Emerging Issues:
Cancer inNew Hampshire
Executive Summary
February 2008
New Hampshire Comprehensive Cancer Collaboration
Development and publication of this report was supported by: the Centers for Disease Control and Prevention (PA02060) under cooperative agreement number U55/CCU-121912, the New Hampshire Division of Public Health Services(DPHS), the New Hampshire Comprehensive Cancer Control Program, the NH Comprehensive Cancer Collaboration, and the Foundation for Healthy Communities.
VISION
The vision of the New Hampshire Comprehensive Cancer Collaboration is for cancer incidence, morbidity, and mortality to be significantly reduced or eliminated and for the people of New Hampshire to enjoy health and quality of life.
MISSION
The mission of the Comprehensive Cancer Collaboration is to reduce significantly the incidence of, suffering from, and mortality due to cancer for people in New Hampshire through prevention, early detection, treatment, rehabilitation, and palliation. We will accomplish this goal by means of an integrated and coordinated alliance of stakeholders that will utilize available epidemiological data and evidence based research to set priorities for action.
EXECUTIVE SUMMARY
This report was prepared for the New Hampshire Comprehensive Cancer Collaboration Emerging Issues in Cancer workgroup by the PlymouthStateUniversityCenter for Rural Partnerships in collaboration with researchers at Keene State College. The purpose of the report is to detail emerging issues related to cancer, which can be introduced to health care providers, policy makers, health care advocates, and the general public in New Hampshire. The information in this literature review will also be provided to the other NewHampshire Comprehensive Cancer Collaboration workgroups to inform and help inthe development of their education and media campaigns.
The World Health Organization Cancer Control Programme describes cancer’s worldwide reach.
“Cancer affects everyone – the young and old, the rich and poor, men, women and children – and represents a tremendous burden on patients, families and societies…Yet, many of these deaths can be avoided. Over 40% of all cancers can be prevented. Others can be detected early, treated and cured. Even with late stage cancer, the suffering of patients can be relieved with good palliative care (WHO 2006).”
Cancer is a generic term for a group of more than 100 diseases that affects all body parts. What all cancers have in common is unrestrained cell growth and division caused by damage to the genes regulating the cell division and repair cycle. This rapid growth of abnormal cells can grow beyond their usual boundaries and invade adjoining body parts. Cancer is caused by internal and external factors. Internal factors include inherited mutations, hormones, immune conditions, and mutations caused by metabolism, etc. External factors include tobacco, radiation, chemicals, or infectious agents, etc. (ACS 2007). Much time may pass in-between exposure to an external factor and detectable cancer, but it all starts with one abnormal cell (ACS 2007; WHO 2006). Research into all aspects of cancer is ever-growing causing an ever-growing understanding of the disease.
Research into all aspects of cancer is ever-growing, causing an ever-growing understanding of the disease. However, people want to know what is their risk of getting cancer? Every person can develop cancer, but some people have varying risks that decrease or increase this chance. Risk is a mathematical probability of something occurring. Scientists calculate cancer risk estimates by studying large groups of people to discover the probability that a person or category of people will develop cancer over a certain time-period (Mayo Clinic 2007). According to the American Cancer Society publication Cancer Facts & Figures- 2007 American men have a lifetime risk of slightly less than 1 in 2 of developing cancer. The lifetime risk for an American woman developing cancer is slightly more than 1 in 3. Lifetime risk is a term that describes the probability that a person will develop or die from cancer over the course of a lifetime. Lifetime risk is a type of absolute risk- the actual numeric chance or probability of developing cancer during a specified time period. There is another type of calculated cancer risk- relative risk. Relative risk is a comparison of a certain risk factor and the people exposed to that specific risk factor. Relative risk looks at the strength of relationship between a risk factor and the heightened or lessened chance of cancer (ACS 2007; Mayo Clinic 2007).
In 2005, New Hampshire Comprehensive Cancer Collaboration (NHCCC) released its plan, Cancer in New Hampshire: A Call to Action 2010. The first priority is to ensure that it not just be a report on cancer but “function as a clearly defined action plan to reduce the incidence, morbidity and mortality of cancer.” Incorporated into the NHCCC plan in the spring of 2005, the Emerging Issues (EI) workgroup was charged with the goal of identifying emerging issues in cancer in New Hampshire and developing an action plan that will benefit New Hampshire residents and health care providers. Towards that aim, the EI workgroup identified a priority objective to increase public and provider awareness regarding emerging issues in cancer in New Hampshire. The EI workgroup proposes to achieve that goal in two phases. This report comprises part of Phase One.
Phase One of the EI workgroup action plan includes a strategy to identify existing national and local resources that contain evidence-based research on emerging issues in the following areas: primary prevention, early detection, treatment, survivorship, and palliation; environmental factors that may lead to cancer; and emerging studies and data relevant to New Hampshire residents and providers. Phase Two will includea plan forthe dissemination of “emerging issues” information in order to increase awareness of the public and providers, with a specific emphasis on prevention and environmental factors relevant to New Hampshire residents and providers.
This report is intended to inspire additional conversation and research on the emerging issues in cancer. The authors hope that the report will become a “living document” that will grow and develop with more input. In its current form, it is comprised of a literature review, internet-based research, and correspondence with scientists and health care providers. Students at PlymouthStateUniversity and Keene State College[1] conducted research for this report with oversight by the director of the PlymouthStateUniversityCenter for Rural Partnerships.
Emerging issues include new scientific discoveries, new developments in health care, and topics of renewed public interest. Data collection for this document proved challenging in that many scientists and health care providers were unable to provide information about the latest emerging issues for identifiable reasons. Therefore, not all emerging issues in New Hampshire are included. In some instances, scientists were unable to report on emerging issues prior to undergoing a rigorous peer review process and publication. Some information was proprietary in nature, and researchers were unwilling to report it to the authors of this report. Finally, busy schedules of scientists and health care providers made it challenging to collect information within a specified time frame. Once this report is made public, the authors hope that additional information will be forthcoming.
For the most part, emerging issues in New Hampshire are the same as those in the rest of the country, with some exceptions. There are a few differences due to our geography, rural areas, cultural make-up, and geology. For example, because of the state’s unique geology, radon and arsenic can pose significant cancer hazards for New Hampshire residents. The uneven distribution of health care providers, hospitals, and palliative care providers within the state also impacts outcomes associated with cancer and its treatment. Social inequality and poverty pose challenges for cancer diagnosis and treatment in New Hampshire, as it does elsewhere in the United States. Finally, because many of the state’s employers are small businesses, access to health insurance is a particular concern for the population.
This document focuses on the predominant forms of cancer in New Hampshire; therefore, information on certain types of cancer, such as leukemia and brain cancer, are underrepresented.
KEY TOPICS: AN OVERVIEW OF EMERGING ISSUES
This section highlights prominent emerging issues noted in the literature review and conversations with scientists and health professionals.
Tobacco Use
The negative health impacts of tobacco use are well established; however, current research focuses on the effects of tobacco advertising, behavioral counseling, and the methods best used to reduce smoking (smoking bans, smoking cessation programs, etc.). This section of the literature review focuses on emerging issues regarding the effects of advertising on tobacco use and the methodology used in smoking cessation programming and behavior counseling.
The types of advertising researched include those made by smoking companies as well as public service announcements geared toward reducing tobacco use. In the studies cited, advertising of tobacco products was found to have a direct effect on teens’ use of tobacco products and that reducing the exposure to tobacco product advertising reduces the number of young smokers. These studies recommend that restrictions on tobacco advertising be increased, and tobacco-warning labels be made more effective.
Studies also indicate that one-on-one behavior counseling with numerous meeting points over a sustained time period are extremely beneficial in helping mothers reduce their smoking, and therefore, the exposure of Environmental Tobacco Smoke (ETS) to their children.
Exposure to Radiation
Studies show that radiation is both a cause of and treatment for cancer. Ionizing radiation has recently been linked as a cause of several cancers, including childhood leukemia, breast cancer, and skin cancer (Belson et al. 2007; Cardis et al. 2007; Lichter et al. 2000). As the effects of therapeutic ionizing radiation become better known, the role of ionizing radiation in cancer screening is inevitably affected. New screening tools are sought, such as ultrasound for breast cancer screening. Scientific studies have shown that ultraviolet radiation is a well-known cause of skin cancer though the exact role on the human body is still incompletely known. Emerging issues related to ultraviolet radiation include gene-environment interactions related to skin cancer susceptibility, peoples’ behaviors regarding sun safety, and the possible therapeutic role it plays in reducing the risk of non-Hodgkin’s Lymphoma, breast, colon, ovary, and prostate cancers.
A study of the Portsmouth Naval Shipyard indicates that there has been a connection to higher levels of exposure to ionizing radiation and an increase in leukemia cases (Yiin et al. 2005). However, researchers conclude that more research needs to be conducted to definitively conclude the findings because of the small population size of the study. Therapeutic radiation has been connected to an increased risk for developing basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).
Studies indicate that education programs about proper skin protection against ultraviolet radiation (UV) exposure have been beneficial in improving the skin protection habits of individuals. In addition, providing multiple points of contact for education reinforcement has been found to be most effective(Olsen et al. 2007).
Cumulative Exposure to Pollutants
Growing evidence shows that the human body is exposed to numerous toxicants at low levels. Though each individual pollutant is encountered at assumingly “safe” levels, the cumulative effects of many pollutants may cause numerous diseases, including cancer. Citations include the environmental pollutants arsenic, radon, MtBE, pesticides, dioxins, coal tar, and more. An additional source of cumulative exposure may also include the chemical ingredients in some personal care products. Our research also indicates that human biomonitoring is a growing field by the Centers for Disease Control and Prevention (2001, 2003, 2005) and others such as Angerer et al. (2007) that is being used to detect and track cumulative exposure to pollutants.
Arsenic
There is current and on-going research regardingarsenic in drinking water. The United States Geological Survey (USGS) is working to document areas where high levels arepresent (Ayotte et al. 2006). This research concludes that the use of well water from private sources may correlate with excess bladder cancer mortality in New England. Analytical studies are underway to clarify the relation between suspected water contaminants, particularly arsenic, and raised bladder cancer rates in northern New England. Ayotte et al. (2006b) also created a model to predict the probability of arsenic levels beyond the recommended levels.
MtBE
The United States Geological Survey (USGS) is mapping areas with high levels of MtBE. Whether or not MtBE is a carcinogen is not yet clear.The research on MtBE in the state is not tied to any health effects. Current focus is on mapping the occurrences of MtBE in public and private wells in New Hampshire. A study for RockinghamCounty is completed (Ayotte et al. 2005), while another statewide study is currently undergoing peer review (Ayotte, pers. comm.).
Air Quality
There is significant research on the dangers of occupational and environmental exposures to a variety of airborne contaminants (radon, particulate matter, arsenic), in addition to smoking, that may have a connection to lung cancer. Some of the most important emerging and ongoing concerns for exposure in New Hampshire are indoor radon levels, outdoor ambient air particulate matter (PM) concentrations, and exposure to cigarette smoke. The studies cited in this report indicate that there is a need for increased education about indoor radon exposure risks for homeowners in particular. Studies also show that PM exposures of size cut less than or equal to 2.5 microns comprised of metals and other volatile organic compounds are gaining the attention of regulators nationwide; however, the need for more analytical data has been stated. Research at Keene State College identifies diesel exhaust as a possible factor in lung cancer in occupational settings and possibly for the general population.
Diet and Nutrition
Scientific debates about the role of nutrition in cancer risk and prevention are on-going. There are several citations on the benefits of a Mediterranean diet on cancer prevention. There are new studies on Vitamin D deficiency and cancer (Grant 2006; Giovannucci et al. 2006; Meyer 2004; Schwartz and Skinner 2007). According to Giovannucci & Michaud (2007), metabolic disruptions caused by obesity increase occurrences of certain cancers such as colon, prostate, andpancreatic cancer. Obesity may also reduce the effectiveness of treatment (Stroup et al. 2007; Dignam et al. 2006; Pierce et al. 2007).
Healthcare Access
In the interviews conducted with health care providers for this review, equitable access to high-quality health care was identified as a recurring theme. Interviewees believed that before cancer incidence and deaths can be reduced, New Hampshire residents must have access to healthcare for preventative education, screening, and, if needed, treatment. The literature review indicates that there are many barriers to healthcare access in New Hampshire: cost, insurance, distance, personal beliefs, and disparities due to gender, race, ethnicity, primary language spoken, or socio-economic status.
Cancer Prevention AndScreening
Information on cancer prevention was not readily available on all kinds of cancers. In the case of colorectal cancer, there was information on screening, which remains a significant concern. Emerging issues in colorectal screening include issues found in other cancer screening programs: risk assessment, genetic testing, patient-health care provider communication, access to health care, social disparities, and cultural beliefs. Citations found in this section discuss these issues and areas of improvement.
Currently, there are no evidence-based guidelines for colorectal screening (Marcella et al. 2007).The other topic of interest in screening has been about prostate cancer,The symptoms and signs of prostate cancer usually manifest after it is too late to 'cure' the condition, making screening for the cancer essential to reduce prostate cancer deaths (Frydenberg & Wijesinha 2007). Screening usually takes two forms: prostate specific antigen (PSA) and digital rectal examination. Many barriers exist to screening, particularly cultural beliefs, patient-health care provider communication, and perceived risk. Citations in this section address these barriers and others with discussions on improving prostate screening for all men.
Cancer Treatment
Emerging issues in cancer treatment include targeted therapies aimed at the biochemical pathways or gene interactions in the development of cancer. Early studies of targeted cancer treatments show promising results. With these studies, researchers are led to believe that generalized treatment for the body part the cancer is affecting may be replaced by a treatment based on the molecular biology of the mutated cells. Such studies include targeted treatment of non-small cell lung cancer (Zalcman et al. 2007), multiple myeloma (Anderson, 2007), and nucleotide-based targeted therapies for prostate cancer (Sowery et al. 2007). Additional studies and clinical trials are underway, such as the TailorX Trial, which is using molecular profiling to determine who will benefit the most from chemotherapy.
This review found that many patients struggle with the decision to use surgery, chemotherapy, radiation, or other “traditional” treatments for cancer. Some patients are choosing complementary therapies, in part or in whole, to treat their cancer. According to studies cited, complementary/alternative therapies are becoming increasingly popular and research into their use, their effectiveness, and their relationship with traditional therapies are emerging issues worldwide. This section includes citations on general use of complementary therapies with several references specifically on dietary supplements.
Palliation
Palliation is care given to patients and families who face life-threatening illness by providing pain and symptom relief, spiritual and psychosocial support from diagnosis to the end of life and bereavement (WHO 2006). This review suggests a general misperception about palliation asbeing only hospice care for the end-stage of life. Emerging issues in palliation include the use of behavioral interventions (Redd et al. 2001) and mind-body therapies (Astin et al. 2003) in symptom management versus an emphasis on medications. The research work on the role of chemotherapy and radiation in palliation is also reviewed in this document.