National Cancer Control Plan in US: 'Blueprint' From ACS

The American Cancer Society (ACS) has undertaken a major initiative to refocus nationwide efforts for cancer control in the decades ahead, which it describes as "a blueprint toward the control of cancer and a mortality reduction goal for the year 2035."

"It is our hope that this blueprint will be a call to action for cancer patients, family members of cancer patients, professional organizations, government agencies, the medical profession, academia, and industry to work together to implement what is known about cancer control," write the authors, led by ACS Chief Medical Officer Otis W. Brawley, MD, MACP.

The vision is outlined is a series of articles in CA: A Cancer Journal for Clinicians.

The ACS notes that although there has been steady progress in reducing cancer mortality, "it is clear that much more could, and should, be done to save lives through the comprehensive application of currently available evidence-based public health and clinical interventions to all segments of the population."

"The foundation of a national cancer control plan to reduce the burden of cancer is a group of initiatives to ensure equal and full access to the combination of preventive and therapeutic measures that are already proven effective. We believe this is a moral imperative," Brawley and coauthors explain in an introduction to the series.

"These goals cannot be achieved, however, without recognizing that the roots of health care disparities are deep, reflecting fundamental determinants of health, such as poverty, conscious and unconscious racism, barriers to the availability of healthy foods, a 'built environment' that limits opportunities for physical activity, and the lack of systems that ensure access to high-quality health care. Any national cancer control plan must include meaningful efforts to address these determinants of health," they write.

"An Assessment of Progress in Cancer Control," the first article of the series, which was published online July 10 in CA: A Cancer Journal for Clinicians, focusses on disparities and how cancer mortality trends differ across the nation.

Since 1991, there has been a continuous decrease in cancer mortality, due primarily to rapid declines in death rates for lung, colorectal, breast, and prostate cancer. Together, these account for nearly half of all cancer deaths, the ACS authors note. The reasons for the decrease include improvements in cancer prevention, screening, early detection, and cancer treatment, they note.

Despite these successes, challenges remain in reducing cancer burden and increasing cancer control. One major challenge are the continuing disparities in cancer-related mortality among different populations. Relevant factors include race/ethnicity, socioeconomic and educational level, and geographic region. Many of the differences in mortality are primarily due to the inability to obtain adequate medical treatment and preventive care. Remedies include education, interventions to promote adoption of a healthy lifestyle, vaccinations, and cancer screening.

"The most important aspect of this paper are the disparities and the observation that people who are college educated have a lower cancer death rate than those who are not," said Brawley. "If every American had the same risk of death as those who are college educated, a quarter of them would not occur — that's about 150,000 deaths that could be avoided.

"This doesn't require any new drug or any new science or any new treatment," he told Medscape Medical News. "It simply requires getting everything we know about the prevention and early detection and treatment of cancer to all Americans."

Prevention is cheaper and far more effective than screening in saving lives. Dr Otis Brawley

Brawley emphasized that a concerted effort is needed at cancer prevention. "This will save far more lives and prevent far more deaths than any kind of screening intervention," he said. "This is not a statement against screening but simply that prevention is cheaper and far more effective than screening in saving lives. Screening saves lives in the short term, whereas prevention is a long-term investment. But we need both."

Racial Disparities

Race/ethnicity is defined with respect to five groups: American Indian/Alaska Native, non-Hispanic white, non-Hispanic black, Hispanic, and Asian/Pacific Islander. Although the populations within these categories are extremely heterogeneous, they share some characteristics that can inﬂuence cancer risk. As an example, breast cancer risk factors can be inﬂuenced by culture, such as age at menarche, which in turn is inﬂuenced by diet during childhood. Some minority groups, such as black and American Indian/Alaskan Native populations, are much more likely to live in poverty as compared to whites.

Mortality data for all cancers combined show that for the period 1990-2015, there were persistent differences by race/ethnicity in the rate and speed of decline. Many health disparities stem from inequalities in access to preventive and therapeutic healthcare, and the introduction of new, effective health interventions has often led to an increase in disparity between those populations that have access and those who do not. The ACS report points to the fact that in the 1970s, mortality rates from colorectal and breast cancer were very similar among black and white populations. Differences in mortality began to accelerate in the 1980s with the increased availability of effective screening and treatment.

Geographic Disparities

The report notes that although a great deal of emphasis has been placed on racial disparities, geographic location can affect cancer mortality regardless of race. As an example, the age-adjusted breast cancer death rate decreased by 39% overall for the periods 1988-1990 and 2013-2015, but the decrease was only 20% to 29% in 10 states.

Another example is colorectal cancer, for which the death rate dropped by 49% overall between the periods 1980-1982 and 2013-2015. But in eight states, the reduction was only 12% to 31%. The smallest reductions in breast cancer mortality occurred in six of these states (Oklahoma, Arkansas, Mississippi, Alabama, Georgia, and West Virginia).

Although a number of factors contribute to geographic disparities, including variations in risk factors and in access to screening and high-quality treatment, these are all inﬂuenced by socioeconomic factors, legislative policies, and proximity to medical services. And it is "not a surprise," notes the ACS, "that the states with the least progress tend to be those with the highest prevalence of citizens who are socioeconomically deprived and/or black." There are substantial geographic cancer disparities among white Americans, even by neighborhood within cities, that largely parallel differences in socioeconomic status, it adds.

"Health disparities have changed over time," said Brawley. "It used to be just black/white, and then socioeconomics were recognized as an important aspect of it. And now its Mississippi vs Massachusetts."

Education Level

The ACS found that educational attainment is a measure of socioeconomic status, and irrespective of race/ethnicity or geographic region, a lower level of education is associated with a higher risk for death for nearly all cancer types. Cancer types with the largest relative risks are those for which the disparity is most preventable. These disparities largely reﬂect inequalities in the prevalence of cancer risk factors, such as smoking, obesity, physical inactivity, an unhealthy diet, and access to high-quality screening and treatment.

"Knowledge is really important," said Brawley. "For example, about 15% of American adults smoke cigarettes, but in some states, that figure is closer to 30%, whereas in California and Utah, its 10%."

These disparities relate to education, he continued. "We are talking about education and poverty issues, and many people have diets and weight that are more conducive to increasing cancer risk, whereas more educated people tend to be thinner and have a healthier diet.

"There are some of the things that we need to work on," Brawley said. "Diet, smoking and exercise — so it isn't just insurance and gaining access to healthcare.... That's certainly a part of it, but we need to think of education and a healthier lifestyle. But getting adequate care to all Americans may be more difficult than developing a new treatment."

The article on disparities is the first of a series.

"Forthcoming articles will be on cancer prevention and cancer screening, and then how we provide healthcare in the United States, and how pay for it," Brawley told Medscape Medical News. "There will also be an article on survivorship and then looking at cancer in 2035."

Authors Rebecca L. Siegel, MPH, Ahmedin Jemal, DVM, Phd, Jiemin Ma, PhD, and Otis W. Brawley, MD, are employed by the ACS and work in the intramural research department, which received a grant from Merck Inc for research outside the submitted work. Their salary is solely funded through the ACS. The other authors have disclosed no relevant financial relationships.

CA Cancer J Clin. doi:10.3322/caac.21460.

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