See referenced original article on pages 000–000, this issue.
On the threshold of a dream†
Article first published online: 12 JUN 2006
Copyright © 2006 American Cancer Society
Volume 107, Issue 2, pages 217–220, 15 July 2006
How to Cite
Marks, J. S., Orleans, C. T. and Gerlach, K. K. (2006), On the threshold of a dream. Cancer, 107: 217–220. doi: 10.1002/cncr.21991
- Issue published online: 5 JUL 2006
- Article first published online: 12 JUN 2006
- Manuscript Accepted: 10 APR 2006
- Manuscript Received: 30 MAR 2006
- Robert Wood Johnson Foundation or its Board of Trustees
The report from the American Cancer Society (ACS) Incidence and Mortality Ends Committee by Byers et al. offers the clearest look yet at the possibilities on the horizon in the fight against cancer.1 Stated straightforwardly by the authors, cancer mortality rates have declined steadily since 1990, reducing by 300,000 the number of cancer-caused deaths that would have occurred between 1990 and 2002 had the rates not declined. This progress deserves celebration as a tangible and hard-won achievement in this nation's 35 year-long War on Cancer.
The report by Byers et al. is a midcourse assessment of progress toward a bold challenge by the ACS to reduce the U.S. cancer mortality rate by 50% between 1990 and 2015. Their conclusion is that, although it is terribly ambitious, the ACS challenge may be achievable if we apply fully the scientific knowledge gained over the past 25 years and if new research developments are as positive as early signs indicate, but we must accelerate greatly our current rate of progress.
The lesson is not so much one of headline-grabbing scientific and technologic breakthroughs but of new knowledge systematically and widely applied. Their assessment underscores the need for concerted effort to eliminate racial/ethnic and income-related disparities, with the hopeful sign that recent declines have been greatest among African Americans balanced against findings of slower progress among Hispanic Americans. In addition, it is clear that, although future progress will be fueled by discoveries of new methods for prevention, early detection, and treatment, it will depend ultimately on the extent to which all that we know about effective population-based and individually oriented interventions are applied broadly to those in greatest need. More implicit than explicit in this last conclusion is the recognition that societal will and commitment—as evidenced by the adoption of policies and interventions that reduce tobacco use and exposure, improve access to mammography and other cancer screenings, and provide insurance coverage for state-of-the-art treatment—have been fundamental to the declines in cancer mortality. We all recognize that, as a nation, understanding basic mechanisms of disease causation—the genetics, the biomolecular mechanisms—is important for curing cancer and other diseases. Many of us have not been as aware of or, accordingly, as committed to the understanding that how our society is organized, what our policies foster or inhibit, and what our communities encourage and our healthcare institutions support are equally fundamental causes of good or ill health, warranting study and action. If our societal forces are not in alignment, then scientific advances stall, and the value realized is a meager fraction of its potential. Scientific understandings about any disease that are not widely applied to individuals in need ultimately are wasted. Similarly, widespread application of practices and policies that have no scientific evidence of effectiveness are just as futile. Scientific discovery and its widespread application must never be divided, because each bears little fruit without the other.
One of the best examples of aligned forces in cancer control is the story of tobacco. Much has been learned about tobacco-caused cancers, nicotine addiction and treatment, and the importance of price and marketing in affecting use rates, especially among youth. Because of these discoveries, comprehensive, science-based, tobacco-control policies and interventions were implemented in communities and health care settings across the nation, and adult smoking prevalence has dropped by >40% since the first Surgeon General's Report in 1964.2, 3 Hailed as one of the greatest public health successes in the second half of the 20th Century, this achievement has depended not only on the identification of effective interventions but also, and equally fundamentally, on their widespread application.
At the broadest community and societal level, interventions that have proven to be effective and for which there are now evidence-based guidelines include tobacco tax increases, clean indoor air laws, countermarketing and cessation media campaigns that can be targeted to high-risk populations, reduced out-of-pocket treatment costs, and improved access to effective telephone quit-line assistance and to over-the-counter cessation medications.4, 5 The strong scientific evidence on which these guidelines rest provides a powerful rationale for widespread social and policy changes to reduce tobacco use.
Today's tobacco-control landscape and the societal changes it reflects seemed nearly unattainable at the beginning of the 1990s. Clean indoor air laws of varying levels of comprehensiveness now protect >35% of the population and rapidly are accelerating toward a national “tipping point,” combined state and federal cigarette taxes now average $1.30 per pack, 42 state Medicaid programs and 98% of health plans in the U.S. provide coverage for at least 1 form of evidence-based treatment for cessation, both Medicare and the Veterans Administration cover cessation counseling, and every smoker has access to free telephone counseling through a single toll-free number (1-800-QUITNOW).6
Tobacco cessation treatments—both behavioral counseling and pharmacotherapy—have been codified into clinical practice guidelines.7 Broad health care system changes, like reminder systems to prompt practitioners, have been identified that support treatment delivery, and failure to treat tobacco use is regarded as a failure to meet national health care quality standards.4, 6–9 Through these changes and other efforts, we have made significant progress in closing the gap between “what we know” and “what we do” when it comes to tobacco use screening and treatment, especially in primary care.8–10 The proportion of health plans in the U.S. that use some system to identify smokers rose from 15% in 1997 to 71% in 2002, and >66% of smokers report receiving quitting advice from their providers.11
These prevention and treatment successes of the last few years will make possible further considerable reductions in tobacco-caused cancer deaths by 2015. By working aggressively to align and implement evidence-based policy and health care strategies, we could substantially boost the modest 1% to 2% annual decline in adult tobacco use12 and even may double the annual quit rate. In New York City, aligning policy changes that motivate cessation (high tobacco taxes and a comprehensive clean indoor air law) with the promotion and delivery of free medication and quit-line counseling produced a quit rate of 11% after 1 year and 15% after 2 years, resulting in 200,000 fewer smokers. These are the fastest population tobacco use declines ever recorded and are feasible in communities across the country.13 Health plans have achieved similar tobacco use reductions through health care systems and local policy changes.8, 14, 15 The National Action Plan for Cessation recommends taking these examples to scale by funding a barrier-free telephone quit line that would provide free counseling and medication and a paid media campaign to promote its use. The authors of that plan estimate this would lead to 1 million new exsmokers and 200,000 fewer tobacco-caused deaths each year.3, 16 Although only a national quit line has been implemented, the vision of dramatic changes in tobacco-caused cancer deaths could become a reality if significant resources are provided either through a settlement of the Department of Justice lawsuit against the tobacco industry16 or with support from state Master Settlement Agreement or tobacco taxes.
We also are on the threshold of important improvements in rates of colorectal and breast cancer screening. Both are included, along with tobacco-use screening and intervention, among the top priorities for clinical preventive services17 and among the top 20 targets for national health care quality improvement.9 The same kinds of health care systems and reimbursement policy changes that have been found effective in improving the delivery of tobacco-use screening and intervention also have been found to boost the delivery of routine cancer screening, including for breast and colorectal cancer.8, 9 Although they may be farther in the future, increasing national obesity prevention efforts modeled after those used in tobacco control18 eventually also may add to reductions in cancer deaths.
What we have learned in the past 2 decades about effective, population-based risk reduction and health care quality improvement has driven unprecedented change. The stage is set for significant reductions in cancer death rates, and the urgency has never been greater as we face the aging of the population and daunting increases in health care costs. But realizing the promise depends enormously on how we apply the fruits of scientific inquiry to close the gaps between “what we know” and “what we do” to eliminate preventable cancer deaths; and “what we do” depends fundamentally on effective, concerted will, advocacy, and leadership and on the power of broad societal alliances—among public health and heath care leaders, policy advocates and policy makers, researchers, and the public.
There are increasing signs that our society is becoming more coordinated and connected and is increasing its concerted actions. A few years ago, leaders from the ACS, the National Cancer Institute (NCI), and the Centers for Disease Control and Prevention (CDC) formed the National Dialogue on Cancer, a forum for leaders to discuss what could be done to eliminate cancer as a major public health problem at the earliest possible time. This unique collaboration has roughly equal representation from the private, not-for-profit, and public sectors. The name eventually was changed to C-Change, because members became more interested in actions that could be taken jointly to address cancer and to encourage the organizations they lead to take bold steps to do even more.
In addition, in the last several years, the CDC began to support states to develop Comprehensive Cancer Control plans that detail the actions states could take in addressing cancer, dealing with everything from prevention to palliation. In most states, these have evolved into permanent coalitions that bring in representatives from the clinical, public health, research, survivor, and advocacy communities, among others. In some states, these coalitions have become a vehicle for bringing local attention to the states' needs and helping to generate funding. At the national level, the NCI and the ACS have become integral parts of the training and technical support to the state coalitions. The Lance Armstrong Foundation, along with the CDC, developed a model section for survivorship service and support for the state plans. The CDC began to align its cancer funding so that states could apply for resources that fit within the priorities in the plans. In addition, as 1 of its top priorities, C-Change has encouraged every state to develop a plan and has provided technical assistance. The state coalitions, combined with committed leadership through C-Change, bring hope for significant progress in translating science-based cancer-control interventions into policy and practice over the next 10 years. Most important, they visibly add to and have an impact on our society's commitment to accomplishing these objectives.
All of these forces are now able to capitalize on the substantial expansion of cancer surveillance and monitoring over the past decade. The NCI's Surveillance, Epidemiology, and End Results (SEER) network long has been the basis for population-wide measures of cancer incidence, supporting registries in a limited number of states and covering approximately 14% of the U.S. population. In the mid-1990s, Congress asked the CDC to support the non-SEER states to improve the quality of their registries. Now, nearly all states have population-based registries; and, for the last few years, the NCI and CDC have combined data from greater than 40 state registries to produce the first U.S. Cancer Incidence reports.19
The significance of cancer as the first noninfectious, chronic disease for which nationwide monitoring is now possible cannot be overestimated. States and communities now can investigate reports of cancer clusters using their registries; and, even more important, they can use these registries to investigate issues of coverage, quality, and disparities in screening and treatment and to assess directly their impact on cancer morbidity and mortality. It becomes even more critical that we ensure the detection of all cancers at the earliest stage possible and that those with cancer receive the highest quality care as research provides us with more and increasingly effective tools to help patients with cancer. Most of the past research in quality of care has been done in specific hospitals or cancer centers and rarely has assessed the quality of care for individuals in rural areas or among individuals with limited insurance and access to care. State cancer registries now provide the case information necessary to carry out that assessment.
The tremendous progress and increasing opportunity outlined in the report by Byers et al.1 thrust the cancer community and its far-reaching objectives, if we are serious about realizing them, right into the middle of the national dialogue about how to fix our health care system so that we can offer all that our science has enabled us to learn. Although there is enormous near-term potential, by no means is faster progress assured. Most states added tobacco cessation to their Medicaid benefits package in recent years, but they are now struggling with the overall cost of their share of Medicaid costs. There is no assurance that tobacco cessation will remain covered. Nationally, the crisis in health care coverage generally is of great concern, because the number of uninsured and underinsured continues to grow. Existing programs to provide coverage for breast, colorectal, cervical, and other cancer screenings for the uninsured cannot meet the existing needs of the nation and are at risk of losing ground.20 Even state funding for tobacco control has diminished in recent years despite the Master Settlement Agreement and large increases in tobacco taxes. All of these factors threaten the successes we have achieved as well as future progress on cancer.
If we cannot deliver what we discover and develop, then, as a nation, should we have spent the resources to discover and develop? The more hopeful and meaningful question is, “Can we afford not to prevent, detect, and cure this dreaded disease?“ Do we have the will to make our collective dream become a reality?
- 2The need for, and value of, a multi-level approach to disease prevention: the case of tobacco control. In: SmedleyBD, SymeSL, editors. Institute of Medicine. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, DC: National Academy Press; 2000: 417–449..
- 6The top priority: building a better system for tobacco cessation counseling. Am J Prev Med. In press., , , , .
- 7Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, 2000., , , et al.
- 9AdamsK, CorriganJM, editors. Institute of Medicine. Priority areas for national action: transforming health care quality. From the quality chasm series. Washington, DC: National Academies Press; 2003.
- 11Addressing tobacco in managed care: results of the 2002 survey. Prev Chronic Dis. 2004; 1: A04., , , et al.
- 12Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 1997-2001. MMWR Morb Mortal Wkly Rep. 2005; 54: 625–628.
- 13New York City Department of Health. Available at: http://www.nyc.gov/html/doh/html/pr/pr062-05.shtml Accessed March 24, 2006.
- 17Priorities for improving utilization of clinical preventive services: results. Am J Prev Med. In press., , , , , .
- 19U.S. Cancer Statistics Working Group. United States Cancer Statistics: 2000 Incidence. Atlanta: Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2003.
- 20Illogical cutbacks on cancer. New York Times. March 20, 2006: A23..