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OCR for page 186
25. Cancer
Cancer is the second leading cause of death in the
United States, constituting approximately 20 percent
of all deaths. The leading killers are lung, colorectal,
and breast cancers. Over 30 percent of Americans
now living eventually will develop some form of
cancer. Many cancer deaths are preventable, however.
The American Cancer Society estimates that about
178,000 people died in 1989 from cancer, who might
have been saved by earlier diagnosis and treatment.
(#177)
'Cancer' is not a single disease, according to
Michael Ske~els of the Oregon Department of Human
Resources, abut rather a diverse set of clinical and
epidemiological entities. Perhaps the only feature
that cancers share in common is the underlying
process, which involves a loss of control of normal
cell growth." (~321)
Although many approaches to preventing cancer
were mentioned in the hearings, this chapter focuses
primarily on cancer screening and on secondary
prevention issues. It highlights two forms of cancer
that affect women breast and cervical cancers-and a
type of cancer that is increasing at a rapid pace,
malignant melanoma. Many of the risk factors most
often associated with prevention of cance~smoking,
dietary habits, exposure to toxic substances, and other
environmental causes are addressed at length in
Chapters 10, 12, 17, and 18.
Witnesses make the point that the people stricken
by cancer are just as diverse as the disease itself, and
efforts must be made to target screenings, prevention
programs, and treatments to the needs of each specific
group. Many testifiers express grave concern about
the cancer morbidity and mortality rates among
Blacks. Robert Rutman of the University of Pennsyl-
vania says, "The excess cancer risk facing the Black
population is not only a major moral and ethical
problem, it also is a costly financial one." Hispanics,
too, are singled out for special attention, as are
women who need to be brought into screening
programs, especially mammography screening.
Harold Freeman of the American Cancer Society
is concerned that the United States, as a nation, is
not attending to the poor, minorities, and others who
are not part of the mainstream. We have directed
most of our attention to those who can understand
our language and pay our price. Unfortunately, many
186 Healthy People 2000: citizens Chart the Course
people are dying who are not in that category."
(#443J
Although only 12 witnesses focused their testimony
specifically on cancer, 52 addressed it in discussions of
other topics.
SPECIFIC CANCERS
During the course of the seven hearings, lung
cancer the most common fatal cancer for both men
and women received considerable attention. However,
other cancers were not overlooked. According to
Skeets.
In males, the second and third most common
primary sites for fatal cancer are the prostate
and the large intestine (colorectal cancer). In
1987, breast cancer was the second, and colorec
tal cancer the third leading type of fatal malig
nancy in females.2 (#321)
Recognizing the importance of colorectal cancer,
Linda Randolph of the New York State Department
of Health suggests an objective of Increasing the
proportion of adults who have occult blood testing,
sigmoidoscopy, and digital rectal examinations per-
formed at regular integrals." (#177) Oral cancer,
discussed at some length especially by dentists and
dental hygienists, is covered in Chapters 10 and 26.
Breast and Cervical Cancer
Although effective screening techniques exist to detect
breast and cervical cancer, many women are not
taking advantage of them. Witnesses testifying about
these cancers emphasized the importance of increasing
the percentage of women who are screened.
Until recently surpassed by lung cancer, breast
cancer was the leading cause of mortality in women.
According to American Cancer Society statistics cited
by witnesses, approximately 142,000 cases of invasive
breast cancer are diagnosed each year, and one third
of the women who develop breast cancer in 1989 will
die of it.3 Morbidity and mortality from this disease
could be reduced, several witnesses emphasize, if more
women used the three screening techniques: breast
self-examination, physical exam, and mammography.
OCR for page 187
(#256; #336; #452; #484)
Similarly, inadequate use of screening is resulting
in needless deaths from cervical cancer. Witnesses
call for increases in the number of women who
undergo Pap smears to check for cervical cancer.
Ann Norman of the University of Washington
focused on the need to get more older women
screened: approximately one out of every ten women
in this country will develop breast cancer, and 75
percent of those cancers will be detected among
women 50 years of age or older.4 She notes that
although older women are at greater risk of dying
from breast or centrical cancer than younger women,
they are less likely to participate in cancer screening.s
Norman also cites research showing that older women
are about as likely as younger women to survive these
cancers if they are detected early.6 (#336)
Norman and others note that the National Cancer
Institute (NCI) Goals for the Year 2000: Cancer Con-
trol for the Nation7 addresses screening of older wo-
men, whereas the 1990 Objectives failed to target this
group. She argues that NCI goals should be included
in the Year 2000 Health Objectives. Those goals are
(1) to increase the percentage of 50- to 70-year-old
women who have an annual physical breast examina-
tion combined with mammography to 80 percent (it
is now 45 percent for physical examination alone and
15 percent for mammography), and (2) to increase the
percentage of women 40 to 70 years old who have a
Pap smear every three years from 57 to 80 percent.
(#336)
In addition to older women, witnesses suggest that
low-income and non-White women be targeted in
programs aimed at increasing screening utilization.
(#020; #256; #452; #488; #615) Alvin Mauer and
Mona Arreola of the University of Tennessee, Mem-
phis, report that a year-long study of women admitted
to a local hospital for treatment of breast or uterine
cancer showed that poor women were coming in for
breast cancer treatment at a later stage than others.
Their study found that the reasons for the advanced
stage at diagnosis could not be explained easily.
The results of the study indicated that, unfor
tunately, none of the simpler hypotheses were
upheld. The women interviewed knew about
cancer and its warning signs; they experienced
no difficulties in gaining access to health care.
The problem of delayed presentation appeared
to be related to underlying psychosocial
behavioral factors that confounded the iden
tification of a simple solution.8 (#256)
Jose Lopez of the San Antonio Tumor and Blood
Clinic made similar observations about Hispanics. He
cites figures from one study in New York on know-
ledge and use of breast cancer detection among
Hispanics: fewer Hispanic women did breast self-
examination within the last year than non-Hispanic
women; fewer Hispanic women have had a mam-
mogram; and fewer have had a Pap smear. (~488)
An important impediment to the use of mammog-
raphy is cost, according to witnesses. Even with the
recent addition of mammography coverage to Medi-
care, gaps remain. Guy Newell and Charles
LeMaistre of the University of Texas M.D. Anderson
Hospital and Tumor Institute suggest a number of
ways to reduce the cost of mammography screenings;
for example, fewer films could be taken in routine
screenings.9 Newell and LeMaistre emphasize that
cost and other barriers must be overcome so that
more women can undergo mammograms.
Increased use of mammography depends on
scientific consensus, policy making, marketing
strategies, and cost reduction, among other
factors. Endorsement of mammography screen-
ing by the medical profession coupled with
availability at reasonable costs for the individual
will be required for the widespread application
of mammography screening. Until screening for
breast cancer becomes a routine preventive
practice, deaths from breast cancer will continue
to be an increasing public health problem.
(#484)
Addressing specifically the need to overcome
barriers to testing among older women, Norman says
that more research is needed on psychosocial factors,
the role of physicians in assuring that older women
are screened, and other areas. Innovative programs
and approaches to the use of screening among older
women should be tested as well. (~336J
Malignant Melanoma
Malignant melanoma was portrayed as an ideal
candidate for an aggressive prevention program by
William Robinson of the University of Colorado
Health Sciences Center. He said that this type of
skin cancer, which almost always affects Caucasians,
has reached epidemic proportions. The incidence of
malignant melanoma is increasing faster than any
other cancer, yet the disease is largely preventable.
(#708)
Cancer 187
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The rising incidence of the disease is due to
increased exposure to sunshine and ultraviolet light,
caused by changes in clothing habits and migration to
the sunbelt, Robinson explained. It is a disease of
the upper middle class. Those affected typically have
brown, light brown, or light reddish hair and non-
brown eyes. "We know what causes it, and we know
who to target for the educational campaigns that need
to be carried out," he says. This is an area in which
a concerted prevention campaign could greatly reduce
morbidity and mortality. (#708)
POOR AND MINORITIES
The inadequate utilization of breast and cervical
screening techniques among Blacks and Hispanics is
part of a broader-based gap in cancer prevention in
those communities, witnesses reported.
Although limited national data on cancer rates
among Hispanics indicate that they apparently have
lower rates of some of the most common malignan-
cies, several factors contribute to an increased risk of
some types of cancer mortality, according to Lopez.
He cites several factors to account for the increased
risk, including later stage of cancer at diagnosis; lack
of access to the health care delivery system; and
certain knowledge, attitudes, and practices regarding
cancer that are peculiar to Hispanics. (#488J
Lopez says that Hispanics are more fearful of
getting cancer than other people, but they show, at
best, a moderate awareness of the major risk factors
for the disease. It is necessary to overcome psycho-
logical, cultural, and economic barriers to reach the
Hispanic community with cancer programs, he added;
"Hispanics tend to be fatalistic, feel there is a stigma
attached to cancer, and have questions and concern
about the treatment and the costs." (~488J
Hispanics in California follow the national pattern
of "substantially lower" cancer incidence than non-
Hispanic Whites, but Lester Breslow of the University
of California, Los Angeles is concerned that as
Hispanics "adopt the culture and way of life" of the
area, there will be a "very sharp Use" in their cancer
rates. He calls for Year 2000 Health Objectives to
give "explicit attention to minority problems." (#026)
John Bruhn of the University of Texas Medical
Branch at Galveston points out that in some areas of
Texas and for some types of cancer (stomach, liver,
and gallbladder for males; uterine and cervical cancer
for females), Mexican-Americans already are more
188 Healthy People 2000: Citizens Chart the Course
vulnerable than Whites. He says that "targeted edu-
cation programs and readily available screening clinics
should be of high priority. (#235)
The picture is even bleaker for Blacks, who "still
have the highest overall age-adjusted cancer rate for
both incidence and mortality of any U.S. population,"
according to Osman Ahmed of Meharry Medical Col-
lege. (~269) Judith Glazner of the Denver Depart-
ment of Health and Hospitals quotes several statistics
for Black women illustrating the gap: ~Nationally, the
incidence rate for breast cancer has increased 1 per-
cent per year; but while the mortality rate for White
women has remained unchanged, for Black women it
has increased 1 percent per year. For uterine cancer,
the mortality rate among White women has declined
2.4 percent per year for the past five years, whereas
for Black women, it has decreased by only 1.1 per-
cent.~° f#377)
Margaret Hargreaves, Osman Ahmed, and their
coauthors from Meharry Medical College cite
American Cancer Society figures indicating that in the
last 30 years, cancer death rates for Blacks increased
40 percent, whereas the White rate increased only 10
percent; 30 years ago, Black and White rates were
about the same. Data for 1967-1973 show that fewer
Blacks than Whites had cancer diagnosed at an early
stage when the chances of cure are greatest. Blacks
are less knowledgeable than Whites about warning
signs and cancer tests, they noted. (#615)
The NCI recognizes the need to reach minority
groups if its goal of reducing cancer mortality 50
percent by the year 2000 is to be met, according to
testimony, and the NCI is beginning to address these
issues. Minority representatives emphasized that cul-
turally sensitive information about cancer and cancer
detection tests is essential to any health education
effort. Cancer in minority populations is discussed
further in Chapter 6.
Testimony from the American Cancer Society
(ACS) underscores the increased risk of cancer among
poor people. Harold Freeman, ACS spokesman,
reports that there is a 10-15 percent lower survival
rate among poor people in America, regardless of
race. At least half of the difference in survival is due
to late diagnosis. He says that the increased preva-
lence of risk factors, such as smoking, poor nutrition,
environmental exposures, and alcohol intakes also
contribute to the variations. (#443)
Primary prevention aimed at controlling risk factors
could probably control two-thirds of the cancers,
OCR for page 189
according to Freeman. However, efforts aimed at
improving secondary prevention-primarily early
diagnosis~re also important because the poor tend to
seek care late. Instilling preventive habits is not easy,
REFERENCES
1. American Cancer Society: Cancer Facts and Figures, 1989. Atlanta: 1989
Freeman acknowledges: "It is difficult to convince
someone who is being shot at to have a rectal exam."
(~443)
2. National Center for Health Statistics: Health United States, 1989. (DHHS Publication No. [PHS] 90-1232),
1990
3. American Canoer Society: op. cit., reference 1
4. Seidman H. Mishinski M, Gelb S. et al.: Probabilities of eventually developing or dying of cancer-United
States, 1985. CA Cancer J Clin 35~1~:36-56, 1985
5. Gallup Organization: 1983 survey of public awareness and use of cancer detection tests for the American
Cancer Society. New Jersey: The Gallup Organization, 1983
6. Baranovsky A, Myers MH: Cancer incidence and survival in patients 65 years of age and older. CA Cancer J
Clin 36~1~:26-41, 1986
7. Greenwald P. Sondik EJ (Eds.~: Cancer Control Objectives for the Nation. 1985-2000. National Cancer
Institute. NCI Monographs, No.2. (NCI Publication No. 86-2880), 1986
8. Mauer AM, Rosenthal T. Murphy J. et al.: Delayed Diagnosis in Breast and Uterine Cancer: A Study in
Secondary Prevention. Unpublished study, Memphis: University of Tennessee, 1986-1987
9. American Cancer Society: Workshop on strategies to lower the cost of screening mammography, July 16-18,
1986. Executive Summary. Cancer 60:1700-1701, 1986
10. National Cancer Institute: Cancer Statistics Review, 1973-1986. (NIH Publication No. 89-2789), May 1989
11. American Cancer Society: Cancer Facts and Figures for Black Americans. New York: 1986
12. American Cancer Society: Cancer in the Economically Disadvantaged: A Special Report. Prepared by the
Subcommittee on Cancer in the Economically Disadvantaged. June 1986
TESTIFIERS CITED IN CHAPTER 25
020 Bernstein, Robert; Texas Department of Health
026 Breslow, Lester; UCLA School of Public Health
177 Randolph, Linda; New York State Department of Health
235 Bruhn, John; University of Texas Medical Branch at Galveston
256 Mauer, Alvin and Arreola, Mona; University of Tennessee, Memphis
269 Ahmed, Osman; Diehard Medical College
321 Skeets, Michael; Oregon Department of Human Resources
336 Norman, Ann Deucy; University of Washington, School of Social Work
377 Glazner, Judith; Denver Department of Health and Hospitals
443 Freeman, Harold; State University of New York at Buffalo
452 Santee, Barbara and Alexander, Alpha; National Board of the YWCA of the United States
Cancer 189
OCR for page 190
484 Newell, Guy and LeMaistre, Charles; University of Texas M.D. Anderson Hospital
488 Lopez, Jose; San Antonio Tumor and Blood Clinic
615 Hargreaves, Margaret; Meharry Medical College
708 Robinson, William; University of Colorado Health Sciences Center
,,
190 Healthy People 2000: Citizens Chart the Course
Representative terms from entire chapter:
american cancer
