Public health and cancer prevention: Success and future challenges in cancer policy
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Medical research has revealed much about cancer prevention, but is the information reaching all Americans, and are they acting on it” Today, at the American Association for Cancer Research’s Sixth Annual International Conference on Frontiers in Cancer Prevention Research, being held from December 5 to 8 in Philadelphia, Pennsylvania, researchers explore the question of how best to translate cancer prevention science into public health policy.
Quitting smoking and inoculation with the human papillomavirus (HPV) vaccine are two ways that major segments of the general population can drastically lower their risk of developing certain cancers, yet researchers have found that these messages are not necessarily translating into action by the public. Likewise, researchers found that minority women fare worse between time of breast cancer diagnosis and treatment, then do Caucasian women, highlighting a worrisome gap in health care among racial and ethnic minorities.
Policies to reduce tobacco harm: What works? Abstract no. A29
To discourage cigarette use, the strategies that are working best on a global basis are to use large graphic package warning labels, ban cigarette advertising, institute smoke-free policies, increase cigarette prices and implement methods to prevent smuggling and counterfeiting of tobacco products, say researchers at Roswell Park Cancer Institute involved in an International Tobacco Control (ITC) Policy Evaluation study. What hasn’t worked as well as hoped is mandating tar and nicotine levels in cigarettes, they add.
The researchers have been investigating progress on controlling tobacco use from the ongoing Framework Convention on Tobacco Control (FCTC), the treaty devoted to improving public health put forth by the World Health Organization.
The FCTC was adopted by WHO’s member states in May, 2003, and became legally binding for those countries that ratified the treaty in 2005. To date, 151 countries have done so, and are thus required to implement the policies within three years.
“For the first time ever, we are beginning to scientifically assess which governmental tobacco control policies are working and which ones are not,” said K. Michael Cummings, Ph.D., MPH, chair of the Department of Health Behavior at Roswell Park Cancer Institute. “In the same way that evidence-based medicine has been built from rigorous evaluation of treatment options, our goal is to contribute to the development of a sound science base for tobacco control policies.”
The ITC serves to study which policies are working best in countries that have imposed restrictions, says Cummings. Cummings started the study in four countries in 2002 with a $1.5 million grant from the Robert Woods Johnson Foundation, and to date, $35 million has been raised to expand the research into 15 countries, utilizing the aid of 60 investigators from 17 research institutes.
Because randomized clinical trials can’t be used to evaluate government policies, the ITC study uses as controls those countries that have implemented tobacco control policies and compares the effects on tobacco use behaviors in countries that have not, such as the United States. It is tracking tobacco use behaviors of 1,000 to 2,000 participants in each of the countries, Cummings says. “This is a new model for global public health research that can be used to evaluate other public health policies such as HIV, diet, and cancer screening,” he said.
“It made sense for WHO to start off with tobacco as a focal point for action since tobacco use is the leading cause of preventable death in the world today and is a growing epidemic in the developing world,” he said. Tobacco use was responsible for 100 million deaths in the 20th century, and that number is expected to grow to 1 billion in the 21st century, he says.
ITC researchers have found that boosting tobacco taxes, comprehensive advertising bans, smoke-free laws, and strengthening cigarette package warnings is an effective recipe for reducing tobacco consumption. “Our research on package warnings has revealed that these warnings, especially if they are large and graphic, are more effective than anyone realized, especially in poorer countries that can’t afford expensive counter-marketing campaigns,” he said.
An example of a policy that hasn’t worked, Cummings says, is the European Union’s (EU) establishment of maximum emission standards for tar and nicotine. The goal was to make cigarettes less toxic, but the testing method adopted by the EU was flawed and cigarette makers increased filter ventilation to get around the new rules. Actual exposure to toxins didn’t change. “The well intentioned, but flawed EU policy has given smokers the false illusion that their cigarettes deliver less tar and nicotine, when they don’t,” he said.
The ITC has also established the first international cigarette repository, which currently holds 10,000 cigarette pack varieties from 15 different countries. This research shows that tobacco manufacturers alter their products frequently without revealing that they are doing so, he says. “Foods and drugs are regulated so that consumers are informed when the products are altered. The same should be true for tobacco products,” Cummings said.
Physician Intentions and HPV Vaccination: The First Year. Abstract no. A104
Before last summer, when the FDA approved use of the first vaccine developed to prevent cervical cancer, 92 percent of several hundred family care physicians surveyed in the poorer urban areas of metropolitan New York City said they would recommend the vaccine to their young female patients. But over a year later, only 10 percent of these same physicians had actually vaccinated some of their patients, report researchers at Columbia University.
While vaccines usually take time to come into widespread use, a delay in use of this proven cancer preventative will result in lost opportunity for many young women, says the study’s lead investigator. Sherri Sheinfeld Gorin, Ph.D., a senior member of the Herbert Irving Comprehensive Cancer Center and Associate Professor of Health Behavior.
“Routine use of the vaccine will play out over time, but how many women will be deprived in the intervening years”” she said. “Physician recommendation is key to vaccination, and these findings suggest there is a critical need for strategies that encourage physicians to follow through on their own good intentions.”
The study first sampled 235 multi-ethnic/racial urban primary care physicians with a questionnaire in early 2006 to see if these doctors intended to discuss use of the human papilloma virus (HPV) vaccine, when approved, with their young female patients. “It’s important to know if physicians plan to educate their patients about HPV prevention, because fewer than one-third of the population has heard of HPV,” Sheinfeld Gorin said.
They found that 92 percent of the physicians were extremely or somewhat likely to use the vaccine and that doctors who routinely offer pelvic examinations for their female patients, who are more familiar with the professional guidelines for cervical cancer screening, and who are female, were most likely to offer the vaccine.
But a follow-up audit of a proportion of patient charts in these practices, conducted between 12-18 months after the vaccine was approved, found that only 10 percent had vaccinated eligible young patients. By contextual comparison, 14 percent of patients received the hepatitis B vaccine in 1991, about one year after it was approved for universal use among infants.
Sheinfeld Gorin says she has some clues as to why so few physicians actually used the vaccine once it was approved. One is cost: even though the vaccine’s $360 price tag is usually reimbursed by insurance, physicians have to pay for their vaccine stocks up front, they have to store them and make sure they don’t expire. “That is a financial burden some physicians don’t want to have until use of the vaccine becomes more commonplace,” she said.
Another is that physicians may not have had a chance yet to discuss the vaccine with their young patients. But the most likely scenario, based on other studies, is that physicians presume patients will not be accepting of an HPV vaccine, Sheinfeld Gorin says. “So they don’t talk about it yet, and expect that social acceptance will improve in the future,” she said. “But, in fact, research has shown that patients are quite responsive to the vaccine. That’s why we need a strategy now to help physicians discuss HPV vaccines with their patients.”
Contact: Greg Lester
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American Association for Cancer Research
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