigue, any of those signs or symptoms of illness, Medicare will pay if a fasting blood glucose is ordered, but if someone has a family history or three generations of diabetic family members, a blood glucose test on that person in the absence of signs or symptoms of the disease is not covered.

This question came up recently; Secretary Thompson was quite interested in adding glucose screening for diabetes, so we went through quite a round of discussions, particularly with our general counsel. The feeling was that the statute did not actually prohibit us from going through a regulatory process to add payment for diabetes screening. But it would have to be done through a regulatory process, and if we went through a formal rulemaking for this, we would also have to explain why we would be adding it for diabetes screening in the presence of high-risk characteristics and not for screening of other potentially discoverable conditions in the setting of high risk characteristics. So, anyway, that is just some of the legal and regulatory framework. Not to say that anybody that works up in Baltimore is constitutionally opposed to screening and prevention. It is simply an issue of very limited legal and regulatory ability to pursue that.

One other point to make, which is that in pursuing statutory change in prevention as a category of benefits in the Medicare program, one should be mindful that there are interests lined up that would like other categories of

benefits added to the program too, and some of them are fairly extensive. We don’t cover telemedicine very well. There is no statutory authority for covering the evolution of electronic delivery of health care. For example, the current Medicare system will only pay for physician-patient encounters if they are face-to-face. That seems kind of unreasonable, because a lot of encounters can be accomplished quite efficiently through email or through some kind of electronic medium. But the statute doesn’t allow Medicare to pay. Many people would like to alter the statute to allow Medicare to pay for these kinds of services.

There are a lot of people who would be interested in Medicare’s paying for drugs and devices in the context of clinical trials. Medicare already pays for routine services rendered to patients in clinical trials, but not the experimental interventions, and only in federally sponsored trials. So, in other words, there is a fairly long list of missing benefit categories that prevention is competing with. It is not easy to make the case for prevention and not all the other equally meritorious, or arguably meritorious, services.

The recent House and Senate Medicare bills seemed remarkable for the absence of many preventive benefit enrichments to the program. The only ones I am aware of are payment for the initial preventive examination, waiving the deductible for colorectal cancer screening, increased payment for mammography, and diabetes screening. In the House bill these are, I think, the four items that deal with prevention, and there is nothing in the Senate bill that I’m aware of. I do think that trying to push for and make the case for preventive benefits as evidence-based, cost-effective services makes a lot of sense. I’ve also heard about some sort of flexible spending account for preventive services. Such an account would allow each Medicare beneficiary a certain amount of money. This was actually a recommendation of the Partnership for Prevention report (Partnership for Prevention, 2003) that somebody from CMS suggested. It would accommodate things like PSA testing in the absence of clear evidence. It would allow patient choice instead of a paternalistic governmental decision on benefits. It is not possible currently but an interesting theoretical approach.

Ms. Helen Darling: There is though in the House bill a medical savings account that is not an MSA, but actually more like a health reimbursement account. So it might be used for that purpose. It has a high price tag, so it may not survive conference.

Dr. Len Lichtenfeld: The Medicare Payment Advisory Commission in its 2002 report made the observation that the Medicare population has changed. The increasing population element is going to be the well elderly moving into the Medicare group, and we are going to have to pay some attention to prevention in this population. I am glad to hear you make comments about the current bills, because I have found it incredibly frustrating to try to get any accurate information about anything that pertains to any of

these bills. Dr. Gerberding from the CDC was talking the other day stressing the importance from her perspective of prevention as part of the Medicare bills. She said that she was going to be following them very closely as a top priority, so prevention is still on the table.

A second thought concerns a booklet I have on my desk describing Medicare preventive services for women. I found it dauntingly difficult to understand this book, because of conundrums, such as the Pap smear is paid for, but the examination to do the Pap smear is not covered, or this was covered in full, but that is covered in part. One of the important barriers to access for preventive care if you are not a wealthy person is the presence of copays. For example, in colonoscopy the 20 percent copay, even at Medicare rates, can be an obstacle.

Dr. Lewis Sandy: The only thing I would comment on has to do with vulnerable populations, those who have the greatest gap between what we know should be delivered and isn’t, particularly for low income adults. Children are in far better shape because they have S-CHIP and Medicaid. Low income adults are increasingly going to be shut out of the health care financing system, to a great extent now, more as we move forward. So, in terms of disparities, and particularly focusing on how low income adults receive preventive services, this seems to be a major area that currently has, and will have an even greater gap as we move forward. That gets to issues of support for CDC in breast and cervical cancer prevention and screening and extending that to colorectal cancer. I don’t see how low income adults are going to get screening for colorectal cancer unless something like this is put in place.

Ms. Helen Darling: The more we keep just saying general prevention, the more the world will tune you out. So, you need to be specific. It is very important you say what it is you want and provide the evidence. If you keep saying preventive benefits aren’t covered, everybody just wants to walk away, because number one, they know they cover a lot of them; and the current cost and affordability crisis is not a sustainable business model. So, get specific, prove what works, demonstrate it, and it will get paid for, but it won’t if we keep talking about general prevention.

Dr. Peter Greenwald: You mention that a lot is covered. What is a lot?

Ms. Helen Darling: A lot of care, much of which isn’t labeled prevention. When CBO scored a new screening mammography benefit for the catastrophic bill, they scored it at zero, because they said it was already being paid for by Medicare as mammograms under general health care.

Dr. Nancy Lee: The two most important things I don’t think are covered are organized evidence-based ways to keep people from, or help them stop, smoking, and the other big thing is to help people figure out how to lose weight and increase activity. I don’t think either of those is covered, correct me if I’m wrong.

Dr. Peter Greenwald: The other thing I wonder about is pediatric/adolescent age group smoking cessation, or prevention which is a more effective.

Ms. Helen Darling: That’s on our information list. Ways to help parents understand how they might be successful in keeping teenagers from smoking.

Dr. Susan Curry: The biggest risk factor for smoking initiation is parents smoking. So, if you target cessation, you will get prevention. If you look at the projections out to 2050 (I’m not saying we shouldn’t be taking a longer view), your biggest gain in terms of reducing morbidity and mortality is with smoking cessation, not with smoking prevention. So, I think you don’t want to pit one thing against another, but I do think that there are ways of focusing.

Participant: Since the initial premise of Medicare was for illness and injury, and that stems from a time when the population demographics were very different than they are now, and prevention was not understood in the same way—that money that is put out now would certainly be saved later with the smoking cessation programs—could a regulatory solution be worked through Congress to change the basis of the illness and injury wording in statute?

Dr. Sean Tunis: I think there is a pretty clear consensus that the historical structure of the Medicare program as a statute that was written in the mid-60s is out of date. It was the episodic acute illness and injury model. We didn’t think of the care of the elderly in terms of management of chronic illness over time, coordinated care, and so on. That being said, given that that is the legal statutory structure of the program, it would have to be changed through a statutory mechanism. That is certainly not something we should take off the table, but remember that part of the reason for the defined benefit design has to do with setting limits to resources expended. I suppose it is possible that if Medicare became a means-tested program, as some would have it, we could move away from defined benefits. But when you start playing around with the fundamental structure of the program, you can’t just fool with little pieces of it.

Ms. Hellen Darling: There is some value in just picking one or two unequivocally agreed upon conditions, or circumstances, or treatments, or diagnostic screening, or whatever it is. The reason some have prevailed and others haven’t is because they had a compelling case. The problem with going in with lots of things is, you lose them, but if you go in with smoking cessation, for example, that is something that you can define sufficiently, the evidence is compelling and has been for awhile and is getting better and better. It is much easier to continue to fight off all the other interests, because you have the evidence and they don’t. There will be an attack, but the nar-

rower and more compelling the argument, the easier it will be to defend, and the harder it will be for others to make the same case.

I tried for example to change mental health benefits in Medicare, and not only got eaten alive by all the usual forces including all those who wanted their own pet project, but we even got attacked by the different professions, because one professional group said, if you let others come in, it will kill the bill. Then the others said, if you don’t let us in, we’ll kill the bill. So even with something there is no argument about, there are these other forces. But I think probably smoking cessation may be one which you could define narrowly enough to make it really attractive for everybody.

Dr. Sean Tunis: As a fairly good model recently, medical nutrition payment was actually added as a Medicare benefit. Interestingly, medical nutritionists had not previously been official Medicare providers eligible for payment under Medicare. They came in with an IOM study on medical nutrition therapy, with the best evidence supported condition, and what really helped in the bill too was that the Secretary was asked to do a report on additional conditions for which medical nutrition therapy could be extended.

Dr. Len Lichtenfeld: What I think I am hearing is that clearly prevention in Medicare, as separate from commercial insurance, is a real issue and needs further attention. That requires study and it also requires action. Unfortunately, we had hoped that this discussion was going to occur as part of the debate of a restructuring of Medicare. The present restructuring is happening quickly and quietly so no one really knows the details as yet. I don’t know whether our chance has passed.

Ms. Helen Darling: I think members of Congress would say we’re targeting now on the prescription drug benefit because that is so important. But if anything, they will come back with renewed enthusiasm. They do know they need to restructure the program.

Participant: I just wanted to make a couple of comments. When you start talking about evidence-based and speaking about things like behavioral interventions or behavioral modifications, what works in one population isn’t necessarily going to work in another. When you think about evidence-based, you need to think for whom, because if you work in a specific population and you are talking about weight loss intervention or other sorts of physical activity programs, one program is not going to be effective for everybody.

Dr. Peter Greenwald: Is there evidence that smoking cessation for the Medicare population is effective?

Participant: There is a lot of evidence, but not for the cancer risk given the lead time for development of cancer. The evidence is good for cardiovascular risks. There are effects within five years.

Participant: I can’t quote it chapter and verse, but there are some studies that have been looking at recovery from invasive procedures including

cancer treatments with benefits in recovery time to smokers who quit versus those who don’t. So it is not just the diseases but physiological reactions.

Dr. Len Lichtenfeld: CMS has a demonstration project where they chose seven states, and they are going to randomize usual care versus special care, including paying providers for smoking cessation in the over 65 population. Accrual for that program is supposed to be done in September 2003. They want 40,000 people, they’ve got 5,000 so far, I believe. I’m sure that there is evidence to show smoking cessation is effective in this population. The general principle is that prevention—I think as one of the other comments for this meeting—is not only good for cancer but applies for a number of other conditions that we discuss.

Dr. Cheryl Heaton, American Legacy Foundation: I’m not sure if I agree with the primacy of cessation as primary prevention. I’ll share with you a document that RTI prepared for our board at the American Legacy Foundation, where we do spend a great deal of our resources on primary prevention of smoking for the youth campaign, a media and grass roots campaign called the Truth Campaign. What they concluded was that they were roughly equivalent. You could stop a lot more from ever starting with the primary prevention and media campaign and grass roots activities, but of course the payoff would be far delayed. But you have got a four to one preferential impact with the dollars spent in adolescence versus further in the life cycle.

When I became president of this foundation three years ago from my former position as Professor of Public Health at Columbia, it would have been impossible for what I’m about to say to have come out of my mouth. So, I am a convert to something that I had very little faith in during my 20 years in public health prior to coming to this job, that is, the ability of mass communications to substantially reframe the way Americans view any particular issue, as a consumer or even in terms of how they feel about it as a lifestyle question, and whether they even view it as a lifestyle question.

I’ll take the Truth Campaign as an example, where we have an enormous impact on stopping young people from picking up the smoking habit, probably about equivalent to the impact that price has had. For instance, by simply reframing the act of smoking, in the case of adolescents, as a rebellion, to not smoke is rebellious, because there is a corporate engine out there that needs you for continued profitability. The result is, it reframes everything. I think that we underestimate the role that mass media can play on changing adult behavior around things like diet. I don’t think we have ever made the investment that would be equivalent say to the investment that we have made in the Truth Campaign, or that ONDCP is making, I think unfortunately in some respects not terribly fruitfully, in the drug campaign. My own view is that they chose the wrong drug.

I am now a great believer in the impact of mass media. If we were to invest three to four hundred million dollars a year as a mass media campaign, so that every man, woman and child in the United States would have five to six impressions per month, I think you would be amazed at what would slowly happen culturally. I think the massive decline in smoking that has occurred in California is almost entirely attributable to the mass media campaign activating peoples’ thinking about smoking. It resulted in the change in the clean indoor air laws; it resulted in many more people seeking cessation services; it resulted in many adults quitting, and children didn’t start because they didn’t see their parents smoking. So, we have to be careful not to give the impression of one intervention being a higher priority than another; we need both.

Ms. Helen Darling: The Ad Council every year allocates a certain amount of money to do pro-bono work. We have been actually pushing—and the IOM and the American Cancer Society could be influential as well—to enlist a young woman -she has got a single name and she’s gorgeous, she is a young singer. I just saw her the other morning on CNN. They showed her talking about how she had decided that she wanted to be fit. The whole thing was about how fitness was important to her, not necessarily being thin, which she also was, but it was about fitness and about food. Now, something like that will place an emphasis on being healthy as a positive for young women in America. There are millions and millions of 13 and 14 year olds who would love to be like her. Something like that could have so much more power than anything we could ever do.

Dr. Susan Curry: I think what has been very clear in this discussion is the complexity within both the public and the private insurer-payer role; it is complicated, it is messy for the major insurers, for Medicare it is statutory and the language is outdated. But I also heard that there is a willingness and interest in both worlds to coalesce around some very specific targeted evidence-based initiatives. If we just pick the low-hanging fruit, we will make progress.

We talked a lot about tobacco cessation and paying attention to making sure that we provide the public with the best that there is to help people quit. We talked about trying to move that through, with maybe a model for doing so and for working on nutrition, too. What has also been interesting to me is that, having said all those things, the discussion then suggested that maybe we are not the most effective leverage point, and there are other ways that we can achieve this.

I would make a personal point that there is no one single way. If you can be more effective with mass media, that does not get the payers and the insurers and the health care delivery systems off the hook, because media campaigns work, there is going to be greater demand on the part of consumers for the systems to catch up.

Ms. Helen Darling: We certainly didn’t mean that if we were successful in changing the environment, anyone was off the hook. It is more a recognition that the problem is multifactorial, the solutions must be multi-pronged, and they have to recognize that if you are going to reach any one person, you are going to have to do it dozens of different ways, especially thinking about disparities. The approach that would work really well for one group won’t for another We probably need a couple of hundred tool kits that we can apply in the case of the employer and in the case of Medicare and Medicaid, all around the country with all sorts of different people. The solutions will have to be highly varied, and you want to be nimble about how you apply them.

Dr. Len Lichtenfeld: I was really impressed with the data from Group Health that showed that only two percent of subscribers were getting PSA testing, especially in relation to the comment that shared decision making may be an excuse for making no decision.

Dr. Robert Smith: I like the program at Group Health, but I would say that two percent implies actually discouraging the test (although it’s now up over 20 percent). But what impresses me about Group Health is that they send out a notice saying you are due for your mammogram on a certain date.

This is how it’s done in Sweden. They send a letter saying your appointment is in two weeks. Shorter than that is too soon. Longer is too late. If the woman can’t make it, she reschedules. The compliance rates are close to 75 percent on the first appointment, and on follow-up—90 percent. So making an actual appointment is as easy as a reminder. Data show that women are getting mammograms in the U.S. but not at the optimum regular intervals. We know that an encounter with a trusted clinician or health plan can be very influential. So this sort of reaching out needs to be encouraged.

Ms. Helen Darling: The problem is that there is a shrinking proportion of Americans that are HMO subscribers. The majority are now in preferred provider organizations. We have to have policies and procedures now that are focused on what is typical.

Dr. Nancy Lee; You don’t need a system for individual providers, There is software for that; the difference is to set up the appointment ahead of time.

Participant: One actionable item. I still am convinced that medical spending plans, not the kind you described, but the pre-tax medical spending plans that can go up to, I believe, $5,000 per year for an individual, are under exploited. As some of you may have known before Weight Watchers got in there and was negotiating, nutritional and tobacco interventions were not covered. That was not considered something you could spend your own pretax dollars on. You now can do that. It is an opportunity for employers to develop an organized and systematic way to identify smokers at job entry and give them the option of a medical spending plan. The problem is, you

can’t carry it over. Maybe the regulatory framework could be looked at, because it is in the IRS code, and make it more user friendly, and make that part of the whole system.

Dr. Lichtenfeld: That is a wonderful idea. I would want to know, for those employers who are offering those plans, what choices are people making, how are preventive services being covered, and if they are on the menu, how they are being selected

Ms. Helen Darling: Most of the consumer directed health plan models, as they are called, now have a prevention module. Actually most employers, try very hard to get employees to use appropriate services; that is good for both employee and the employer.

Dr. Clement Bezold, President, Institute for Alternative Futures, Moderator: In this discussion we hope to look at the average time for innovation and focus in particular on, first, how we can change the current process of funding, reporting, and disseminating research results in cancer prevention to decrease the time it takes to get information on effective strategies into clinical practice and public awareness and, second, on what new research funding or shared funding initiatives are needed to increase the number of studies that apply rigorous scientific methods to evaluate dissemination strategies.

Dr. Ralph Coates, Associate Director for Science, CDC: In consultation with colleagues in the Cancer Division and other parts of CDC and with others we work with in research and in programs, I developed several ideas in response to the questions that were posed. First, we might change our applied research initiatives and the way that we write announcements to assure both a focus on dissemination and application of rigorous methods. We might increase funding for proposals that move community intervention research more explicitly into dissemination. We need to specifically fund more research that replicates successful interventions in populations and in community settings where those interventions have not been tested before and in particular with underserved and minority populations. In addition, we need to fund more research specifically for implementation of well evaluated and replicated interventions to find out how to implement them in public health settings and with community organizations and health care systems. Then, once there is more translation of community intervention research into practice, we need to conduct evaluations with those groups that are providing those new evidence-based services to determine if the interventions are ef-

fective in the ways that we had anticipated. As noted in the IOM report, there is less funding for this type of research than there is for developing new interventions. What we need is more focused research on how to get those new interventions into practice.

Second, we might explicitly bring the US Preventive Services Task Force and the US Task Force for Community Preventive Services into our research announcements. We should make better use of their recommendations, their evidence reviews, and their methods, by referencing and summarizing them in our announcements. The main benefits of this approach are to identify needs for more evaluations of community interventions and for replications of effective interventions in new populations and new settings and to guide research methodologically and to promote rigorous research.

With regard to publication and reporting, in the work the Division of Cancer Prevention and Control is doing with the NCI and others on the Community Guide, one of the challenges has been to adequately evaluate the published community intervention research and to summarize findings across studies because of the way information is reported. Frequently, information that would allow us to say how generalizable findings are in the different populations is missing. There is often missing information about the methods that are used in the studies, affecting the ability to do a rigorous evaluation. Findings are reported in ways that make it difficult to summarize them and to integrate the findings across studies.

So, a third suggestion has to do with developing guidelines or recommendations for publication of results from community intervention research, similar to guidelines that aid the work done by groups like the U.S. Preventive Services Task Force. The CONSORT statement provides recommendations from journal editors, trialists, and methodologists on how to summarize and present information from clinical trials (Moher et al., 2001). It would be helpful for a meeting like this to support the development of something like a CONSORT statement for community intervention research to assure that methods are more comprehensively presented and to help with issues of generalizability and with summarizing findings.

Dr. Jon Kerner, Assistant Deputy Director for Research Dissemination and Diffusion, NCI: If the statement from the agenda question is from the Balas article (Balas and Boren, 2000)—that it takes an average of 17 years for research to be translated to clinical innovation—there was a critical piece missing from that which is that it takes 17 years to turn a fraction of original research to the benefit of patient care. That is a pathetic commentary on how long it takes. Some would argue that a deliberative process is necessary to ensure that what emerges from research has implications for practice, but I think we could probably do better than 17 years to get a fraction (and that is in a primary care practice setting where there is an infrastructure). In terms of community settings it probably takes longer because the infrastruc-

ture isn’t there. So, how can we change the current process of funding, reporting, and disseminating research results in cancer prevention to decrease the time it takes to get them into practice and public awareness?

We need to look at how we do discovery. Much of the intervention research we do doesn’t necessarily involve in a proactive or partnership way either the communities being studied or the clinicians who are ultimately expected to adopt the approach. We need to replicate the CCOP (community clinical oncology program) model in primary care practice. We need researchers and clinicians working together. We need community partners and researchers working together to make sure that the initial intervention being developed has any dissemination potential at all, because it is too late to be addressing that question after you have done the efficacy trial. So, we need to change the way we do research. An interagency working group at NIH and DHHS is looking into this kind of participatory research. I think that is an important issue.

Dr. Coates spoke about development, that is, how we move from discovery into practice. I will not duplicate his remarks, but I will say that if we are going to work in partnership, we have to recognize that we can’t all be doing everything. In fact, can we do anything that is evidence-based, because frankly on the federal level we are addicted to funding discovery? So, CDC has new de novo intervention research. NCI does. All these different agencies do, and we have all agreed that we need more dissemination research, replication research, and implementation research. So, we have to decide explicitly who is going to take the lead. Perhaps the American Cancer Society should be considering doing dissemination of research through the ACS divisions. I think CDC should take a leadership role in doing dissemination research through state health departments. The perfect example of this is the practice-based research network from the Agency for Healthcare Research and Quality. It would be encouraging if NCI could help to cofund testing cancer control interventions in primary care settings. That is where a lot of the action that is described in the IOM report is taking place as opposed to other things like chemoprevention which are often better tested in medical oncology centers.

How do we ensure that what we learn from the science influences practice? We have to start at home. Recently, the Health Subcommittee of the Research Coordinating Committee discussed a recommendation that no new demonstration program go out of the Department without evidence that the science-based agencies have been involved in developing the RFP, are involved in evaluating the applications, and perhaps are involved in helping to develop the evaluation plan. In the Steps for a Healthier US program, we were rushing to catch up. The science-based agencies came in late in the process, and it had some impact. We have a new health disparities initiative from CMS costing $25 million a year. I am hoping that we can have a con-

structive dialogue with CMS to make sure that the strategies they use to address cancer health disparities will be evidence-based, that the RFP will be based on the best available science, and that when the proposals come in, the science-based agencies will participate with the delivery agencies in trying to figure out what are the best approaches that have a reasonable chance of being adopted and implemented over the long haul.

The last question is about new funding initiatives. I think what we need to do is more dissemination of the research, and that should be a partnership, and we also need more research dissemination and diffusion which is slightly different. We have got some specifics; we have a new collaborative web portal with CDC, ACS, NCI, and SAMHSA (and soon AHRQ will be involved) called the cancer control planet. I invite you to take a look at cancercontrolplanet.cancer.gov. These are steps in the right direction for the kinds of partnerships that I think the report identifies.

Dr. Peter Greenwald, Director, Division of Cancer Prevention, NCI: How can we change the current process of funding, reporting and disseminating? I would first develop one or two or three priorities from a report such as this. Then I would drive toward that goal with persistence and milestones. If you have a huge laundry list, you won’t get there. I stated what I would put as top priorities this morning. One was for CMS, Medicare and Medicaid, to include preventive services. The challenges are the cost and the need to examine things now covered that don’t merit coverage. Given that it is treacherous because of all the vested interests, it would be a good place for an IOM analysis of what does merit coverage and what doesn’t, including preventive interventions as well as others. The other action I propose is the inclusion of physical activity as part of regular elementary and middle or junior high school education so that every student gets it. It would be a huge step, and we have been going in the wrong direction.

What new research funding initiatives are needed in cancer prevention? There are two general approaches to cancer prevention, a public health approach and more recently, a medical approach. On the public health side, state health agencies could be funded to address this, but I am afraid that has collapsed in the past few years. I would endorse restoring that and seeing to encouraging a rigorous ability to address prevention research at the state level. I would also support basic nutritional science, and the reason is that one size fits all is no longer valid. We are learning more and more that there is individual variability. We need the epidemiological evidence complemented by understanding individual variability in response to activity.

On the medical side there is exciting and growing progress. For example, in the breast cancer prevention trial with tamoxifen, we have already demonstrated that we can reduce incidence by half in women who have the risk of a 60 year old. There were some adverse effects, so we are addressing that both by testing another agent and through genomics to see whether we

can predict which women are likely to benefit and which are likely to get the adverse effects. Then we can focus on the best candidates. These findings will affect the roughly 70 percent of breast cancer that is hormonally driven. The way to approach the other 30 percent is by testing agents that do not work through hormonal pathways, and that is in progress. So, the ultimate aim is for 90 percent reduction through medical approaches. It would be crudely equivalent to blood pressure or LDL cholesterol—find who is at risk and intervene with prevention.

Another example in colorectal cancer, involves Dr. Ahlquist at the Mayo Clinic (Ahlquist, D.A., 2002). He has a method of looking at DNA in the stool. Cells are sloughed from the normal colon, colon polyps, and colon cancer all the time. Through DNA analysis their origin can be determined. DNA patterns should enable screening these as preliminary data. The discovery of a non-invasive colon cancer screening test that is accurate, sensitive, and specific, even if it only decreased colonoscopy by 70 or 80 percent, would be a huge step forward because diffusion would be far easier. I think we have enough of a lead to support research funding of non-invasive screening to complement colonoscopy even while we promote more colorectal screening.

I would say the biggest area that needs support with funding is training. Nobody is trained to do what we do in cancer prevention. We need to develop physicians and other scientists able to do prevention, and we need to provide incentives for our leading research institutions to make that a major focus.

Dr. Robert Graham, Acting Deputy Director, AHRQ: I came at this a little bit differently than the previous three speakers. As I looked at the first question and the question of priorities in investment, it seemed to me that it needed to be broken down. The question is preceded by the statement that we have evidence that it will take 17 years for translation or diffusion of only a fraction of findings into primary care practice. I am skeptical about that; I come from an environment prior to going back into government where I was dealing with practicing physicians every day. The impact of drug marketing is such that you go from approval to 30 percent market share in 6 months. What are the lessons there that may be applied to what we try to do in clinical medicine in terms of social marketing, in terms of targeting? How is that done? That is a behavioral change that we see every day, 6 months, 18 months, a real difference in terms of market share, in terms of physician prescribing behavior. That is not 17 years.

There are four nodes of the translation process that we need to keep in mind. We must deal differentially with the interface between these nodes as we try to accelerate translation. The nodes are: is it known?—the knowledge development; then: do they know it?—does the practitioner know it? So, there’s an interface between what is known, what is regarded as state-of-the-

art, and what the practitioner actually knows. Next: did they do it? There is a lot of evidence that a practitioner will know the right intervention but not do it all the time; and then: does it have the anticipated or desired effect? I knew it. I did it. Did what was supposed to happen really happen? Actually I think that last is very important, because it is a feedback loop to the first one—is it known.

We have the presumption that our challenge is to get people to do the right thing and good things will result. Well, yes, you can look at one knowledge loop, at beta blockers, and say that that works. However, there is another knowledge loop, hormone replacement therapy, where we thought we knew where we were on translation and were driving towards one particular clinical outcome, and then when we found that we didn’t get the anticipated or desired effect, we needed to work our way back and try to reeducate people and change their practice behavior.

So, in response to the first question, we have to look at what interface we are dealing with in terms of the translation cascade. Different interventions, I think, are necessary to translate knowledge to knowingness than may be necessary to translate a practitioner’s fund of knowledge to behavior. Even when we get to the point of having the practitioners behave the way that we think is appropriate, we need clinical skepticism about whether the outcomes are exactly what the design predicted.

The 17-year cycle is subject to critical appraisal and to the influence of non-clinical procedures as we break this cascade down. I am not a drug marketing executive, but I have had a lot of experience looking at the impact on clinical practice of how effective that marketing is. How can we apply that experience to changing clinical behaviors outside of that field? Is it all driven by marketing? Is it driven by repetition? Do we have to have the social marketing and the detail people? Is that effective? If it is effective, should we be using it?

Dr. Jon Kerner: I heard the drug company model as an example of how things move very swiftly. The report focuses on things like smoking cessation, diet, and physical activity counseling, the delivery or the recommendation for screening interventions. There is not much profit in those, and, of course, profit drives what the drug companies are doing to get the adoption of a product. So, it is not clear that social marketing and product marketing can be transposed with each other in the absence of profit. I am curious whether or not you think it is fair to compare them, as we look at persuading primary care practitioners to adopt practices without special reimbursement or other incentives.

Dr. Robert Graham: I agree that the dynamics may not be the same. That is the research question. Doctors change their behavior. Primary care physicians change their behavior on a whole series of matters from which they derive no direct profit. How are they doing that? The research question

is whether or not those principles and strategies are adaptable to what our objectives are clinically.

Dr. Peter Greenwald: The drug companies have moved toward public marketing to create demand even for prescription drugs, and they presumably have sales evidence that has encouraged them to go in that direction. So, that may well be something that we could do in prevention.

Dr. Jon Kerner: Right, although it is profit that drives the investment in the public marketing. Our profit is the public good not a private good, and do we have the resources to do the marketing? One other comment about that, Dr. Curry; this morning you talked about making prevention a standard of care in health care systems. A lot of the report focuses on training for that. But a survey of primary care practitioners and ob-gyns that we did at Sloan-Kettering in the mid-1980s showed that the number one predictor of counseling in smoking cessation was whether the doctor had quit smoking. The number one predictor on counseling in physical activity was whether doctors had changed their physical activity, and the number one predictor on counseling on nutrition was whether they had changed their diets to lose weight.

So, regarding training on adopting evidence-based programs, if it is a push/pull model, maybe the pull has something to do with what the doctors’ own personal health behaviors are. Maybe we should focus some on changing their behaviors as well as the systems approach to using the evidence.

Dr. Peter Greenwald: There is an old study from Boston, I think, of obese physicians and obese low SES people who were put into a program to lose weight. The low SES people did best. The explanation put forward was that physicians who could have responded to the message already had the message and so you had the hard core left. So, your suggestion is going to be a hard thing to carry off.

Dr. Susan Curry: We know that in recommending screening for colorectal cancer, physicians are much more likely to push that after one of their patients has been detected with cancer, and this tends to fade somewhat over time. So, providers might be encouraged by contact with some of these screening successes. I was intrigued by the notion of looking at what works in the diffusion of new medications. This might speak to the importance of involving the end users in the design and conduct of the research that you are doing, because pharmaceutical companies can be very innovative in doing what are called seeding studies. They know that if you can get providers to do something six or seven times, like prescribing a new medication, you are going to start to change their practice patterns.

They will design studies where they recruit very large numbers of practices who are charged with and paid for enrolling very small numbers of patients in these “randomized clinical trials.” They have got all the right language and the protocols for science, but what they are really trying to do is get these doctors to prescribe their drug enough times that it becomes a regu-

lar practice. So, a research question that could be included in studies that actually involve front line providers is the extent to which participation in these studies translates into a change in practice patterns once the study has ended.

Dr. Peter Greenwald: Yes, that is exactly right in clinical oncology, and it could be done in public health. What we did was we had 52 locales, community practices with their hospitals, taking part in clinical trials. Part of the result is the information, like the recent prostate prevention trial, but another part is the motivation for cancer control. Since these doctors and their staffs were taking part in the trials, they saw them as their trials. The rigor of taking part in the clinical trial was a continuing education experience, and since the trials were theirs, they bought into the results quickly. The results had quick credibility. So, the adoption and diffusion of what was learned was greatly accelerated by having this whole network take part in the trial development and implementation.

Dr. Jon Kerner: And I think that is the same hypothesis in the practice-based research networks at AHRQ. By getting primary care practitioners involved in the trials from the beginning, if the trial works, there is an early adoption network for evidence-based results out there ready to go.

Dr. Clement Bezold, Moderator: I heard earlier about the pharmacoeconomics of nutrition as an issue. It relates to the future of study design; how long before we know either pharmacogenomics of drugs or nutrition that will allow us to focus our designs, that is, the first aspect—what is known, and then how long before we have the infrastructure that allows a clinician to use that information? How will that then affect the clinician’s involvement in studies like this?

Dr. Peter Greenwald: First if you want to say nutrigenomics, fine, although the foods were there before the drugs, working through all those pathways as they were developed. However, you are correct in the sense that we need to know in nutrition the same thing that has been studied in pharmacology; what are the pathways and how do you influence them and can you predict based on the genetics of the individual or group. It’s a very, very complex issue in nutrition, so there are a lot of questions, and it is complicated to get projects designed and peer reviewed.

Right now our food supply is very rapidly changing. It is different than it was 10 years ago, and 60 percent of the foods in the supermarket today have engineered components, sometimes genetically engineered largely due to corn and soy involvement. The technology is driving the change, marketing, and production, and suppressing pests, and all of these things, but not health so much, except to the extent that consumer behavior is affected. We think we need a leading edge of very intensive nutritional science that can help to see that the changes will lead to better health. Without it, health is

not one of the major considerations in the change, and we may be in for some unpleasant surprises.

Ms. Eastman, Oncology Times: Relating to the hormone replacement therapy trial, I wonder what effect, perhaps a chilling effect on prevention, results like that have on clinicians who were using HRT and believed they were getting a certain clinical prevention result which is now shown not to be the case.

Dr. Robert Graham: I am not sure that I would focus that specifically on the prevention aspect. I think it was the latest example of the nature of medical science and the changes that can occur as we find evidence that invalidates what we thought we knew and results of interventions that we thought we could count on. When new knowledge comes along, we have to be flexible enough to adapt and change. Something like the HRT trial that affected so many people gets a lot of publicity, but similar events play out every day in other areas of clinical medicine at a much smaller level.

Dr. Peter Greenwald: I would add that the clinical trial is the gold standard of evidence in therapeutics and prevention where it is applicable. This is an instance where trials were never done, when HRT started in the early 1960s. The rationale for it did not derive from a randomized well-conducted clinical trial, and that was why Bernadine Healy when she was head of NIH felt that we needed such a trial. The lesson is that it is a very good investment to have the best of evidence-based research before we make national health policies.

Dr. Ralph Coates: In reading through the report I noticed that it said that there is convincing evidence that alcohol consumption is a breast cancer risk factor. I know that Health Canada says that there is a possible relationship, and the World Cancer Research Fund says that there is a probable relationship. What is confusing for people doing comprehensive cancer control planning or wanting to do community interventions on risk factors is identification of what those risk factors are.

The U.S. Preventive Services Task Force does a good job for chemoprevention. They now have recommendations for tamoxifen for primary prevention, and we have a lot of different groups issuing lists of risk factors, doing their own evidence reviews, and assembling groups of experts to make judgments. One thing that would be helpful could be assembly of a group to address making better sense of the observational studies, or identifying risk factors, or at least that there are non-harmful factors.

Dr. Peter Greenwald: It is easier to have criteria for evidence when you have a preventive effect that can be tested in a clinical trial. When you have an adverse event, like alcohol causing breast cancer, you obviously can’t do a clinical trial, and anyway you have a fairly low relative risk. The surprise is how much consistency there is in the epidemiology that alcohol is a risk factor. It surprised me. I have never trusted the evidence on amount

because when questionnaires are done asking how much women or people in general drink, the results are nowhere near the total amount of alcohol sold in the United States. I think rigorous criteria for evidence with a balanced expert group is probably the best you can do.

Dr. Jon Kerner: If we take diffusion of innovation theory and the “is it known” question, you could say, Is it known by the early adopters or when is it known; is it known by that sort of middle group?” The theory calls them laggards which I find a little pejorative. I would call them the last adopters. Do they actually care? What motivates physicians to change practice? If we focus only on what is known, and we don’t systematically involve our audiences, not only in the research itself, but in helping develop the programs and products that are ultimately trying to get the information out, we are probably going to miss the boat.

So, having shipped out to every state legislature in America, the summary of the report on states reducing tobacco use, I would venture to guess 95 percent of them went into the circular file because they just didn’t care. Also, a lot of what we do in the Federal Government is to make the assumption that if we get it out there it is known. Maybe it is but if recipients never read it and observed it, the fact that we sent it made no difference.

So, a fundamental dilemma is that we need to do more audience research. With regard to what Dr. Graham was talking about in the pharmaceutical industry, I can assure you they do really good audience research. We need to do more of that. Our hands are somewhat tied at the federal government level though because we have this little problem called OMB clearance which makes it very difficult for us to survey and figure out what our audiences want. That is actually where a public-private partnership would be quite helpful.

The Robert Wood Johnson Foundation and the American Cancer Society and a lot of other agencies could go out and do some of that audience work for us and with us so that we have a better idea, and we can stop assuming that simply because we produced something that summarized the evidence anybody actually cared to look at it, read it, and then presumably did something about it.

Dr. Bob Vollinger, Division of Cancer Control and Population Sciences, NCI: Your idea about getting the right messenger in your earlier comments about behavior patterns in providers predicting their practice got me thinking about social epidemics, connectors, and people who have disproportionately strong influences. I’m wondering whether we can determine the characteristics or patterns of providers who have disproportionate effect over their patients in tobacco control advice or certainly in obesity and can we identify those people and focus on them rather than using a kind of scatter-shot approach.

Dr. Jon Kerner: I would say that that is equally true for public health departments and state health departments. Who are the critical people whose opinions and behaviors might influence others? If we really want to understand how evidence-based innovation is adopted, we need to understand how those critical actors play a role. There is a lot of opinion out there about what works, and often it isn’t based on any evidence. In fact, I would argue that the biggest barrier to the adoption of evidence-based interventions is the addictive quality of making stuff up on your own, sort of this desire to innovate. Many local foundations which support community-based activity at the delivery end fund novelty only. If it isn’t new they don’t want to see it. And so all these systems that promote novelty may work against all of these systems that are trying to promote adoption of evidence-based approaches. They often don’t talk with each other and sort that out.

The third piece of the puzzle is definition. We have best practices. We have evidence-based. These terms are used as if they were interchangeable, but I don’t think they are. “Best practices” is often a collection of anecdotes describing the best we have got. Then, there is “evidence-based” which has been tested in a research study and shown to be efficacious. They are used as if they are one and the same thing. So, we have a definitional problem. We don’t know necessarily the systems and the system leaders, and there are forces working against taking up evidence-based approaches that we don’t fully understand. All three of those things bear more research.

Ms. Susan Dimock, Office of Senator Jack Reed: I heard a couple of times today that legislators don’t care or don’t want the information. Maybe that is true, but the staff genuinely does care and is interested in finding new information, which then gets transmitted to the legislator. However, the thing that has surprised me most about working on the Hill is the lack of time staff has to look at anything. They love to go to talks, and they love to get material. If you give them something, and then make a little noise about it, the ones that are interested will pay attention. I don’t know if that also works in the House or at the state level, but in the Senate most of them I know want to do good. In health there are lots of hearings with government agencies, or there are fellows who come out of the medical world or the academic world who want to do something on issues.

Dr. Jon Kerner: That is a really good point. I think I was the one who commented earlier about them not caring. In fact, it is not a question of them not caring, if they have time to think about it. It is competing priorities. How much attention can you devote to any particular health issue at any moment? NCI has this thing called a cancer progress report that was sent to the staff on all the health committees, and not a single individual ever got back to us about whether they liked it or not. Why? I suspect that they didn’t have time to look at it. As a result, we are trying to talk to former staffers to understand what would be the best way to disseminate. This would be a question for the

IOM. What would be the best way to disseminate the findings of this report so that it would be maximally useful to Senate staffers?

Dr. Clement Bezold, moderator: Great. My group has been running seminars for congressional staff for 25 years and there are tricks to it. One is knowing who are the ones, the mavens, among the staffers who will get the other folks there.

Dr. Len Lichtenfeld, Moderator: In this discussion, we hope to explore who is accountable for ensuring education in prevention and early detection, what leverage points there are for monitoring delivery of evidence-based prevention interventions, and how state health departments and federal agencies, like CMS, can advance prevention as a priority

Dr. Hal Sox, Editor, Annals of Internal Medicine:, I am going to try to point out some obvious leverage points for patients and for the Centers for Medicare and Medicaid Services. The problem is poor physician performance. In a study in a New Hampshire primary care practice, 14 percent of patients who were interviewed after seeing a physician said they had had a sigmoidoscopy according to usual practice guidelines, 45 percent had had a fecal occult blood test, 65 percent of women under age 60 had had Pap smears, and 66 percent had had a mammogram if they were over 50 (Sox et al., 1997). Now, is that good or is that bad? Some of it is obviously bad; some of it isn’t too bad.

The focus here is on physician education, but I am going to argue that the situation is really a lot more complicated than simply education. Focusing for the moment on physician education, internal medicine has a competency-based resident curriculum (Ende et al., 1997) which makes it possible to evaluate the ability of a physician by measuring skill in specific competencies in the patient care setting. The Residency Review Commission for Internal Medicine is planning to evaluate residency programs by measuring how well their residents achieved certain clinical competencies.

Passing certification and recertification examinations involves preparation, which means reading education materials, like the Medical Knowledge Self Assessment Program (MKSAP) of the American College of Physicians and educational programs created by the American Board of Internal Medicine. Here is another opportunity for physicians to learn and keep up their skills.

Other factors affect the physician’s skills in day-to-day practice. One is ongoing evaluation of practice. As the paying for quality concept gains mo-

mentum and as the Health Plan Employer Data and Information Set (HEDIS) has a stronger and stronger position of leverage with individual health plans and practices, a physician’s ongoing daily practice is going to undergo continuing scrutiny. Another factor is point-of-care decision support. Increasingly, we are going to see medical decision support systems become an integral part of the practice of medicine. To the extent that those contain evidence-based practice guidelines for cancer screening, physicians will learn how to practice in accord with current practice norms. Finally, as I will argue later on, patients will affect what doctors do. We hope that all of these educational inputs for the physician are generally going to be framed around evidence-based practice guidelines, such as those of the U.S. Preventive Services Task Force.

Patients are a major force for change. I have learned, as a journal editor, something about the public’s insatiable appetite for information about how to improve their health and how to increase their chances of living to be old and healthy. The public media play an enormous role in educating people about research results in major journals, such as JAMA, Annals of Internal Medicine, and the New England Journal and other journals, which are provided through the newspapers, through the television, and through magazines, the latter especially magazines whose principal audience is women. Our journal summarizes the results of research articles in lay language for patients. I hope that other journals will adopt this approach to educating the public.

Staff and system supports play an important role in assuring the public that physicians, nurse practitioners, and other providers make the right decisions about cancer screening. Educational programs should target staff, not only providing the cognitive knowledge required to screen for cancer, but also teaching them how to change practice and how to monitor successfully the effects of efforts to change. Physicians generally want to do the right thing. They will generally do what they are told to do, as long as it doesn’t threaten patient health; and they need a supportive staff that will remind them what to do and be sure that they carry through.

Payers are an important influence on physicians. Medicare pays for a number of screening services, which sets the standard for most of the other payers in the country. In the study done in New Hampshire, the single factor that best predicted practice compliance with cancer screening guidelines was the scheduling of an annual examination to focus simply on screening and nothing else (Sox et al., 1997). Unfortunately, CMS does not pay for an annual health promotion visit. They should, especially as patients stay in the Medicare system for life, whereas other payers don’t have strong incentives to cover screening activities simply because patients move from payer to payer, so that any individual payer is rarely in a position to reap any cost savings from risk reduction and early detection. Finally, anything that CMS

can do to align payment with good medical practice will eventually provide more time for physicians to spend with their patients.

Dr. Ron Davis, Trustee American Medical Association, Director, Center for Health Promotion and Disease Prevention, Henry Ford Health System: One of my favorite cartoons shows a patient asking her physician, “Hundreds of years of medical progress, and all you can tell me to do is eat less?” I think that is part of the challenge we face in this day of tertiary care and high-tech medicine. Sometimes it is hard to get people to pay attention to and take seriously these important behavioral issues. When they do take it seriously, they want a quick fix—another cartoon I use shows a man at the counter of a pharmacy telling his pharmacist, “I’ll have an ounce of prevention”—but unfortunately it is not that easy.

Let me address the questions posed to us for this panel discussion: first, who is responsible for ensuring that graduate curricula and continuing education programs include adequate coverage of cancer prevention and early detection; and second how can we encourage professional organizations and academic medical centers to make this an educational priority. Undergraduate medical education is controlled by the Liaison Committee on Medical Education, which is operated jointly by the AMA and the AAMC, the Association of American Medical Colleges. So that is obviously a leverage point for influencing the curricula in medical schools. ACGME (Accreditation Council for Graduate Medical Education), and the individual residency review committees (RRCs) are the bodies that accredit graduate medical education, so those are additional points at which we can influence national educational policies. Beyond that, we can work with individual medical schools, with individual residency programs, to try to ensure that they address cancer prevention and early detection.

A third area for leverage, the first being accreditation organizations, the second being individual residency programs, is through the certification boards (the American Board of Internal Medicine, the American Board of Surgery, and so forth), because they write the exams people take. If you put into the exams questions on cancer prevention and early detection that will encourage residency programs to teach their trainees to master the content of those exams. So, we need to get appropriate questions in those exams.

A fourth area of focus is the medical societies. If the American Academy of Family Physicians says that family practice residencies ought to teach something, then the RRC for family medicine will be more likely to put that into accreditation requirements, and the individual programs will teach it. So getting the medical societies on board will be helpful for their policy development as well as the content of their continuing medical education conferences.

Next, what leverage points are there for monitoring the performance not only of health care providers, but also systems of health care delivery to in-

sure infrastructure and accountability for delivery of prevention interventions? First, obviously again accreditation. One of the other hats I wear is being on the board of the JCAHO as an AMA representative. When the IOM report on patient safety and medical errors came out, JCAHO took that seriously and very quickly put rules on patient safety into its accreditation standards. The IOM report on cancer prevention and early detection didn’t get anywhere near the attention that the one on medical errors did. The impact of the patient safety report (and the publicity surrounding it) is what we ought to be striving to achieve.

Through its ORYX (www.jcaho.org/accredited+organizations/hospitals/oryx/index.htm) process, JCAHO is moving towards more outcomes-oriented accreditation standards. ORYX is a series of outcomes measures on which hospitals are examined. Two ORYX measures assess whether smokers hospitalized for myocardial infarction or community-acquired pneumonia receive smoking cessation advice or counseling. In 2002, JCAHO-accredited hospitals began to collect data on standardized (or “core”) ORYX measures, including those on inpatient smoking cessation counseling. This is an example of how our issues can be incorporated into accreditation guidelines.

NCQA, the National Committee for Quality Assurance, which accredits HMOs in this country, includes many preventive services as quality indicators in the HEDIS “report card”—mammography; childhood, adolescent, and adult immunization; treatment for tobacco use and dependence; Pap tests, among others. There are probably six or eight preventive services in HEDIS.

We also can leverage change in the health care delivery system through coverage and financial incentives. As one example of a progressive policy, Blue Cross Blue Shield of Minnesota is now paying physicians for putting down the ICD-9 code (305.1) for tobacco dependence on claims forms (Manley, 2001). If physicians record that on a claims form, regardless of whether they offer an intervention or treatment, they get a payment. This is an example of a positive incentive. The concern on the part of some people was that doctors would abuse that. That is not happening.

Finally, how can state health departments and federal agencies, such as CMS, advance this priority? I’ll make three points in this regard, all pertaining to Medicaid. One is ensuring Medicaid coverage of cancer prevention and early detection. Secondly, related to that is managed care contracting. As you all know, most Medicaid programs are substantially capitated or fully capitated. Through managed care contracting, you can very effectively leverage performance in a particular area. Thirdly, Medicaid can support training and education. In Michigan, for example, our Medicaid program has given a grant to a preventive medicine residency program administered by the University of Michigan School of Public Health. This is part of a Medi-

caid initiative a few years ago to fund innovations in medical education. The idea is to fund projects that bring benefits to Medicaid beneficiaries. We argued that this program would train more preventive medicine physicians, many of whom would stay in Michigan and treat indigent patients on Medicaid. That is an example of Medicaid support for training and education, which I think is worth pursuing elsewhere, although given the financial constraints at the state level, which are attributable in large part to Medicaid economics, it is going to be hard to sell.

Dr. Robert Smith, Director of Cancer Screening, American Cancer Society: As I looked at this report, I thought, we’ve got this critical need for undergraduate and graduate medical education. The report also emphasizes that quite a few clinicians didn’t have the benefit of exposure to this kind of material. They were already out in practice. So the entire burden of training has rested on CME.

By what elective means could this material be included, or not, in education? With mammography, the way training began to take place in residencies was that radiologists got questions on mammography on the radiology boards. Accordingly, it became part of residency training. I note that repeated, heated calls for changing undergraduate medical education to include appropriate and enhanced preventive content have been routinely ignored. The real challenge is how you leverage the importance of training on the key issues that account for five or six of the leading causes of preventive mortality in this country. It seems self evident that it requires considerable leverage with the AAMC.

The other thing that offers real potential is the recognition that much of CME in its present form is broken. The common lecture format is largely ineffective, and this is increasingly acknowledged. Also, it isn’t clear what drives the content of a CME course, but some topics are clearly esoteric, and others may be included because they address ways to be more efficient, for example, to reduce office costs or add additional billing. As I review primary care CME, I find it is generally weak in the area of cancer compared with other areas.

The important question is whether there should be key content that ought to be included. In lots of areas were we rely on competency, key content is well defined. The FAA, for example, requires commercial pilots to demonstrate competency in key areas of knowledge and proficiency, and these competencies largely define the regular training schedules required by airlines. Could we say that for certain kinds of CME, certain key content, coverage of key topics that affect public health, is required? Then how do we build in incentives for applying this knowledge to preventive care? There has to be an incentive for the physician to assimilate and use the CME knowledge in practice. The incentive to get engaged in smoking cessation, for example, is reimbursement.

This CME opportunity arises because the Council of Medical Specialty Societies and the American Board of Medical Specialties have acknowledged that CME is not working and needs to be revamped. They have called for a new design including a commitment to life long learning, periodic self assessment, and demonstrated competence in patient care, communication skills, and medical knowledge. They stress the need to get away from passive lecture-based learning, greater emphasis on self assessment, focused instruction, interactive versus passive learning, and constant feedback. We now need to bring the content of this report to these boards and urge that this content be integrated into the CME structure of each specialty board including primary care. We have an opportunity to build in cancer prevention and detection as part of routine primary care.

Dr. Nancy Lee: I’m glad the effectiveness of CME was brought up because that has been my concern. I think people choose it for odd reasons. What is the evidence of the effectiveness of continuing education programs for medical providers? The way it is structured right now, my understanding is that we don’t have a lot of evidence that it is having the effect we want, whether it be in cancer prevention, new treatment for hypertension, or knee surgery. The lecture-based thing in the morning and time off in the afternoon is questionable.

I have been depressed in our efforts to train our providers in the cancer screening program on some basic issues about clinical and programmatic policies. We have done a series of telephone in-depth focus groups that sample across the country from our program. We find that our providers don’t really pay much attention to some evidence-based guidelines. That is just an example of how we are not doing a good job in keeping our providers up to date, giving them the tools to move forward and abandon old techniques and move towards new ones in general. Then, how do we get them to help on smoking cessation and diet and exercise? Those are both very difficult areas, and it is something that we really need to take charge of.

Dr. Robert Smith: Do you think that the doctors don’t have the cognitive knowledge related to the role they might play in cancer control, or that it simply isn’t applied consistently in the practice setting?

Dr. Nancy Lee: I don’t think we physicians have been given lots of skills on how to help people stop smoking and help people to lose weight. Maybe we are not the people to do this. Maybe other health care providers are needed, but in many settings they are not available, and it would be another visit for the patient. We don’t even know how to continually work with patients to get them to the point where they accept going to smoking cessation classes. I don’t think appropriate training is routinely available to many providers, and I don’t think we can get adequate reimbursement either for that kind of work. It’s not a procedure.

Dr. Robert Smith: That’s the thing about the Pap smear, for example, it’s a procedure and it’s a paid office visit. One of the problems with asking people to practice evidence-based medicine is that, is some instances, there is a disincentive for their practice to start doing that. We ideally would have something to replace it with. Also, the office usually isn’t even set up to do it efficiently. Clearly a lot of counseling doesn’t have to be done by the physician.

Participant: So how does the physician get the patient to those ancillary services?

Dr. Len Lichtenfeld: Is the actionable item to change or influence the paradigm of care so that the physician and the healthcare system find other ways of empowering other people in the system to engage in this process, to help make it a reality? Is that going to be part of the solution, instead of the doctor having to do everything all the time?

Dr. Ron Davis: I would agree with that. I think the strategy will be different, depending on what kind of medical practice you are talking about. The solo practitioner is in a different situation than a 400-physician group practice. More doctors are becoming part of group practices, and we have potentially much more leverage with them than with individual practitioners.

For example, when I got to Henry Ford Health System in 1995, we had an 800-member Henry Ford Medical Group. At that time they got bonus pay determined by various performance indicators. Those indicators were mostly financial, like hospitalization rate and length of stay, and there were no quality-of-care indicators, much less preventive services indicators. I was pushing for those, and fairly soon we ended up having some, at least for pediatricians and family physicians. There was one for pediatric immunization rate, for example. With medical groups, if we can get these indicators into performance measurement, then people will pay attention to them. Physicians will often find someone else in the office to implement a preventive service. That’s easier with a large group practice, but with the solo practitioner, or with two or three docs in small offices, it is much more difficult to get these things done.

Participant: You mentioned NCQA and HEDIS earlier. What opportunities do we have to partner with managed care organizations? What are they doing now in anticipation of HEDIS and colon cancer screening down the road in 2004?

Dr. Ron Davis: I think there is a lot of truth to that—what gets measured, gets done. I have seen that in my own institution, and I have heard it from others. If a new measure is added to HEDIS and others rotated out, then that determines the priorities in the quality improvement program. So, there is a lot of opportunity, when you see a HEDIS measure like that one coming down the pike, to partner with managed care organizations in a par-

ticular community or at the national level with a large health plan such as UnitedHealth, which invests a lot of money in quality improvement.

Dr. Sandra Reed: In our four-physician practice, for the last six months we have had a weight loss program that is performed by our two nurse practitioners. We identify patients and refer them to our nurses. They have more time than we do to spend on the counseling sessions and follow-up visits with these patients. So, I think physicians are willing to implement these things, but I don’t think we have done a good job in educating them in how to do it.

Dr. Hal Sox: It is relatively easier to change a big practice like Henry Ford, because it can afford the support personnel to implement system change and the information systems to monitor practice. A small practice can’t afford any of these necessities of 21st century medicine. I see helping the small practice to make system changes as one of the great challenges for medicine.

Dr. Sandra Reed: I think the biggest obstacle is helping them to identify the systems that need to be implemented and helping them to have a way to implement these systems. A lot of small practices are not computerized. Although they are going in that direction, they have not yet made the investment because it is costly. Our practice is undergoing right now a $250,000 upgrade in our computer system. We were able to do some of these things, but that was a big chunk of change for us. In five years the system will probably be antiquated. It is just extremely costly for small practices to be able to establish the kind of infrastructure within their practice to handle these data.

Dr. Len Lichtenfeld: Let me share a personal observation, having been an oncologist and a primary care internist, in reverse. I had a little piece of paper on my chart. It cost me maybe a penny or two to Xerox the thing, and I would check off what I thought somebody should be having over time. Some of my patients had many pieces of paper. I knew when they had their Pap smear, their sigmoidoscopy, or when they had whatever exam they needed to have on a preventive basis over time.

I think that every patient chart could have that piece of paper in there, checked off, and updated. Every time that person walks in the office, they should be checked. The problem is the people that don’t walk in the office, that is where we fail.

We were not delivering preventive services then that we knew people should have. Reminder systems can get built in; I think there is that opportunity. But, right now, as things have transformed, there is no time. Time has become a very precious commodity. I commented this morning that 7.4 hours a day of a provider’s time would be taken to deliver all the preventive services that we think people should have. It is overwhelming.

Dr. Joseph Lipscomb, NCI: I think there was some mention this morning of evolution towards a consensus statement on preventive activity. I think I heard it involved the ACS, the American Diabetes Association and maybe the American Heart Association. How is that consensus going to be arrived at? Are you thinking about this as a small concise set of guideline statements that people can take in quickly and support the provider’s decision making process in the practice, and be time efficient? I assume that is what this is guiding us toward.

Dr. Robert Smith: When you look at commonly recommended preventive health behaviors and guidance related to physical activity, maintaining a healthy weight, and nutrition, these recommendations are associated with lower risk for a number of chronic conditions, and therefore organizations focused on cancer, heart disease, and diabetes clearly have an opportunity to promote a broader benefit than may be apparent to the public if we focus on just one disease at a time. Also, each of these organizations represents conditions for which periodic testing for early signs of disease is recommended. I think the three organizations have come together, recognizing that they have common interests, and they ought not to be competing for physician and individual’s time and attention. They should have a simple message to the public about maintaining healthy weight, engaging in physical activity, and getting various tests for early detection of chronic conditions at whatever periodicity the evidence justifies.

That seems pretty straightforward, but on the other hand, there is going to be a demand for the underlying evidence-based logic for what happens in those encounters with physicians, their periodicity, and, most important, evidence of cost-effectiveness. Therefore, we are pulling a group together to work through the literature on recommended preventive health measures and model age-specific periodicity and potential findings that could support a return to a model for periodic checkups, since we abandoned the every-year check-up, and haven’t replaced it with anything. Right now, it’s pretty much what we and the doctor decide, so some people get regular checkups and other people never get checkups. I believe that it is likely that encounters for the purpose of preventive medicine could be supported at some age and gender-specific periodicity, but it is important to determine whether or not there is evidence to support an alternative model for periodic health encounters.

Dr. Joseph Lipscomb: What’s the time frame for this evidence review?

Dr. Robert Smith: The game plan right now is to try to get going as quickly as possible, making calls to the experts in the field that have been thinking about his issue, in particular some representatives from the USPSTF. Rather than come out and say this is the right thing to do, we would say here is the evidence for what is the most cost-effective thing to do, provided, of course, that the evidence is there. In the discussion this morning, people frequently talked about helping people to lose weight. But

normally you don’t get counseled about obesity until you are obese. We first need to have those messages when you’re a young adult and have gained five pounds beyond your weight when you graduated from high school.

Participant: I spent the last four years building a suite of software programs ready to use in the physician’s office, or for that matter in the corporate environment, which empower the individual to retrain and also provide the physician with a quick way of directing someone into a program that they can follow and which could be individually modified. Furthermore, the programs incorporate tracking systems so you can remotely monitor whether a person has been using a program, what their weight is doing, on a graphic display. They allow for the empowerment of both the patient and the physician and permit a continued exchange so you could follow whether patients are doing what’s been assigned. If they are making progress, they could be encouraged or if not, challenged in some other way. I think the use of the internet to interact with the patient in ways much of which are automated, is something interesting, and something I’ve thought a lot about over the last four years.

Dr. Ron Davis: Dentists and veterinarians have done a better job than we have in medicine in utilizing recall and reminder notices, although in some instances, like childhood immunization, we are starting to improve. Our goal should be to do recall for all those who miss an appointment and to send reminders to patients for all upcoming appointments. But short of that, whenever patients contact the health care system, we ought to check to see what they are due for or what they are overdue for.

Here is where informatics strategies are key. If someone calls the doctor’s office because he or she has abdominal pain, or if a patient goes to the emergency room, at that point the provider ought to pull up the patient’s medical record on the computer which will use software intelligence to indicate whether the patient hasn’t had a mammogram in so many years or is due for this or that check. Some health systems are moving toward that, but we still have a long way to go. That is something we should work toward.

Dr. Robert Smith: I agree. Also, it seems to me there is the additional problem of role ambivalence. We talked a lot this morning about patient demand. Maybe in many settings physicians are waiting for patients to ask for something; in other settings—in almost all settings perhaps—the patients look to physicians to advise them what to do and what not to do. What we want to do is create a model for what each group can expect from the other.

The demand side can really bring about a lot of change. We have very good examples of that. So the more patients start asking for something, the more physicians are revising their standard of care, the more they start initiating care they perceive patients desire. We are seeing this in colorectal cancer, a very good example. The likelihood that an individual has been screened is highly associated with having had a checkup. If patients haven’t

been screened, it’s usually not for a lot of personal reasons; it’s just because their doctor hasn’t brought it up.

Dr. Hal Sox: I would note the research opportunity. I don’t remember seeing a study in which somebody asked patients right after they left the doctor’s office, did you ask the doctor about doing a breast cancer screening? Did the doctor bring up the subject of screening? If not, did you ask about it? It is clear that the public is intensely interested in screening policy. But I don’t think we have a good handle on just how truly activated they are, how willing they are to go and say to a doctor—what about a Pap test?

Dr. William Dietz: I’d like to come back to counseling for nutrition and physical activity. I think there are four critical elements in the disease care system—effectiveness, efficacy, bias, and system change. We don’t have proven effective strategies in primary care to counsel on nutrition, physical activity, and some other clinical preventive services. So we can’t very well expect a physician to do something without proven effectiveness, and we can’t expect a physician to do something that that physician doesn’t feel will be effective; there is no self-efficacy.

Another problem, once somebody becomes overweight, is that in many quarters obesity is still considered a personal failing. The patients are responsible for this problem, let them solve it. I think that is a pervasive bias throughout society. Finally there is the issue of systems. How can physicians provide sensible nutrition advice? I’m not sure I see that as the physician’s role. I think the role of physicians in obesity care is to initiate and oversee it, but not to deliver it, for all the reasons that we’ve discussed, reimbursement, time, and so on. For example, I don’t even know whether the recommendation for smoking cessation is being commonly implemented in physicians’ offices, and whose responsibility it is and how often it is done. That might be a useful model to think about as an indicator for how far we go to start something for which there is evidence of efficacy and effectiveness, as opposed to obesity, for which we have none.

Dr. Nancy Lee: I spend most of my time promoting screening, but I would like to go on record as saying that the really hard work is in primary prevention. Our problem with cervical cancer screening is that at the population level, we may actually over screen. We are getting pretty good at mammography screening. There are disparities, but we are getting there. Colorectal cancer screening, we have a long way to go, but we know what to do. We have got a lot further to go in the tobacco, nutrition and physical activity. I think that should be something that the IOM could spend a lot of time on, rather than tweaking around the edges of something we already know something about, like screening. We need to improve on that, but we actually know those systems, and I think we have a lot more that we don’t know about.

Dr. Len Lichtenfeld: I don’t think we do anywhere near the job we should be doing in colorectal cancer screening, given the potential return on investment we have, which is literally right in front of us.

Dr. Nancy Lee: We know how to do it, because we have done it. To me, those systems are not too much different than what we have already got in place for breast and cervical cancer screening, but we’ve got really different systems that you are going to need for primary prevention.

Dr. Len Lichtenfeld: What is the role of medical schools, what is the role of medical organizations, how do you get the information out there, how do you change the pattern, how do you provide the backup? The IOM report, while perhaps not an indictment, is clearly not an endorsement of our medical educational system. Who fixes it? How does it happen?

Dr. Hal Sox: Well, part of the problem is acquiring knowledge, but I would argue that that is probably the smaller part. The larger part is figuring out how to institute system changes in your own workplace, so that the right actions are taken with every patient.

Dr. Sandra Reed: I talk to my patients about stopping smoking. They see me once a year and walk out the door, and the next year they come back, and they are still smoking. We need some type of implementable system that can start the ball rolling in your office when you have got them there. Then somebody else has got to do the legwork and follow-up, because I don’t have time. I’ve got the smoke line, the number. You give it to them, and they come back the next year, and they are still smoking. First of all, the patient has to want to stop smoking. We can tell them they need to, but if they are not ready internally, we can send them out the door every year with that 1–800 number, and it is going to go in the trash can.

So you’ve got to get the patient ready, and then have the information and the system set up so they can access it and have success. I have written prescriptions for Zyban, and they come back next year, and they are still smoking. It’s the same thing with weight loss. I have talked to my patients over and over about weight loss. We are starting a program now in our office; we have a dietician there who counsels the patient on diet and exercise. But that patient has to be ready to make a lifestyle change. Our environment does not allow that very easily. Our lifestyle—everybody’s lifestyle—is counterproductive to weight loss. It is a bigger thing than just bringing the patients in and getting them set up in a system. When they go into the real world, they have to fight to do the right thing with diet and exercise and activity, because the American lifestyle is not set up for that.

Dr. Len Lichtenfeld: So, you would like to see more emphasis on what we discussed earlier, public education, mass media approaches to try to set the stage to make it happen.

Dr. Hal Sox: I think Dr. Reed is also talking about implementing effective systems for supporting smoking cessation in a small practice. For exam-

ple, one person in the practice should have the job of talking with a patient who has decided to quit smoking and setting in place a reasonable treatment program and arranging for follow-up care.

Dr. Sandra Reed: We need an inplementable plan for follow-up, whether that’s calling every two weeks to ask how is the smoking cessation going, what can we do to help you, or have you used the 1–800 number. We need something that works, that is proven to work, or we are wasting our time, and it’s expensive to have our staff call the patients, especially if you’re not getting reimbursed for it.

Dr. Ron Davis: I think accountability gives us the best chance to effect change, but it has to be realistic. We can’t ask for accountability to administer all the services recommended by the U.S. Preventive Services Task Force guidelines, because that could take seven hours a day of a physician’s time (Yarnell et al., 2003). So pick the most important ones from the Partnership for Prevention, working with CDC and others, where they rank the three or four most important preventive services (Coffield et al., 2001), and then hold people accountable for those.

Dr. Robert Smith: NCI, CDC, and ACS are working on a book about lessons learned from screening which would define a range of interventions of varying intensity. A practice could decide what’s the least that could be done to improve delivery of preventive care, and what benefits could they expect from the implementation of that new policy or tool.