TOMEKA HARPS hadn’t seen a doctor in five years, despite a history of abnormal Pap tests that showed precancerous cells in her cervix. The mother of three didn’t have health insurance and found her medical appointments at the community health clinic to be inconvenient and impersonal.
“It was just a hassle and it took so much time,” says the 34-year-old Brandon, Mississippi, resident. “You never had one-on-one with the doctor in a personal way. They didn’t know me from the man in the moon, so I just stopped going.”
But Harps never misses a Sunday service at New Horizon Church in Jackson. When a nurse in her congregation mentioned a cancer screening event that offered same-day results at the University of Mississippi Medical Center (UMMC) Cancer Institute clinic in Jackson, Harps put the event on her calendar. The free event—which featured breast and cervical cancer screenings and melanoma skin checks—also provided lunch, entertainment for children, an opportunity to meet with a financial adviser, and cooking and exercise demonstrations.
After her Pap test, Harps found herself waiting for the results. “I thought they forgot about me,” she says, noting that people she knew from church had come and gone. That’s when she was escorted into a room and told she had cervical cancer.
“It was the worst day of my life, but it was the best day, too,” Harps says. “I have never in all my life been treated so kindly.” Nurses stayed late to comfort her and call her husband, and staff from the county health department helped her sign up for health insurance through Medicaid.
Within days of the screening, Harps had seen an oncologist, and by the end of the week, she had a treatment plan for her stage IIB cervical cancer. She completed treatment—which included radiation, chemotherapy and brachytherapy—at UMMC Cancer Institute in May 2017.
Stephen Raab, a pathologist at UMMC, decided to plan the event to help medically underserved communities in the area. Mississippi has the highest percentage of people living below the poverty line of any state in the Union. In addition, from 2000 to 2014, the state ranked 50th out of 51 for cancer mortality out of 50 states and the District of Columbia. The event that Harps attended, called “See, Test & Treat,” was sponsored by the CAP Foundation, the charitable arm of the College of American Pathologists.
“Cervical cancer is a completely preventable disease if you can catch a cervical abnormality early,” says Karim Sirgi, a pathologist and president of the CAP Foundation. “And breast cancer is treatable if detected early, so that’s our [rationale] in focusing on these two.”
Programs like “See, Test & Treat” fall under the wide umbrella of cancer control—efforts to reduce the burden of cancer through screening, vaccinations and public education campaigns that emphasize healthy behaviors. These initiatives, which often are part of a statewide cancer control plan, rely on the cooperation of community members, hospitals, advocacy groups and government at all levels.
The best-known example of a cancer control effort is the group of initiatives put in place since the release of the 1964 U.S. Surgeon General’s report, Smoking and Health. The trailblazing report directly linked smoking to lung cancer. Since then, the proportion of U.S. adults who smoke has dropped from more than 42 percent in 1965 to just 15 percent in 2015. However, smoking is still the leading cause of preventable death in the U.S.
A First in the First State
Cancer control efforts often focus on cancers that carry the greatest burden and are associated with proven strategies for making an impact on incidence and mortality. “In the domain of cancer control, you always have to start with tobacco control because it has the greatest impact, and then you work your way down the list of major cancer domains, including colorectal cancer screening, HPV vaccination, and obesity as a risk factor for many types of cancer,” says Robert T. Croyle, director of the National Cancer Institute (NCI) Division of Cancer Control and Population Sciences.
To learn more about where your state ranks in cancer incidence, mortality, screening, vaccination and smoking, visit State Cancer Profiles, a website of the National Cancer Institute and the Centers for Disease Control and Prevention.
In 2016, experts noted that colorectal cancer screening, human papillomavirus (HPV) vaccination and increased tobacco control efforts could avert approximately 390,000 new cancer cases and 318,000 cancer deaths in the U.S. each year. The statistics, included in a report released by the National Cancer Moonshot Initiative, were cited to support recommendations for accelerating cancer research and spurring progress against the disease. Former Vice President Joe Biden led the Moonshot effort.
Biden needed to look no further than his home state, Delaware, for an example of what an effective colorectal cancer screening initiative looks like. In 2001, then-Governor Ruth Ann Minner established a task force to determine how to combat high rates of cancer and cancer mortality in the state. Two years later, a newly formed Delaware Cancer Consortium—with appointed volunteers from private industry and government—devised a statewide colorectal cancer screening and treatment program.
“We knew we couldn’t solve all the problems at once. So we asked, ‘Can we pick a couple of problems to solve and show that we can get things done so we can move on to new projects?’ ” says Stephen Grubbs, an oncologist who served on the consortium and worked at Christiana Care’s Helen F. Graham Cancer Center and Research Institute in Newark, Delaware.
The program offered provider reimbursement for colorectal cancer screening and treatment for those who met income eligibility requirements. The state also rolled out a campaign to publicize screenings, and it hired nurse navigators to help guide patients to screening services. The campaign also provided outreach at churches and community centers to raise awareness among African-Americans, who had lower screening rates than whites.
The results were dramatic: In 2001, before the program started, 48 percent of blacks over 50 and 57 percent of the total population over that age had received colorectal cancer screening. (For adults at normal risk, 50 is the recommended age to begin screening.) In 2009, as a result of the program, screening in the state had jumped to 74 percent for both blacks and whites over 50. In addition, deaths linked to colorectal cancer had declined, especially among African-Americans. In 2001, the colorectal cancer mortality rate for blacks in Delaware was 31.2 per 100,000. By 2009, that number had dropped to 18 per 100,000, which was almost as low as the rate among whites. (Rates among whites declined from 19.5 to 16.9 deaths per 100,000 from 2001 to 2009.)
“I challenge anybody to show me anywhere in medicine on a statewide level that they eliminated a health care disparity, but that’s what we did,” says Grubbs, who is now the director of clinical affairs at the American Society of Clinical Oncology.
Tobacco control efforts have had successes and setbacks.
Jan. 11, 1964: The U.S. Surgeon General releases Smoking and Health, which reviews more than 7,000 studies and conclusively links smoking to lung cancer.
1965: Smoking incidence among adults is 42.4 percent. All cigarette packages are required to carry a health warning.
1967: Television and radio are required to donate free air time for anti-smoking commercials to balance cigarette advertising.
1970: The federal government imposes a ban on cigarette advertising on television and radio to take effect in 1971.
1975: The Minnesota Clean Indoor Air Act becomes the first statewide law to require separate smoking areas in public places.
1986: The Surgeon General’s report acknowledges the harmful effects of secondhand smoke.
1987: Lung cancer surpasses breast cancer as the leading cancer-related cause of death among U.S. women.
1994: California issues a statewide ban on smoking in restaurants, offices, stores and other large workplaces. It is the first of its kind in the U.S.
1997: Smoking incidence is 24.7 percent among U.S. adults.
1998: Forty-six states sign the Master Settlement Agreement with tobacco companies, under which the companies agree to pay billions in annual payments to go toward efforts to discourage youth smoking and promote public health.
2014: The average state tax for cigarettes is $1.69 a pack, with New York topping the list at $4.35. E-cigarettes become the most commonly used tobacco product among U.S. middle school and high school students.
2015: The U.S. adult smoking rate is 15.1 percent.
2016: Twenty-eight states and the District of Columbia have prohibited smoking in workplaces, restaurants and bars. States collect $25.8 billion from the Master Settlement Agreement and taxes associated with tobacco products, though only 1.8 percent is spent on smoking prevention or cessation, according to the Campaign for Tobacco-Free Kids.
A Comprehensive Plan
Cancer control planning falls on the shoulders of each state (as well as the District of Columbia, tribes and tribal organizations, territories and Pacific Island Jurisdictions), says Nikki Hayes, who leads the National Comprehensive Cancer Control program at the U.S. Centers for Disease Control and Prevention (CDC), the federal agency that funds state cancer control efforts.
States use cancer incidence and mortality data to determine problems, set goals and measure progress. National initiatives, such as Healthy People, a federal program that sets goals for healthy behaviors in 10-year increments, also provide targets.
For example, Healthy People 2020 established a nationwide target for HPV vaccination of 80 percent of adolescents by 2020. The vaccination series, which is recommended to be given routinely to children ages 11 and 12, protects against cervical, throat, mouth and other cancers. However, anti-vaccination sentiment among some people, a stigma surrounding the sexual nature of how the virus spreads, and the relative newness of the vaccine have all contributed to low vaccination rates. In 2016, just six in 10 adolescents ages 13 to 17 had received the first in a series of HPV vaccinations.
To help increase vaccination rates, the CDC and the American Cancer Society established the National HPV Vaccination Roundtable in 2014, a coalition of representatives from about 75 organizations. The roundtable explores strategies to improve health care provider training, school-based parent education, national educational campaigns and cervical cancer survivor involvement.
“Successful cancer prevention and control planning implementation really does rely on a number of factors, and that’s everything from adequate resources to implement programs, strong collaboration, having coalitions at the state and local level, and having this network of partners that will really help,” says Hayes.
People in the communities are also powerful “agents of change,” says Sanford Jeames, a community health educator who has worked on statewide cancer control efforts in Alabama, Massachusetts and Texas.
“If you have a campaign to educate merchants about consequences of underage tobacco use, it’s great because the merchants get information, like fliers, from the state,” says Jeames, who lives in Austin, Texas. “However, wouldn’t it make better sense to have the local people also talking to their peers, at their church, to the students in their classrooms—as opposed to just the merchants who are selling cigarette or tobacco products? There really is a need to educate the population as opposed to assuming that someone is just going to hear a statewide message because you have one.”
Croyle notes that the NCI has allocated funding to study how to effectively roll out preventive health strategies. In addition, NCI-Designated Cancer Centers, which receive most of the NCI funding for cancer research, are required to define and explain how their center will address cancer prevention, disparities and equitable access to health care in their communities, Croyle says.
“In the last few years, we’ve deliberately been focusing on our cancer centers and how to strengthen their role in cancer control in their communities,” says Croyle. The NCI also funds research into efforts to increase HPV vaccination, implement smoking cessation programs and provide access to cancer care for those living in rural areas, he adds.
Harps’ experience with cervical cancer illustrates how the combined efforts of a professional medical association, a local health department, a church and a medical center can provide tangible benefits. These days, Harps no longer puts off going to the doctor, and she urges her friends and members of her church to get regular checkups. “I tell everyone I know: Get to know your doctor. Don’t delay.”
Sirgi of the CAP Foundation, which funds the “See, Test & Treat” program that benefited Harps, notes that while there is value in statistically tracking the success of such programs, that’s not what comes to his mind first when he thinks about their impact.
“Any time you identify a woman who would have fallen through the cracks, who would have had a lethal disease that could have been prevented or treated because of screening, it’s by itself a great success story,” he says. “Even if an abnormality is not detected, if we are able to bring an underserved woman into the fold and introduce her to what health care can do for her and her family, this by itself for us is a success story.”
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