A Cancer Control Report Card and Blueprint

This is the second in a series of articles about the American Cancer Society (ACS) National Cancer Control Blueprint. The first was an overview of the blueprint and its goals based on an interview with Otis W. Brawley, M.D., MACP. Brawley is chief medical and scientific officer of the ACS. By the beginning of 2019, 6 more articles about the blueprint are planned for publication in CA: A Cancer Journal for Clinicians, and we’ll cover them on cancer.org.

We’ve made a lot of progress controlling cancer. But there’s so much more to do. That’s the main message of the first blueprint article published in CA: A Cancer Journal for Clinicians, “An Assessment of Progress in Cancer Control.” It reviews what we already know works and sheds light on what we can do better.

Our successful past. “Cancer has had a declining death rate every year since 1991,” says lead author, Rebecca L. Siegel, MPH.  Siegel is the scientific director of surveillance information at the American Cancer Society (ACS). “This success is due to a combination of cancer prevention, improvements in screening and early detection, and advances in cancer treatment.”

A primary focus for our future.  As the former National Cancer Institute director, Samuel Broder, MD, PhD, said, "poverty is a carcinogen." Siegel says poorer people are more likely to be exposed to things that can lead to behaviors that cause cancer, like smoking, poor eating habits, and inactivity. Plus, they’re less likely to have access to high-quality health care. These circumstances lead to very large differences in death rates from cancer based on economic status. Economic status is evaluated based on income, education, work experience, and occupation.  Finding ways to reduce those inequalities in our country is key to reducing the differences (disparities) in cancer the people who get cancer (incidence), available treatment, and outcome after treatment.

What’s Worked and What Needs More Work

Cancer control has been more successful with certain types of cancer than others. The goal is to gain control of cancer in underserved populations. That means lowering—or ending—inequalities in people who develop cancer (incidence) and die from it (mortality).

Here are some highlights from Siegel’s Cancer Control Blueprint article.

Lung cancer is an enormous success story, but it still offers the greatest opportunity for improvement. Most lung cancers are caused by smoking. Here’s what worked to bring about a steady decline in smoking rates after its peak in the 1950s and 1960s: widespread education and anti-smoking measures from the government and many other organizations, including the American Cancer Society. Two successful examples, Siegel says, are the increase in taxes on cigarettes and restricted smoking in public spaces.

Yet more people still die from lung cancer than from any other type of cancer. And smoking is still the main culprit. “Smoking is associated with at least 11 other types of cancer too, and it causes about 30% of all deaths from cancer,” Siegel says. Plus, smoking is also a major risk factor for heart disease, which is the leading cause of death in the US.  “In fact, half of smokers will die from a smoking-related disease.” It’s clear that reducing smoking could have a far-reaching effect and benefits the whole society.

What more can be done to help people who smoke quit?  We’ve learned that education works, so we could further the declines in lung cancer with better anti-smoking campaigns that target people with high smoking rates. Those with high smoking rates include American Indians, Alaskan Natives, and people whose highest education level is high school or below, she says. Since we know higher taxes on cigarettes work, we could save lives by increasing taxes in states where they are still low. In Kentucky, for instance, the cigarette tax is among the lowest in the country, and one-quarter of people in the state still smoke. The total population in Kentucky is about 4,500,000. If even 20% of the people who now smoke (1,125,000) quit because of higher taxes, about 225,000 people would reduce their chances of developing a cancer related to smoking.

Use of the HPV vaccine remains low in the United States, even though it could make huge progress against cervical and probably other HPV-related cancers. Advances in controlling the incidence of cervical cancer are mainly due to widespread Pap test screening. But, Siegel says, “if we combined vaccinations for human papillomavirus (HPV) with Pap test screening, we could nearly wipe out cervical cancer.” That’s because almost all cervical cancers are caused by persistent HPV infection. What can we do? Make it a national goal to increase vaccine rates, Siegel says.

Today nearly 9 in 10 children and teens will survive cancer into adulthood, but many of those survivors have serious ongoing health problems. Cancer death rates from pediatric and adolescent cancers have declined year after year since 1970. That’s true today even though more children and teens receive a diagnosis of cancer than in the past. What has helped? Participation in clinical trials, for one. Treatments and treatment processes have also improved.

But, there is more work to do, Siegel says. Why? Because many children who survive cancer have serious, ongoing problems as adults. These can be due to the cancer or the treatment they received early in life while their bodies were still developing. A current focus of research in children’s cancers is to improve treatments so they work better but cause fewer side effects.

Most Needed: Improved Access to Care

In the US, many people lack access to cancer care, mostly because they lack financial resources. This includes a higher number of minorities, including Blacks and Hispanics. That doesn’t just mean that these people don’t have access to high-quality treatment, Siegel explains. Cancer care is so much more than treatment because it includes:

• Preventive health education and programs about healthy eating, exercising, and not smoking
• Vaccinations      
• Cancer screening

Here are examples of what can happen due to unequal access to quality cancer care.

The availability of screening and improved treatment for breast cancer resulted in a large difference in the breast cancer death rate between Blacks and whites. In the 1970s, death rates for breast cancer were similar for Blacks and whites. Beginning in the early 1980s, improved availability of mammography screening lead to a rapid increase in the number of breast cancers found earlier than they had been before those improvements. In general, the earlier breast cancer is found, the less complicated it is to treat. Treatments also improved.

What happened next was telling: By the mid-1990s, breast cancer death rates were, and continue to be, much higher for Blacks than for whites, says Siegel. This is true even though whites are more likely to develop breast cancer.

Many studies found that the reason for these racial differences in death rates was due to:

• Access to high-quality screening
• Follow-up after an abnormal finding
• Access to high-quality surgery 
• Adequate chemotherapy
• Completion of the recommended number of treatments with radiation  

ACS researcher Ahmedin Jemal, DVM, PhD, led one study about this racial disparity. Jemal is the vice president of surveillance and health services research at the ACS. His study showed that access to health insurance played the most important role in these racial differences.

People with a college education have lower death rates from cancer than those with less education. Why? Because they are less likely to choose behaviors or be exposed to factors that increase the chance for cancer, such as smoking, eating unhealthy foods routinely, and being inactive, says Siegel. They also have the financial ability to pay for high-quality cancer care.

In research studies, education is another way to account for income. For example, studies show that nearly 1 in 4 deaths from cancer could be prevented if everyone had the same access to cancer prevention, screening, and treatment as college-educated adults. In 2018 alone, that would mean at least 134,000 fewer people would die from cancer, she says. For perspective, that would be like saving the lives of every person in Columbia, South Carolina.

Many deaths from cancer could be prevented with:

• Increased prevention and early detection efforts to better reach the populations at risk
• More effective education to help people live a cancer-resistant lifestyle that considers where they live and other risk factors
• Improving the access to high-quality cancer care to those who haven’t had it available to them

ACS research is showing what works in fighting cancer. The ACS Blueprint is about working harder to use and share that knowledge and to do that fairly.  To successfully do these things to improve access to care will require the cooperation and work of many stakeholders, including health insurance companies, pharmaceutical companies, hospital systems, cancer organizations, and national, state, and local government officials.