Cancer As A Public Health Concern Powerpoint Presentation

Michelle D. Flores

Jeff Etchason

Cancer is an enormous global health burden, touching every region and socioeconomic level.

American Cancer Society [ACS], 2012, p. 53

The worldwide application of existing cancer control knowledge according to the capacity and economic development of countries or regions could lead to the prevention of even more cancer deaths in the next 2 or 3 decades. In order to achieve this, however, national and international public health agencies, governments, donors, and the private sectors must play major roles in the development and implementation of national or regional cancer control programs worldwide.

Brawley, 2011, p. 68

OBJECTIVES

After reading this chapter the reader will be able to:

1. Compare and contrast global cancer statistics, including types, risks, geographic locations, and treatments in developed and developing nations.

2. Relate economic, personal, and physiological costs of cancers worldwide.

3. Discuss cancer survivorship and palliative and end-of-life care for cancer patients worldwide.

4. Compare and contrast disparities in cancer statistics for vulnerable populations.

5. Discuss the role of cancer registries worldwide.

6. Compare and contrast cancer prevention, control and education strategies.

7. Explain how public policy changes can decrease cancer risks in various global populations.

INTRODUCTION

The fight to eliminate cancer as a major health problem extends around the world (ACS, 2012). Although better prevention, early detection, and advances in treatment have helped some developed nations lower their incidence and mortality rates for certain types of cancers, in most parts of the world cancer is a growing problem (ACS, 2011b). Worldwide, the number of new cancer cases is expected to grow by 50% to a total of 15 million by the year 2020 (Stewart & Kleihues, 2003). By the year 2030, the expected numbers reveal a continuing rise in global burden, with approximately 21.4 million new cancer cases and 13.2 million cancer deaths expected to occur yearly, due only to the growth and aging of the population (ACS, 2012). The future burden may be further increased by the adoption of some specific, unhealthy behaviors and lifestyles associated with economic development and urbanization in low-and middle-income countries (ACS, 2011e, 2012). According to The Cancer Atlas, the global epidemic of cancer is shifting from developed to developing nations (Mackay, Jemal, Lee, & Parkin, 2006), where approximately 85% of the world population resides (ACS, 2012).

This chapter is written from a public health perspective, and is intended to introduce allied health-care professionals to important issues and concepts related to cancer and cancer patient care, both within the United States and in other parts of the world. The four sections address the following aspects of this topic: (1) key cancer and public health concepts and definitions; (2) cancer prevention; (3) early detection, screening, and education; and (4) cancer care considerations, including treatment, survivorship, palliative care, and end-of-life care. Efforts have been made throughout the chapter to highlight cancer-related topics that undergraduate students and healthcare professionals in a variety of disciplines (e.g., nurses, physician assistants, physical and occupational therapists, dieticians) may encounter early in their clinical work. Global perspectives are also provided to highlight both similarities of some issues as well as different challenges that countries throughout the world encounter in addressing cancer.

For detailed information on cancer-related topics presented in this chapter, readers are encouraged to refer to the numerous high-quality national reports, guidelines, textbooks, journal articles, and other current resources cited here. Websites of national organizations that are frequently updated to reflect changes in current knowledge about cancer and cancer care are also highlighted.

KEY CANCER AND PUBLIC HEALTH CONCEPTS AND DEFINITIONS

Cancer and the Comprehensive Cancer Control Approach

An often-cited definition of cancer is provided by the ACS (2012): “Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells” (p. 1). More than 100 different diseases are covered by the term “cancer,” and each of these diseases has a unique profile in terms of the population at risk, symptoms, and prognosis (Curry, Byers, & Hewitt, 2003). If the spread of abnormal cells is not controlled, it can lead to death of the individual affected (ACS, 2012). Cancer can be caused by external factors (e.g., tobacco, chemicals, radiation, infectious organisms) or internal factors (e.g., inherited mutations, hormones, immune conditions, mutations that occur from metabolism); these causal factors, acting together or in sequence, may initiate or promote the development of a cancer (ACS, 2012). A period of 10 or more years often passes between exposure to such factors and the onset of detectable cancer (ACS, 2012). The resulting time period between cancer development, detection, diagnosis, treatment, and possible progression can be quite long, ranging from months to decades, depending on the type of cancer.

For this reason, cancer prevention and control efforts must take a coordinated, long-term perspective (Centers for Disease Control and Prevention [CDC], 2011c; Miller, Hager, Lopez, Salinas, & Shepherd, 2009). The comprehensive cancer control (CCC) process was developed to support the long-term perspective. Through this process, a community pools its resources to reduce the burden of cancer by reducing risk, facilitating early detection, ensuring better treatment, and enhancing survivorship; these efforts, in turn, encourage healthy lifestyles, promote recommended cancer screening guidelines and tests, increase access to high-quality cancer care, and improve quality of life for cancer survivors (CDC, 2011b). One example of a far-reaching, public health–oriented collaboration is the National Comprehensive Cancer Control Program (NCCCP), which is supported by the CDC. The NCCCP is a national collaborative initiative that seeks to create the necessary conditions for dramatically reducing the burden of cancer incidence and mortality and improving the quality of life for cancer survivors (Black, Cowens-Alvarado, Gershman, & Weir, 2005; CDC, 2011b).

In the United States, the NCCCP conducts its work by supporting the development and implementation of state CCC plans (Black et al., 2005). Since 1998, the number of member CCC programs participating in NCCCP has grown from 6 to 65; currently, member programs include all 50 states and the District of Columbia, 7 tribes and tribal organizations, and 7 United States associated Pacific Islands/territories (CDC, 2011b). The CDC’s Division of Cancer Prevention and Control works with national organizations, state health agencies, and other key groups to develop, implement, and promote effective cancer prevention and control practices within the NCCCP.

Internationally, cancer prevention and control initiatives are taking place on every continent. Canada, China, France, and Chile are currently implementing national cancer control programs, for example. According to the World Health Organization (WHO, 2008), the basic principles of cancer control include the following:

■ Leadership to create clarity and unity of purpose

■ Involvement of stakeholders

■ Creation of partnerships

■ Responding to the needs of people at risk

■ Decision making based on evidence, social values, and efficient and cost-effective use of resources

■ Application of a systematic approach

■ Seeking continuous improvement

■ Planning and implementing cancer control using a stepwise approach

Cancer Burden

Burden refers to the size of a health problem in a specified area, as measured by several statistics, such as incidence, mortality, rates, and prevalence, as well as other indicators such as cost, morbidity (“any departure from physiological or psychological well-being” [Mackay et al., 2006, p. 17]), and risk factors (Black et al., 2005; Stewart & Kleihues, 2003). “Cancer is an enormous global health burden, touching every region and socioeconomic level” (ACS, 2012, p. 53). Knowledge of the burden of a disease can help determine where investments in time, money, and other resources may be most effective in reducing the burden.

Recognizing the growing global cancer crisis, the ACS (2011b, 2011e) has established three integrated priorities aimed at reducing the burden of cancer: (1) increasing funding for the control of cancer and other noncommunicable diseases, including making cancer control a political and public health priority; (2) reducing tobacco use; and (3) increasing awareness about the burden of cancer and its leading risk factor, tobacco. The Worldwide Cancer Burden Report (ACS, 2006) described factors that contribute to the burden in developed countries versus those that contribute to the burden in developing countries. Contributing factors include regional differences in age structure, prevalence of major risk factors, availability of detection services, and completeness of reporting data to cancer registries. A 2007 Institute of Medicine (IOM) report on cancer control opportunities in low- and middle-income countries provided an excellent review of the significant burden of cancer in both low- and middle-income countries, and identified major opportunities for such countries to achieve better cancer control, including cancer planning, cancer prevention and early detection/screening, cancer management, and psychosocial support for patients and families (Sloan & Gelband, 2007). Despite the ever-increasing evidence of the growing burden of cancer, far too little continues to be spent globally to manage this growing crisis (Economist Intelligence Unit, 2009).

Regarding the U.S. cancer burden, a decade ago, Colditz, Samplin-Salgado, Ryan, Dart, Fisher, Tokuda, and Rockhill (2002) wrote that sufficient knowledge of cancer causes and prevention was available, at that time, to reduce cancer burden in the United States by more than 50% in the coming decades, if public policies relying on the current scientific knowledge were implemented. Unfortunately, this knowledge has not been translated into systematic action across the country, and the failure to take this step presents a major challenge to current CCC efforts (Black et al., 2005).

In the 2006 Cancer Atlas (Mackay et al., 2006), the burden associated with this disease is discussed within the context of three related topics outlined briefly here: the risk of getting cancer, the incidence of major cancers worldwide, and geographical diversity in the risks of developing cancers.

The Risk of Getting Cancer

Cancer risk is commonly expressed either as lifetime risk (the probability that a person will develop or die from cancer over the course of his or her lifetime) or relative risk (a measure of the strength of the relationship between risk factors and a particular cancer) (ACS, 2012). Although anyone can develop cancer, most cases occur in adults who are middle-aged or older, as the risk of being diagnosed with cancer increases as people age (ACS, 2012). The most common cancers involve epithelial tissues (linings of the airways, gastrointestinal, and urinary systems); the risk of developing these types of cancer increases rapidly with age, as does the overall risk of cancer (Mackay et al., 2006).

Cancer develops when a sequence of mutations occurs in critical genes in one cell of the body, as a result of exposure to carcinogens, such as tobacco, infectious organisms, and chemicals, and internal factors such as inherited mutations, hormones, and immune conditions. Cumulative exposure to such agents increases with time, so that the probability of cancer increases as we age. (Mackay et al., 2006, p. 42)

All cancers involve the malfunction of genes that control cell growth and division, with approximately 5% of cancers being strongly hereditary, meaning that an inherited genetic alteration confers a very high risk of developing one or more specific types of cancer (ACS, 2012). In children, leukemias and cancers of connective tissue are more common than epithelial tissue cancers (Mackay et al., 2006). Information regarding the differences between childhood and adult cancers can be found in the 2007 IOM report on cancer control (Sloan & Gelband, 2007).

Most cancers can be linked to a few controllable factors, including tobacco use, poor diet, lack of exercise, and infectious diseases (ACS, 2011b; Curry et al., 2003); these factors are discussed in the “Prevention” section later in this chapter. Tobacco use is the number one cause of cancer and the number one cause of preventable death throughout the world (ACS, 2012; Shafey, Eriksen, Ross, & Mackay, 2009), and reduction in tobacco use offers the greatest opportunity to reduce the global incidence, morbidity, and mortality of cancer (Curry et al., 2003). In fact, all cancers caused by cigarette smoking and heavy use of alcohol could be prevented completely (ACS, 2012). The most important modifiable risk factors (i.e., risk factors that can be changed), as outlined in The Cancer Atlas (Mackay et al., 2006), include an unhealthy diet (high in saturated fats with an insufficient intake of fresh fruits and vegetables), physical inactivity, infections with viruses or bacteria that cause cancer, and ultraviolet radiation exposure. Other modifiable risk factors are alcohol use, occupational exposures to carcinogens such as asbestos and secondhand tobacco smoke (also referred to as passive smoking), socioeconomic status, environmental pollution, obesity, food contaminants, and ionizing radiation (Mackay et al., 2006). Modifying some risk factors requires individual behavior changes, while modifying other risk factors requires changes at the population level (e.g., by employers or communities); often, improvement in risk factors is best accomplished by employing both individual and population level efforts (Mackay et al., 2006).

Additional perspectives on cancer risk and outcomes, on the continuum from prevention to palliative care, can be gained by reviewing current reports focused on specific racial and ethnic groups. Cancer Facts & Figures for African Americans 2011–2012 (ACS, 2011c) and Cancer Facts & Figures for Hispanics/ Latinos 2009–2011(ACS, 2009) reveal how cancer occurrence and survival are influenced by cultural values and beliefs as well as by the aforementioned risk factors.

Incidence of Major Cancers Worldwide

Cancer incidence refers to the number of newly diagnosed cases of cancer that occur in a defined population during a specified period of time, such as a year (Mackay et al., 2006; Menck & Bolick-Aldrich, 2007). The cancer incidence rate is the rate at which new cases occur in a population and is calculated by dividing the number of new cases that occur during a specified time period by the total number of people who were at risk for the given cancer in the defined population; this rate is generally expressed as the number of cancers per 100,000 people (Mackay et al., 2006; Menck & Bolick-Aldrich, 2007). Cancer incidence differs from cancer prevalence, which refers to how many cases of a particular cancer are present in a defined population at a given point in time (Hutchison, Menck, Burch, & Gottschalk, 2004).

The most common cancers worldwide are lung, breast, colorectal, stomach, and prostate (Mackay et al., 2006; World Cancer Research Fund International, 2011). Liver cancer is the most common cancer for men in several African countries, although Kaposi’s sarcoma is the most common cancer in 13 of these African countries that are severely affected by the HIV/AIDS epidemic. Either breast or cervical cancer is the most common malignancy for women in almost all countries, except for in some East Asian countries, where stomach cancer is more frequent (Mackay et al., 2006). The cancer that causes the most deaths worldwide is lung cancer, followed by stomach and liver cancer, although the pattern is quite different in males and females (Mackay et al., 2006). Cancer affects people of all races, ethnicities, genders, and ages. The cancers that are common in developing countries are those that have a poor prognosis, including cancers of the lung, stomach, liver, and esophagus (Mackay et al., 2006).

Geographical Diversity

The risk of developing different cancers varies widely by world region, as noted by the examples that follow. Studies of migrants or populations who move from one location to another confirm that differences in the risk of various cancers are largely environmental in origin (not due to ethnic or genetic differences) and especially are a product of different lifestyles (Mackay et al., 2006). Liver cancer incidence reflects the prevalence of infection by hepatitis viruses, especially hepatitis B virus. Esophageal cancer rates are high in east Africa and Asia, including China and Central Asia, whereas testicular cancer is rare in African and Asian men (Mackay et al., 2006). Although not rare anywhere in the world, breast cancer is primarily a disease of affluent countries (Mackay et al., 2006). In contrast, the burden of disease from cervical cancer is highest in the poorer southern countries in Africa, Latin America, and South and Southeast Asia (Sloan & Gelband, 2007). Worldwide, lung cancer is the most common cancer, both in terms of new cases and of deaths; approximately 80% of cases in men and 50% of cases in women are caused by tobacco smoking (Mackay et al., 2006). International variations in cancer incidence and mortality have been described for the most common cancers (i.e., lung, female breast, colon and rectum, stomach, prostate, liver, and cervical) in both economically developed and developing regions of the world (ACS, 2006, 2011e). The bacterium Helicobacter pylori (H. pylori) is a major cause of stomach cancer, which is poorly responsive to treatment (Sloan & Gelband, 2007). The prevalence of H. pylori, as well as that of stomach cancer, has declined dramatically even without the implementation of targeted measures in much of the world; this trend suggests the possibility of developing interventions for geographic regions where H. pylori is not declining, which includes most low-income countries (Mackay et al., 2006; Sloan & Gelband, 2007).

In the United States, cancer overall is the second leading cause of death, exceeded only by heart disease (ACS, 2012). One of every four deaths in the United States is due to cancer (ACS, 2012). In 2012, more than 1.6 million Americans are predicted to receive a new diagnosis of invasive cancer and more than a half million Americans are expected to die of this disease—more than 1500 people per day (ACS, 2012). The 2012 new cancer case estimate does not include carcinoma in situ (noninvasive cancer) of any site (except for urinary bladder cancer) or basal and squamous cell skin cancers (which are not required to be reported to cancer registries).

Men in the United States are most often diagnosed with or die from prostate, lung, and colorectal cancers, whereas women are most often diagnosed or die from female breast, lung, and colorectal cancers (United States Cancer Statistics Working Group [USCSWG], 2006). Variations in the incidence and mortality of various cancers, examined according to race and ethnicity and to geographic area in the United States, are complex to explain and have been well described (ACS, 2011b). Such variations may be the result of regional differences in exposure to known or unknown risk factors such as sociodemographic population characteristics (e.g., age, race and ethnicity, geographic region, urban or rural residence), use of screening activities, health-related behaviors (e.g., behaviors related to tobacco use, diet, physical activity), exposure to cancer-causing agents, or cancer registry operations factors (e.g., completeness and timeliness of data collection; specificity in coding data collected for various cancer sites) (CDC, 2005; Devesa, Grauman, Blot, Pennello, & Hoover, 1999; Howe, Keller, & Lehnherr, 1993).

Cancer Mortality

Cancer mortality refers to “the numbers of deaths from cancer that occur in a population during a specified period of time” (Mackay et al., 2006, p. 17). The mortality rate is the rate at which deaths occur in a population and is calculated by dividing the number of deaths that occur during a specified period of time by the number of people at risk for the given cancer in the specified population (Mackay et al., 2006; Menck & Bolick-Aldrich, 2007). Overall, the probability of an individual dying from cancer during his or her lifetime does not differ appreciably between the developed and developing world (Mackay et al., 2006). At the same time, although the risk of getting cancer is higher in the developed world, cancers in the developing world are more likely to prove fatal (Mackay et al., 2006). Evidence regarding the influence of gender on mortality is seen in data from U.S. government research, which indicates that men who are diagnosed with cancer are more likely to die from the disease than are women, due to a higher initial risk and later detection (Beasley, 2011). Other investigators have found that male-to-female mortality rate ratios (MRR) differ markedly, while cancer survival disparities are much less pronounced, suggesting that sex-related cancer disparities are more strongly related to etiology than to prognosis (Cook, McGlynn, Devesa, Freedman, & Anderson, 2011).

The Expanding Role of Cancer Registries

Cancer registries serve as important links between high-quality cancer data collection and high-quality patient care. Despite the enormous contributions made by registries, registry staff often work in fairly low-visibility positions in clinical settings, so healthcare professionals working in hospitals may be unaware of the time- and labor-intensive, and highly technical, work of these cancer surveillance leaders. Thus highlights of cancer registries and the registration process are provided here.

Cancer registries are data collection systems that assess the occurrence and characteristics of reportable cancers. They are designed for the collection, management, and analysis of data on persons who have been diagnosed with cancer (Hutchison et al., 2004). The organized and systematic cancer registration process involves the collection of five items in the fundamental data set: (1) occurrence of cancer, (2) type of cancer (site, morphology, and behavior), (3) extent of disease at the time of diagnosis (stage), (4) types of treatment received by the patient, and (5) treatment outcomes (survival) (Hutchison et al., 2004). Cancer registries exist in a wide range of settings and function within varying organizational structures, such as hospitals, physicians’ offices, radiation facilities, freestanding surgical centers, research centers, and pathology laboratories (Hutchison et al., 2004; USCSWG, 2006). The status of cancer registration in other countries has been addressed by Menck (2004).

Cancer registries may collect details of new cancer cases and their follow-up, either for a defined population (e.g., a geographical area; a particular cancer diagnosis) or for a hospital (Mackay et al., 2006). Registries that seek to collect and maintain data on all possible patients within a defined geographic area (such as a state, province, or city) are referred to as population-based (Hutchison et al., 2004). Because the reader may hear the term “cancer registry” in the course of daily business, two main types of registries are briefly noted here. Hospital-based cancer registries provide detailed information about cancer patients receiving care at the hospital, the nature of their tumors (including the precise histological types and stage of disease), the treatment received, and the outcome of the disease to date (Mackay et al., 2006). Central cancer registries collect cancer information from more than one facility (typically including hospitals, as well as other healthcare facilities such as radiation therapy clinics) and consolidate multiple reports from the various facilities on a single patient into one record (Hutchison et al., 2004). If a patient has multiple primary cancers, special attention is given so that this information is properly captured. Hospital and central registries are unified in a synergistic and complex effort to help reduce the burden of cancer through the common use of cancer patient data (Menck, Deapen, Phillips, & Tucker, 2007).

Two national cancer data surveillance systems from which a healthcare provider will find useful publications when seeking updated U.S. cancer statistics are the Surveillance, Epidemiology, and End Results (SEER) Program and the National Program of Cancer Registries (NPCR). Together, NPCR and SEER collect data for the entire U.S. population (CDC, 2011d).

The Surveillance, Epidemiology, and End Results Program is a federally funded program of the National Cancer Institute (NCI), comprising 20 population-based cancer registries in various parts of the United States (NCI, 2011d). The member registries have been included based on their ability to operate and maintain a high-quality reporting system and for their epidemiologically significant population subgroups (NCI, 2011d). SEER covers approximately 28% of the U.S. population. Established in 1973, it includes population-based information on stage of disease at diagnosis and patient survival data. It is the only comprehensive source of population-based information in the United States that includes stage of cancer at the time of diagnosis and patient survival data (NCI, 2011d).

The National Program of Cancer Registries is a federally funded CDC program that supports central registries and promotes the use of high-quality registry data in 45 states, the District of Columbia, Puerto Rico, and the U.S. Pacific Island jurisdictions (CDC, 2011d). Established in 1995, it covers 96% of the U.S. population (CDC, 2011d; Intlekofer & Michaud, 2007). The NPCR data collected by state cancer registries enable public health professionals to understand and address the cancer burden more effectively in their states; NPCR data are critical to planning state-specific cancer control activities that meet the needs of residents of the participating NPCR states.

Each year, CDC and NCI combine their high-quality cancer incidence data from NPCR and SEER, respectively, to produce an important set of official federal cancer statistics, in collaboration with the North American Association of Central Cancer Registries (NAACCR). The resulting collaborative effort, the annual United States Cancer Statistics(USCS) report, provides state-specific, regional, and national data for cancer cases diagnosed for a single year. The most currently available statistics can be found at http://www.cdc.gov/cancer/dcpc/data (CDC, 2011e).

When registries were first established about six decades ago, they focused primarily on describing cancer patterns and trends and sometimes calculating survival. In the last 20 years, however, their roles have been significantly expanded so that they now play an increasingly important role in planning and evaluation of cancer control activities and in improving the care of individual cancer patients (Hutchison et al., 2004; Mackay et al., 2006; Menck et al., 2007; Parkin, 2006). Cancer registries serve as the “eyes and ears” of cancer control around the world, and the statistics they produce are essential in planning and evaluating activities of comprehensive cancer control programs (Mackay et al., 2006). Some cancer registries continue to follow patients throughout their lifetimes to identify those who have recurring cancer or a second cancer, have received additional treatments, have had progression or remission of disease, and/ or have died (Clive, 2004).

Cancer registries have increasingly important public health and research functions (Mackay et al., 2006). For example, NPCR cancer registry data were recently used in CDC’s first multistate, patterns of care (PoC) cancer research study, designed to assess the completeness and quality of NPCR cancer registry data collected in seven participating states and to determine the extent to which guidelines-based, stage-specific treatments were provided to patients with specific cancer diagnoses residing in those states (Alley et al., 2007; Alley et al., 2008). Such studies provide information that can be used to continue to improve the quality of NPCR registry data and to identify groups of patients (e.g., by age, race, ethnicity) who may be receiving less than adequate care. This type of work can thereby help researchers and clinicians develop a better understanding of treatment disparities and ways to correct them. Obtaining high-quality data—which lies at the core of cancer registry surveillance work—is an important step toward motivating action to reducing the burden of cancer, whether through prevention, screening, treatment, and/or survivorship-related activities (Black et al., 2005). In other parts of the world, cancer registries are active and experienced in some countries, while still in nascent stages in others. The reader is referred to interesting references that trace the development of registries in other countries over the last 65 years (Mackay et al., 2006; Menck, 2004; Parkin, 2006). The International Association of Cancer Registries (IARC) has a global membership and sponsors a variety of publications, including an every-five-years publication in collaboration with IARC, entitled Cancer Incidence in Five Continents. This publication contains statistical data from all the best-quality registries worldwide (Mackay et al., 2006).

Cancer Costs

“The costs of cancer pose an economic burden on both the individual and society” (Mackay et al., 2006, p. 57), regardless of the country being considered. According Harvard University economist David E. Bloom, newly diagnosed cancer cases cost the global economy $300 billion in 2010; the increase in tobacco use, alcohol intake, obesity, and decreased physical activity in poorer countries, according to Bloom, also led to an increase in cancer and diabetes cases (Renick, 2011). Although data limitations do not allow for a worldwide comparison of the economic costs of cancer (Mackay et al., 2006), The Cancer Atlas(2006) has published data from selected countries and described the diverse and significant costs incurred for selected cancers. Three categories of cost domains especially relevant to cancer are often discussed in the literature: (1) direct costs, including both medical costs (e.g., hospitalizations and treatments) and associated nonmedical costs (e.g., transportation to hospital or physician’s office); (2) indirect costs, such as time spent seeking medical care or economic productivity lost due to premature death; and (3) intangible/psychosocial costs, such as pain, suffering, or grief (Brown & Yabroff, 2006). Recent research has shown that cancer has the most devastating economic impact of any cause of death in the world (ACS & Livestrong, 2010). Pointedly, Mackay and colleagues (2006) note that cancer prevention may be the best way to save money for many countries, given that the costs associated with cancer continue to increase.

Not surprisingly, in the United States, the financial costs of cancer are both staggering and rising. All of the cancer-related costs will likely continue to increase because of the anticipated growth and aging of the U.S. population (USCSWG, 2006). Currently, lack of health insurance and other cost barriers prevent many people living in the United States from receiving optimal health care (ACS, 2012). As examples, consider that approximately almost 51 million Americans were uninsured in 2009 (according to U.S. Census Bureau figures), and that almost one-third of Hispanics and one in 10 children (ages 17 years and younger) had no health insurance coverage (ACS, 2012). Such cost barriers are significant, given that uninsured patients and those from ethnic minorities are substantially more likely to be diagnosed with cancer at a later stage, when treatment can be more extensive and more costly (ACS, 2012).

PREVENTION

Cancer, the world’s second biggest killer after cardiovascular disease, is one of the most preventable, noncommunicable, chronic diseases (ACS, 2012; WHO, 2008). This section and the “Cancer Prevention” appendix at the end of this chapter focus on concepts and definitions related to the broad area of cancer prevention, including key actions such as reducing tobacco use and exposure to secondhand smoke; maintaining optimal nutrition, physical activity, and body weight; and minimizing exposure to infectious disease agents. These health-promoting actions can contribute to reducing the global cancer burden over the long term.

Prevention, sometimes described as primary prevention, refers to activities directed toward avoiding the occurrence of disease (ACS, 2011e; Menck & Bolick-Aldrich, 2007). Cancer prevention represents the most beneficial population-based public health approach to reducing morbidity and mortality from cancer. Its ultimate goal is to promote health and potentially eliminate disease risk. Cancer prevention strategies generally focus on known, modifiable risk factors such as exposure to infectious agents, specific lifestyle behaviors, and environmental carcinogens (ACS, 2011d). Some risk factors, such as age, gender, and genetic predisposition, cannot be altered (ACS, 2011d), although these factors can be considered in developing screening strategies. Public health measures that incorporate prevention strategies are meant to benefit people at the individual, community, and environmental levels. Globally, one of the most important mechanisms for implementing these public health prevention measures has been the development and enforcement of policies and/or systems changes. Examples of such policies and systems changes include laws (e.g., controlling tobacco and alcohol use), education and awareness activities (e.g., World Cancer Day), resolutions (e.g., WHO’s Cancer Prevention and Control Report), and clinical care–oriented, preventive services guidelines (e.g., ACS, 2011a).

The “Cancer Prevention” appendix includes a detailed discussion focused on the three examples of key cancer prevention actions, mentioned previously, and the positive changes in lifestyle factors that have the potential to reduce a large proportion of the cancer burden. Although specific research methods and results of analyses related to cancer prevention and early detection activities vary, studies cited are consistent in pointing to the potential benefits of reducing tobacco use, improving nutrition, increasing physical activity, maintaining a healthy body weight, keeping alcohol consumption at low to moderate levels, and getting screened regularly for cancer (Curry et al., 2003).

EARLY DETECTION, SCREENING, AND EDUCATION

Early detection is one of the central components of cancer control and the complementary strategy to cancer prevention. The two core components of early detection of cancer are screening and education (Curry et al., 2003; Gullatte, Phillips, & Gibson, 2006; Mackay et al., 2006). The two primary strategies for early detection are (1) early diagnosis, which is often triggered by the patient’s discovery of early signs and symptoms, leading to an appointment with a healthcare provider, and (2) screening of asymptomatic and apparently healthy individuals to detect precancerous lesions or an early stage of cancer, leading to referral for diagnosis and treatment (WHO, 2006a). It is important to note that screening and treatment services for most cancers may not be available in developing countries because of limited resources.

Given these limitations, countries that cannot afford to implement the infrastructure required to organize screening programs are encouraged to focus on increasing awareness of signs and symptoms of cancer in the general population, thereby leading to early diagnosis and treatment (Sloan & Gelband, 2007).

A high proportion of cancers that are relatively curable in developed countries (because such cancers are often screened for/diagnosed early, and treated successfully) are often not managed as successfully in developing countries due to resource limitations (WHO, 2006b). Variations in cancer burden in developed and developing countries may result in part from differences in access to effective screening and treatment programs. For example, in 2008, more than 85% (n = 530,232) of the new cases of cervical cancer diagnosed worldwide occurred in developing countries that lacked organized screening programs (ACS, 2011e; Ferlay, Shin, Bray, Forman, Mathers, & Parkin, 2010). In the same year, cervical cancer was the fourth leading cause of cancer-related deaths in women worldwide, with 90% of these deaths occurring in developing countries. In more developed nations, cervical cancer estimates have generally declined over the past few decades (ACS, 2011e), likely due to the availability of broadly available screening programs. The prognosis for cervical cancer is generally better and treatment usually more successful if the disease is detected and treated early (WHO, 2006b). Declining death rates worldwide for many cancers in developed nations prove that cancer can be controlled with aggressive intervention.

The “Early Detection, Screening, and Education” appendix at the end of this chapter outlines the general principles governing the introduction of early detection programs and provides a definition of and key concepts related to cancer screening. Specific information regarding screening for breast cancer, cervical cancer, colon and rectal cancers, and prostate cancer is also presented. Also included in this appendix is a discussion of the importance of public and healthcare professional education programs related to cancer screening and early detection efforts.

CANCER CARE CONSIDERATIONS

Cancer Treatment

Employing effective treatment is the single most important strategy to ensure optimal life following a cancer diagnosis, and advances in treatments have enhanced survival for many patients (Mackay et al., 2006). Statistics that show a continuing improvement in 5-year relative survival rate for all cancers (i.e., cancers diagnosed between 2001 and 2007 as compared with cancers diagnosed between 1975 and 1977) reflect the progress being made in diagnosing certain cancers at an earlier stage and the improvements in treatment (ACS, 2012). “Survival statistics vary greatly by cancer type and stage at diagnosis” (ACS, 2012, p. 2). According to NCI (2006), although approximately one-third of all cancers are avoidable through lifestyle changes and early detection, and despite available information that could permit the early diagnosis and effective treatment of an additional one-third of cancer cases, millions of cancer cases worldwide still cannot currently be prevented or cured. Thus new and effective treatments must continue to be urgently be sought (NCI, 2006).

According to WHO (2008), the primary goals of cancer treatment throughout the world, depending on extent of disease and other key variables, are threefold: (1) cure, (2) prolongation of useful life, and (3) improvement of quality of life. WHO (2008) has acknowledged that although the basic principles of cancer treatment are the same throughout the world, the specific treatment approaches adopted in each country should take into account cost-effectiveness, affordability, and social and ethical aspects of care. Services should, however, always be provided in an equitable and sustainable manner. WHO (2002, 2008) has long held that the primary aim for treatment is multidisciplinary management, which is more effective than sequential independent management of patients; such a treatment plan should be linked to an early detection program so that cases are detected at an early stage, when treatment is more effective and there is a greater chance of cure. Careful cancer diagnosis and cancer staging are key steps in providing adequate cancer management, wherever a person receives cancer care in the world; these steps aid in selecting the most appropriate therapies, determining prognosis, and standardizing the design of research treatment protocols (ACS, 2011e).

The main methods of treatment for cancer are surgery, radiotherapy, and chemotherapy, with each of the three effecting cures in certain cancers (ACS, 2011e, 2012). Biologic therapy, targeted therapy, and hormone treatment (sometimes classified as chemotherapy) are other important treatments (ACS, 2012; NCI, 2011b). The three principal modes of therapy may be given alone or in combination for best success, depending upon key patient-related considerations (ACS, 2011e; Stewart & Kleihues, 2003). For detailed information on various therapies and rehabilitation considerations, refer to recently published documents on state-of-the-art treatments, immediate side effects, possible long-term and late-appearing side effects, and treatments that are best suited for particular cancers (e.g., ACS, 2012; NCCN, 2011a; NCI, 2011a).

Two frequently updated sources for cancer treatment information are the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology and the NCI PDQ (Physician Data Query) Comprehensive Cancer Database. Both are known for maintaining highly interactive websites with frequently updated content on an impressive number of topics. The NCCN Clinical Practice Guidelines are a recognized standard for clinical policy in the oncology community, providing easy access to continually updated guidelines based upon evaluation of scientific data integrated with expert judgment (NCCN, 2011b). Included in the NCCN Clinical Practice Guidelines are clinical trials information, available in versions tailored for patients, clinicians, and industry. Interested readers can also access the NCCN Drugs & Biologics Compendium and information about a physician-oriented Cancer Resource Line (for selected cancers) (NCCN, 2011b). The adult treatment and pediatric treatment summaries available on the NCI PDQ cancer information website contain evidence-based summaries of prognostic and treatment information for the major types of cancer in both adults and children, as well as for unusual childhood cancers in the pediatric summaries; summaries are available in professional and patient versions as well as in Spanish (NCI, 2011e). The NCI PDQ houses a comprehensive list of cancer clinical trials, containing more than 8000 abstracts of clinical trial protocols that are accepting patients (NCI, 2011e). A wide-ranging array of other cancer-related topics are covered as well, including subjects such as genetics, complementary and alternative medicine, and supportive care.

Innovative approaches that use the main treatment methods in novel ways are continually under development; thus studying up-to-date literature is invaluable in learning about state-of-the-science approaches to treating cancer. A reported 30% of cancer patients worldwide use complementary and alternative medicine (Mackay et al., 2006). PDQ summaries on complementary and alternative medicine are available; these summaries contain background information about the treatments, a brief history of their development, information about their proposed mechanism(s) of action, and information about relevant laboratory, animal, and clinical studies (NCI, 2011e). In addition to summaries written for health-care professionals, summaries available for patients use language appropriate for laypeople and include glossary links to scientific terms (NCI, 2011e). Also instructive are reviews of medical and psychological concerns of cancer survivors following cancer treatment and barriers to care (Stewart & Kleihues, 2003). Information on coping with cancer concerns and resources focused on living with and after cancer are also available (NCCN, 2011a; NCI, 2011c, 2011f). A resource featuring tools to help both clinicians and cancer patients prevent infections has recently been made available online by CDC (2011a).

Particularly in developed parts of the world (e.g., in northern and western Europe and the United States), advances in treatment modalities (such as improved forms of chemotherapy) have increased survival for many patients (Mackay et al., 2006). In many developing countries, however, patients’ ability to receive prompt treatment care is hampered by poor availability of treatments and delays in seeking cancer care, both of which contribute to lower survival rates (WHO, 2008). WHO (2008) described this challenge, observing:

[I]n many countries, particularly low-income countries, diagnostic and treatment services are not planned rationally. Treatment technologies and infrastructure are not linked to early detection strategies, and there is usually an excessive reliance on costly procedures that serve mainly the wealthy who can afford them. Consequently, a high proportion of patients having cancers that are curable if detected early are diagnosed in advanced stages, at which point a small number receive costly, but ineffective and incomplete treatment. In such settings, the same resources would be better employed, and would benefit a greater number of patients, if they were to be used to fund low-cost palliative care. The development of good quality diagnostic and treatment services to address curable cancers is therefore imperative, especially in the great majority of low-income countries. This would help to save lives, avoid unnecessary suffering and make more efficient use of limited resources. (p. 6)

Even in developed nations, problems in accessing treatment care can vary according to the patient’s geographic location, socioeconomic status, and age (Mackay et al., 2006). ACS (2011e) recently observed that there is increasing emphasis worldwide on the development of specialized cancer centers that apply evidence-based multimodal therapies and provide rehabilitation and palliative care. WHO (2008) has emphasized the importance of guarding against neglecting early detection and palliative care in favor of treatment-oriented approaches, regardless of whether these treatment approaches are cost-effective or whether they improve patients’ quality of life. WHO (2008) further suggested that treatment guidelines should emphasize the importance of avoiding the offering of curative therapy when a cancer is incurable; in such situations, patients with incurable cancers should be offered palliative care instead.

Survivorship, Palliative Care, and End-of-Life Care

More people are surviving cancer and living longer because of advances in early detection, treatment, and supportive care options (Hewitt, Greenfield, & Stovall, 2006; Wingo et al., 2005). Cancer is often experienced as a chronic illness (ACS, 2011e; Foley & Gelband, 2001), and the patient may require specialized care for months and often years. Such specialized care may involve a range of professional services that extends beyond the discipline of oncology (Stewart & Kleihues, 2003). Some experts have noted that improvements in the development and delivery of symptom control throughout all stages of cancer and in other aspects of palliative care needed in the late stages of cancer have not kept pace with the medical advances that have allowed people to live longer (Foley & Gelband, 2001; WHO, 2004). At the same time, the growing body of literature addressing survivorship, palliative care, and end-of-life care attests to the fact that these topics are viewed by many as subjects equal in importance to more cure-oriented topics.

Allied healthcare professionals, such as nurses, physician assistants, physical and occupational therapists, and dieticians, can benefit from developing a working knowledge of survivorship, palliative care, and end-of-life care issues, all of which are pertinent to understanding the patients’ and families’ experience of cancer. Knowledge in these three areas can inform healthcare providers’ clinical practice, helping to improve their ability to deliver high-quality care to patients. Because allied healthcare professionals working in both inpatient and outpatient settings routinely spend many hours each day in service to cancer patients, these skilled healthcare providers often have invaluable and in-depth knowledge of the everyday problems and needs of cancer patients and their families. Armed with up-to-date knowledge about the issues that patients and families face, healthcare professionals can add meaningful information to the patients’ care plans and improve care for patients.

A brief overview of three broad topics—survivorship, palliative care, and end-of-life care—is presented here, along with definitions of selected terms and short descriptions of some key issues. National and international reports, position papers, and guidelines, cited throughout the chapter, can provide detailed discussions of the topics for the reader needing more information.

Survivorship

The risk of developing cancer in one’s lifetime is more than one in three; as a result, each of us is likely to experience cancer or know someone who has survived cancer (Hewitt et al., 2006). In the United States, men have slightly less than a one in two lifetime risk of developing cancer; for women, the corresponding risk is a little more than one in three (ACS, 2012). Nearly 12 million people in the United States (based on statistics from January 2008) are living with a history of cancer (ACS, 2012; Reuben, 2006), with this number representing a tripling of the number of survivors since 1971 (Hewitt et al., 2006). Cancer survivors constitute 3.5% of the U.S. population (Travis, Rabkin, & Brown, 2006), and 68% of cancer survivors (diagnosed between 1999 and 2006) are expected to live at least 5 years after diagnosis (ACS, 2011b). From an international perspective, more than 25 million people throughout the world are cancer survivors, and their number grows daily (NCI, 2006). Although most people eventually die from their cancer, treatment advances are allowing many patients with cancer to live much longer than ever before, with periods of adaptation to cancer as a chronic disease (Foley & Gelband, 2001; WHO, 2004).

Among healthcare providers, patients, families, and the general public, the topic of cancer survivorship is of great interest (Ferrell & Coyle, 2010; Kolata, 2004; NCI, 2011a; Riddle & Boeshaar, 2006). However, the terms “cancer survivor” and cancer “survivorship” have different meanings to different people (Reuben, 2006), and the means by which to refer to this growing population has stirred some controversy (Hewitt et al., 2006). Also, some different views continue regarding who is considered to be a survivor. For the purpose of this discussion, the survivor definition supported by CDC, NCI, and the National Coalition for Cancer Survivorship is used: An individual is considered a cancer survivor from the time of diagnosis through the balance of his or her life; family members, friends, and caregivers are also affected by the survivorship experience and, therefore, are included in this definition (CDC, 2011b; NCI, 2011d). Survivorship care has been described as a distinct phase of care for cancer survivors that includes four components: (1) prevention and detection of recurrent and new cancers and of late effects; (2) surveillance for cancer spread or recurrence, or second cancers; (3) intervention for consequences of cancer and its treatment; and (4) coordination between specialists and primary care providers to ensure that all of the survivor’s health needs are met (Hewitt et al,, 2006). The fourth component, involving development of a detailed plan of coordinated care created by a multidisciplinary team, can help ensure that the survivorship plan is as high quality as the earlier plan that guided the diagnosis and treatment phases of care.

Physical, psychosocial, employment-related, educational, financial, and legal issues may affect cancer survivors across the life span (Reuben, 2004). The diagnosis and treatment of cancer pose a threat to a person’s physical, psychological, social, spiritual, and economic well-being (CDC, 2011b). Using a public health approach, entitled “A National Action Plan for Cancer Survivorship,” a joint effort led by Livestrong (formerly the Lance Armstrong Foundation) and the CDC distinguished between living with cancer (referring to the experience of receiving a cancer diagnosis and treatment that may follow), living through cancer (referring to the extended stage following treatment), and living beyond cancer (referring to post-treatment and long-term survivorship (CDC, 2011b). Although these distinctions are meant to signify the experience of survivorship as a progression, the process is unique for each patient, and movement from one phase to the next may not be clearly delineated (CDC, 2011b), adding to the complexity of providing comprehensive care for cancer survivors.

Securing effective, long-term care is an important strategy for ensuring optimal living following a cancer diagnosis. There is growing agreement among healthcare providers and cancer patients and their families that the transition from active treatment to the post-treatment period is critical to the cancer patient’s long-term health (Hewitt et al., 2006). In addition, cancer survivors need lifelong care to (1) monitor for and treat late effects of cancer therapies, recurrences, and second cancers, and (2) address psychosocial, nutritional, rehabilitation, and other needs that may arise years after treatment ends (Reuben, 2006). Although the medical and psychological effects of cancer and its treatment have been recognized for many years, survivorship has only recently come to be recognized as a distinct phase of the cancer trajectory (Hewitt et al., 2006). Despite the heartening fact that nearly 12 million cancer survivors currently live in the United States (CDC, 2011b), being a survivor comes at a cost: Nearly 75% of people who survive cancer live long enough to develop significant sequelae, in the form of late-appearing or long-term side effects (Haylock, Mitchell, Cox, Temple, & Curtiss, 2007).

Various follow-up care guidelines (e.g., covering screening, evaluation, psychosocial services) to assist healthcare providers in delivering care to survivors have been proposed as a result of advances in knowledge of how to manage conditions that arise in this patient group. In addition, as people with cancer live longer as a result of improved access to effective screening, diagnosis, and treatments (making cancer a chronic condition in many cases), another issue that has begun to generate an increased amount of attention is how to produce and use comprehensive guidelines that adequately address the possible long-term and late effects of a particular cancer diagnosis and treatment (Hewitt et al., 2006). Although no specific care guidelines are widely accepted and followed in many clinical settings, the President’s Cancer Panel (Reuben, 2006) urges the acceleration of efforts to develop and disseminate survivorship follow-up clinical guidelines that are based on the best available evidence (including best practices and expert opinions) until the evidence base is further developed through targeted outcomes and related research. Improving access to care and insurance coverage for healthcare services needed by survivors is another important survivor issue drawing increased attention (Reuben, 2004).

Readers wanting detailed information about the process for creating guidelines for survivorship care are referred to the in-depth discussion by Haylock and colleagues (2007) regarding their work in progress called “Prescription for Living”; an included template provides clinicians with a concise guide to treatment and follow-up care planning while also offering survivors a guide for planning healthful lifestyles. NCI (2011c) provides detailed, online information regarding follow-up care after cancer therapy, including links to guidelines and care plans created by national organizations. An important theme repeated throughout the current survivorship literature is that the care of survivors encompasses the entire cancer control continuum, from prevention, detection, diagnosis, and treatment, through what some refer to as a survivorship phase, with end-of-life care completing the continuum (Pollack et al., 2005).

Palliative Care

In the last 50 years, there have been amazing advances in the treatment and early detection of a few types of cancer and at least modest gains in many other cancer diagnoses. However, some have observed that in our society’s aggressive pursuit of cures for cancer, symptom control and comfort care have been neglected. Recent literature suggests that acute care settings generally focus primarily on curative treatments and are less well equipped to provide palliative care (Hewitt et al., 2006; Wingo et al., 2005). At the same time, the growing recognition of the importance of symptom control and other aspects of palliative care, from diagnosis through the dying process, has been documented (Foley & Gelband, 2001; Hewitt et al., 2006; Patrizi, Thompson, & Spector, 2011). The notion that “patients should not have to choose between treatment with curative intent or comfort care” is still very relevant, more than a decade after palliative care leaders offered that thought (Foley & Gelband, 2001, p. 9). Further, “[t]here is a need for both [treatment with curative intent and comfort care], in varying degrees, throughout the course of cancer, whether the eventual outcome is long-term survival or death” (Foley & Gelband, 2001, p. 9). WHO (2004) has engaged in an in-depth discussion of why palliative care for older people is a public health priority.

Multiple definitions of palliative care highlight the complexity inherent in this term. A National Action Plan for Cancer Survivorship: Advancing Public Health Strategies, jointly produced by CDC, Livestrong, and other partners, defined palliative care, in accordance with the NCI, as follows: “Care given to improve the quality of life of patients who have a serious or life-threatening disease. Also called comfort care, supportive care, and symptom management” (CDC, 2004, p. 65; 2010). Palliative care is also defined as “treatment of symptoms associated with the effects of cancer and its treatment” (Hewitt et al., 2006, p. 481). WHO (2011a) has defined palliative care in cancer as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” Palliative care may begin at the time of a cancer diagnosis and increase in amount and intensity, as needed, throughout the course of a patient’s illness until death (Foley & Gelband, 2001). Comprehensive care should proceed concurrently with anticancer treatment, whether with curative or palliative intent (Stewart & Kleihues, 2003). Treating symptoms is of the utmost importance, as symptoms can influence not only quality of life but also the course of disease (WHO, 2002).

From a global perspective, WHO (2011b) has observed that palliative care measures can relieve physical psychosocial, and spiritual problems in almost all (i.e., more than 90%) patients with advanced cancer. WHO also asserts that global improvements in palliative care do not depend so much upon the creation of specialized palliative care services separate from mainstream health care but rather “upon the permeation of the whole health care system by the principles of palliative care” (Stewart & Kleihues, 2003, p. 299). In addition, because palliative care can be provided relatively simply and inexpensively, such services should be made available in every country (Stewart & Kleihues, 2003).

In its recommendations to member governments, WHO has stated that any national cancer control program should address the needs of its citizens for palliative care. Within such a program, six major skill sets are part of complete palliative care: (1) communication, (2) decision making, (3) management of complications of treatment and the disease, (4) symptom control, (5) psychosocial care of patient and family, and (6) care of the dying (Foley & Gelband, 2001). Some of these skills—such as communication, decision making, and psychosocial care of patient and family—are important throughout the trajectory of illness, whereas other skills emerge and recede in importance at different times. Physical symptoms of cancer can be both acute and chronic, can occur at various times throughout the disease trajectory, and may include pain, fatigue, nausea, hair loss, and others, depending on the cancer site and the types of treatments being used (CDC, 2004). WHO has outlined three specific issues that should be addressed in the context of palliative care for any patient: (1) relief of major symptoms in all stages of disease, especially cancer-related pain relief; (2) comprehensive care of patients who are close to death; and (3) support for the family during the course of the illness and after the patient’s death (cited in Stewart & Kleihues, 2003).

The “pain of surviving cancer”—pain that may be caused by a variety of reasons—is one of the most challenging aspects of achieving quality palliative care for the patient coping with cancer (Kaplan, 2011). Considerable evidence in the healthcare literature indicates that inadequate treatment of pain continues to be a frequent problem, both in countries with few resources and as in technologically advanced countries with adequate resources (ACS, 2011c, 2011e; American Pain Society [APS], 2008; Hill, 1990; Max, 1990; Stewart & Kleihues, 2003; WHO, 2002). WHO (2002) has long asserted that freedom from cancer pain must be regarded as a human rights issue, and unrelieved pain in cancer patients is unacceptable because it is generally avoidable with proper treatment. Paice and Ferrell (2011) summarized current, published U.S. statistics on cancer-related pain, indicating that the prevalence of cancer pain is estimated at 25% for patients newly diagnosed, 33% for patients undergoing active treatment, and greater than 75% for cancer patients with advanced disease. The needed analgesics to relieve most cancer-related pain have been available for decades, and 85% of cancer patients could obtain satisfactory relief using only simple, inexpensive, “low-technology” oral analgesics (Andima, Gulati, & Cubert, 2009; Grossman & Nesbit, 2004; Sloan & Gelband, 2007), with the remaining 15% of patients achieving satisfactory relief using more sophisticated pain control measures (Andima et al., 2009; Cleeland, 1990; Grossman & Nesbit, 2004).

New healthcare professionals who expect to have contact with patients dealing with cancer pain can better appreciate the numerous clinical challenges and issues that are faced by patients and care providers by reviewing current cancer pain publications (e.g., APS, 2008; NCCN, 2011b; Paice & Ferrell, 2011; Sloan & Gelband, 2007). Covered therein are topics such as principles of cancer pain management, techniques related to pain assessment and simple tools to use in communicating with patients regarding pain levels, barriers to cancer pain relief, pharmacologic and nonpharmacologic treatments used for cancer pain, and considerations for special populations. It has been suggested that the implementation of a well-developed, organizational policy approach to managing patients’ pain could be instrumental in changing clinical practice patterns and building institutional commitment to improving pain management (Alley, 2001; Gordon, Dahl, & Stevenson, 2000; Pasero, Gordon, McCaffery, & Ferrell, 1999). Consistent with this deliberate organizational commitment, optimal management of pain requires adequate infrastructure (e.g., sufficient personnel, facilities, drugs) and effective methodology (e.g., modes of drug delivery; dose adjustment by the patient) (Stewart & Kleihues, 2003). Neither a formal, effective organizational commitment to pain relief nor the necessary infrastructure is routinely in place in many healthcare settings.

From a global perspective, quality-of-life outcomes such as adequate pain relief and freedom from nausea are universally accepted as valuable (NCI, 2006), although these outcomes are often not fully achieved. Conceptually, quality of life encompasses not only the physical aspects of well-being but also the cognitive, spiritual, emotional, and social aspects of life; further, it is important to note that a “good” quality of life as viewed by a cancer patient in central Africa may be very different from that defined by a cancer patient in the suburbs of an American city (NCI, 2006). For the interested reader, the topic of pain as a public health challenge is discussed in Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research (Committee on Advancing Pain Research, Care, and Education, IOM, 2011).

End-of-Life Care

A key aspect of palliative care for dying patients is end-of-life care. At the end of life, only a few people (i.e., less than 10%) die suddenly and unexpectedly (Emanuel, Ferris, von Gunten, & Von Roenn, 2010). Most people die after a long period of illness, with gradual deterioration until an active dying phase at the end (Coyle, 2010; Field & Cassel, 1997). Thus providing end-of-life care is an important responsibility for health professionals caring for patients at this stage of life; for such providers, there is an established and growing body of knowledge to guide this care (Ellershaw & Ward, 2003; Ferris, von Gunten, & Emanuel, 2003; Twycross & Lichter, 1998).

End-of-life care is defined as “care provided during the period of time in which an individual copes with declining health from an ultimately terminal illness” (Hewitt et al., 2006, p. 478). The goal of end-of-life care is to achieve the best possible quality of life for cancer patients by controlling pain and other symptoms and addressing psychological and spiritual needs (CDC, 2011b). The previously mentioned, public health–focused National Action Plan for Cancer Survivorship stated that “end-of-life care affirms life and regards dying as a normal process, neither hastening nor postponing death while providing relief from distress and integrating psychological and spiritual aspects of survivor care” (CDC, 2004, p. 4; 2010).

End-of-life care as a healthcare issue continues to grow in prominence, with both patients and health-care professionals advocating for improvements (American Medical Association [AMA], 1996; Holland & Chertkov, 2001; Patrizi et al., 2004; WHO, 2004). From a public health perspective, end of life has three characteristics (also present in other public health priorities): high burden, major impact, and a potential for preventing suffering associated with illness (Rao, Anderson, & Smith, 2002). Unfortunately, most clinicians have received little or no formal training in managing the dying process or death, and families usually have even less experience and knowledge in these areas (Emanuel et al., 2010). Although principles of end-of-life care are well discussed in the literature, it appears that established standards of care are not universally followed, especially in institutional settings, where an estimated 85% of Americans die (Rummans, Bostwick, and Clark, 2000). In a study by Coyle (2010), 70% of Americans said they would prefer to die at home, but only 25% die at home and half die in hospitals. In many European countries, despite the preference of many people to be cared for and die at home, death in the hospital remains common (WHO, 2004). Writing from a highly positive perspective, Patrizi, Thompson, and Spector (2011) provided updates on work being done in the United States to establish and promote national palliative care standards and quality measures. In institutions whose cultures are not focused on end-of-life care, however, challenges remain relative to ensuring good end-of-life care and a comfortable death (Ferris, Hallward, Ronan, & Billings, 1998; WHO, 2004).

People with cancer suffer from a variety of symptoms at all stages of disease and cancer treatment, though symptoms are often more frequent and severe in advanced stages (Foley & Gelband, 2001; WHO, 2004). A WHO paper (2004) addressing palliative care for aging populations reported that a growing body of evidence indicates that older people, in particular, suffer unnecessarily because of widespread under-assessment and undertreatment of problems at the end of life. There is support for the idea that much suffering could be alleviated if available symptom control measures were used more widely (ACS, 2011e; Foley & Gelband, 2001; WHO, 2004). Some authors writing in the public health realm have observed that it is unclear as to whether the trend toward aggressive care in acute care hospitals is occurring in response to patient care preferences or to the culture of acute care hospitals (Wingo et al., 2005). In either case, allied health professionals can benefit from being aware of barriers in the healthcare and medical research systems that can stand in the way of the delivery of effective palliative care and end-of-life care. These barriers, along with conclusions and recommendations to address them, have been outlined by palliative care experts (Ferrell & Coyle, 2010; Foley & Gelband, 2001). The American College of Surgeons, Commission on Cancer’s (CoC) “Cancer Program Standards (CPS) 2011 Project” resulted in publication of standards in 2012; their goal is to ensure that key elements of quality cancer care are provided to all people with cancer treated in a CoC-accredited facility. The CoC standards address patient care needs throughout the diagnosis and treatment process, including psychosocial support, care for cancer-related pain, palliative care, and hospice care (Commission on Cancer, 2011).

Interface Between Palliative Care and Hospice Care

In the United States, some healthcare experts have described the institutionalization of a healthcare system that focuses on either active therapy or palliative or hospice care and does not allow for the appropriate interface between these two approaches (Foley & Gelband, 2001; Holland & Chertkov, 2001; Lynn & O’Mara, 2001; Payne, 2001). Coyle (2010) has stated that hospice may best be described as “a program through which palliative care is intensified as an individual moves closer to death” (p. 5). Hospice care is widely considered to be the most substantial innovation to serve the dying, although many end-of-life patients do not receive hospice care, even in technologically advanced countries (Center for Bioethics, 2005; Coyle, 2010; Foley & Gelband, 2001).

The term hospice has at least three somewhat different uses that can be confusing and misleading (Field & Cassel, 1997). First, a hospice may be a discrete site of care in the form of an inpatient hospital or nursing home unit or a freestanding facility. Second, a hospice may be an organization or program that provides, arranges, and advises on a wide range of medical and supportive services for dying patients and their families and friends, with care based in the patient’s home. The third and most culturally sweeping meaning of hospice refers to an approach to caring for dying patients that is based on clinical, social, and spiritual principles (Field & Cassel, 1997). To gain a better understanding of issues related to evaluating the adequacy of end-of-life care, the reader is directed to the detailed IOM report entitled Approaching Death (Field & Cassel, 1997), which offers a blueprint for change at the global level in end-of-life care practices (Stewart & Kleihues, 2003).

Compilations of Cancer Information With Additional Features

High-quality cancer-related reports, guidelines, books, journal articles, and online resources have been cited throughout this chapter. Some resources provide, in addition to the typical narrative format, additional helpful features. Two examples are The Cancer Atlas (Mackay et al., 2006) and The Tobacco Atlas (Shafey et al., 2009). The Cancer Atlas(2006), which is jointly produced by ACS, CDC, and Union for International Cancer Control (UICC), uses graphic and colorful atlas map formats for making visual points relative to each two-page topic. The atlas also provides a detailed timeline on the history of cancer starting 70–80 million years ago up to the present; tables of risk factors for cancers in various countries; extensive statistics on cancer, indexed by country; information on sources used in the figures, tables, and graphs; and a listing of useful contacts at WHO headquarters and regional offices, WHO cancer programs, and key cancer organizations, indexed by specific countries (Mackay et al., 2006). The latest (third) edition of the groundbreaking report entitled The Tobacco Atlas, which is produced in a collaborative effort by the ACS, the International Tobacco Control Research Program, Georgia State University, and the World Lung Foundation, gives shape and meaning to statistics about tobacco use and control, using a novel, user-friendly format. The atlas uses full-color maps and graphics to illustrate a wide range of tobacco issues, revealing similarities and differences between countries and exposing behavior of tobacco companies (Shafey et al., 2009). The small volume addresses in a detailed manner topics such as types of tobacco use; prevalence of tobacco use among various populations (including health professionals!) and smoking health risks; the costs of tobacco; and an overview of the tobacco trade and the promotion of tobacco. The atlas also details numerous activities under way to curtail, ban, or otherwise limit tobacco usage and availability. The fourth edition of The Tobacco Atlas was released in March 2012 at the 15th World Conference on Tobacco or Health in Singapore (ACS, 2012).

CONCLUSIONS

“Cancer is a major public health problem in the United States and many other parts of the world” (Siegel, Naishadham, & Jemal, 2012, p. 10). In this chapter, the reader has been introduced to a public health perspective on key cancer and cancer patient care issues, both within the United States and in other countries in the world. The goal of this chapter has been to provide allied healthcare professionals with an introductory overview of selected cancer-related topics. Also discussed in this chapter were common challenges experienced as well as varied challenges faced by developed and developing countries of the world as they work to decrease cancer-related morbidity and mortality. Although predicted increases in the number of new cases of cancer are mostly due to a steadily increasing proportion of elderly people in the world, the rate of increase will be even greater if current levels of smoking and the high prevalence of unhealthy lifestyles persist (Mackay et al., 2006).

The content discussed in this chapter includes background information that can be helpful to health-care providers and public health professionals who provide patient services and/or conduct research with an eye toward improving some aspect of cancer care. Regardless of future advances in high-technology medicine, any major reduction in deaths and disability from cancer will come from efforts directed toward cancer prevention, not from cancer cures (Mackay et al., 2006). One of the primary goals of this chapter has been to raise awareness of the importance of cancer prevention activities and to promote cancer prevention efforts among new healthcare providers, with a major focus placed on patient and professional education. If successful, such cancer prevention efforts could result in 2 million lives per year being saved by 2020, and 6.5 million lives per year by 2040 (Mackay et al., 2006). Cancer care considerations briefly outlined in the chapter—specifically, cancer treatment and palliative, end-of-life, and survivorship care—are all important in considering how best to provide high-quality patient care.

ACKNOWLEDGMENTS

Appreciation is expressed to Temeika Fairley, PhD, Division of Cancer Prevention and Control, CDC, for her contributions to the “Prevention” and “Early Detection, Screening, and Education” sections of this chapter.

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

STUDY QUESTIONS

1. What are some reasons for the disparity of cancer incidence, treatments, and survivorship among vulnerable populations worldwide?

2. Compare and contrast global methods of pain control and palliative care.

3. Discuss examples of economic and political restrictions for cancer care worldwide.

4. Using a social justice lens or framework, how do you think cancer treatments could be more equalized worldwide?

CASE STUDY

A population-based case-control interview study of 309 childhood leukemia cases and 618 healthy population control children was conducted in urban Shanghai, China. Excess risks for both acute lymphocytic leukemia (ALL) and acute non-lymphocytic leukemia (ANLL) were associated with intrauterine and paternal preconception diagnostic X-ray exposure, and with maternal employment in the chemical and agricultural industries during pregnancy. ANLL was linked to maternal occupational exposure to benzene during pregnancy, whereas both ALL and ANLL were significantly associated with maternal exposure to gasoline and the patient’s prior use of chloramphenicol. Excess risks included ANLL among children whose mothers were employed in metal refining and processing and ALL associated with maternal occupational exposure to pesticides.

Reference

Ou Shu, X., Gao, Y., Tu, J., Zheng, Y., Brinton, L., Linet, M., & Fraumeni, J. (2006).

Case Study Questions

1. What do you think could be done to decrease the rate of ALL to Chinese children in Shanghai? What policies would be needed?

2. Do you think that the Chinese government would want to make policy changes? What would be reasons for changes and what would be reasons not to make changes?

REFERENCES

Alley, L. G. (2001). The influence of an organizational pain management policy on nurses’ pain management practices. Oncology Nursing Forum, 28, 867–874.

Alley, L. G., Chen, V. W., Wike, J. M., Schymura, M. J., Rycroft, R. K., Shen, T., . . . Fulton, J. P. (2007). CDC-NPCR’s breast, colon, and prostate cancer data quality and patterns of care study: Overview and methodology. Journal of Registry Management, 34(4), 148–157.

Alley, L. G., Wike, J. M., Chen, V. W., Kahn, A. R., Roshala, W., Fulton, J., . . . Snodgrass, J. (2008). Challenges and lessons learned in examining patterns of cancer care in National Program of Cancer Registries (NPCR) states. Journal of Registry Management, 35(1), 27–33.

American Cancer Society (ACS). (2006). The worldwide cancer burden report. Atlanta, GA: Author.

American Cancer Society (ACS). (2009). Cancer facts & figures for African Americans 2011–2012. Atlanta, GA: Author.

American Cancer Society (ACS). (2011a). ACS guidelines on nutrition and physical activity for cancer prevention. Retrieved from http://www.cancer.org/Healthy/EatHealthyGetActive/ACSGuidelinesonNutritionPhysicalActivityforCancerPrevention/index

American Cancer Society (ACS). (2011b). Cancer facts & figures 2011. Atlanta, GA: Author.

American Cancer Society (ACS). (2011c). Cancer facts & figures for Hispanics/Latinos 2009–2011. Atlanta, GA: Author.

American Cancer Society (ACS). (2011d). Cancer prevention & early detection facts & figures 2011. Atlanta, GA: Author.

American Cancer Society (ACS). (2011e). Global cancer facts & figures (2nd ed.). Atlanta, GA: Author.

American Cancer Society (ACS). (2012). Cancer facts & figures 2012. Atlanta, GA: Author.

American Cancer Society (ACS) & Livestrong. (2010). The global economic cost of cancer. Atlanta: ACS.

American Medical Association (AMA). (1996). Good care of the dying. Journal of the American Medical Association, 275, 474–478.

American Pain Society (APS). (2008). Principles of analgesic use in the treatment of acute pain and cancer pain (6th ed.). Glenview, IL: Author.

Andima, L., Gulati, A., & Cubert, K. (2009). Interventional pain management in the patient with cancer (pp. 437–516). In M. D. Stubblefield & M. O’Dell (Eds.), Cancer rehabilitation: Principles and practice. New York, NY: Demos Medical.

Beasley, D. (2011). American men with cancer more likely to die than women. Reuters. Retrieved from http://www.reuters.com/article/2011/07/12/us-cancer-genderidUSTRE76B4W220110712

Black, B. L., Cowens-Alvarado, R., Gershman, S., & Weir, H. K. (2005). Using data to motivate action: The need for high quality, an effective presentation, and an action context for decision-making. Cancer Causes and Control, 16(suppl 1), 15–25.

Brawley, O. (2011). Avoidable cancer deaths globally. CA: A Cancer Journal for Clinicians, 61(2), 67–68.

Brown, M. L., & Yabroff, K. R. (2006). Economic impact of cancer in the United States. In D. Schottenfeld & J. F. Fraumeni (Eds.), Cancer epidemiology and prevention (3rd ed., pp. 202–216). Oxford, UK: Oxford University Press.

Center for Bioethics. (2005). End of life care: An ethical overview. University of Minnesota’s Center for Bioethics. Retrieved from www.ahc.umn.edu/img/assets/26104/End_of_Life.pdf

Centers for Disease Control and Prevention (CDC). (2004). A national action plan for cancer survivorship: Advancing public health strategies. Atlanta, GA: CDC & Lance Armstrong Foundation.

Centers for Disease Control and Prevention (CDC). (2005). Behavioral risk factor surveillance system operational and user’s guide. Version 3.0. Atlanta, GA: Author.

Centers for Disease Control and Prevention (CDC). (2010). The national action plan for cancer survivor-ship. Retrieved from http://www.cdc.gov/cancer/survivorship

Centers for Disease Control and Prevention (CDC). (2011a). About the Preventing Infections in Cancer Patients program. Retrieved from http://www.cdc.gov/cancer/preventinfections/about.htm?source=govdelivery

Centers for Disease Control and Prevention (CDC). (2011b). Cancer survivorship. Retrieved from http://cdc.gov/cancer/survivorship

Centers for Disease Control and Prevention (CDC). (2011c). National Comprehensive Cancer Control Program (NCCCP). Retrieved from http://www.cdc.gov/cancer/ncccp

Centers for Disease Control and Prevention (CDC). (2011d). National Program of Cancer Registries (NPCR). Retrieved from http://www.cdc.gov/cancer/npcr

Centers for Disease Control and Prevention (CDC). (2011e). United States cancer statistics. Retrieved from http://www.cdc.gov/cancer/dcpc/data

Cleeland, C. S. (1990). Pain assessment. Advances in Pain Research and Therapy, 13, 287–291.

Clive, R. E. (2004). Introduction to cancer registries. In C. L. Hutchinson, H. R. Menck, M. Burch, & R. Gottschalk. (Eds.), Cancer registry management principles and practice (2nd ed., pp. 31–49). Alexandria, VA: National Cancer Registrars Association.

Colditz, G. A., Samplin-Salgado, M., Ryan, C. T., Dart, H., Fisher, L., Tokuda, A., & Rockhill, B. (2002). Harvard report on cancer prevention: Vol. 5, Fulfilling the potential for cancer prevention: Policy approaches. Cancer Causes & Control, 13, 199–212.

Commission on Cancer (CoC). (2011). Cancer program standards 2012: Ensuring patient-centered care, v. 1.0. Chicago, IL: American College of Surgeons. Retrieved from www.facs.org/cancer/coc/cocprogram standards2012.pdf

Committee on Advancing Pain Research, Care, and Education, Institute of Medicine. (2011). Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, DC: National Academies Press.

Cook, M. B., McGlynn, K. A., Devesa, S. S., Freedman, N. D., & Anderson, W. F. (2011). Sex disparities in cancer mortality and survival. Cancer Epidemiology, Biomarkers, and Prevention, 20, 629.

Coyle, N. (2010). Introduction to palliative nursing care. In B. R. Ferrell & N. Coyle (Eds.), Oxford textbook of palliative nursing(3rd ed., p. 3). New York: Oxford University Press.

Curry, S. J., Byers, T., & Hewitt, M. (Eds.). (2003). Fulfilling the potential of cancer prevention and control. Washington, DC: National Academies Press.

Devesa, S. S., Grauman, D. J., Blot, W. J., Pennello, G. A., & Hoover, R. N. (1999). Atlas of cancer mortality in the United States, 1950–1994. Bethesda, MD: National Cancer Institute.

Economist Intelligence Unit. (2009). Breakaway: The global burden of cancer—challenges and opportunities. Commissioned by Livestrong.

Ellershaw, J., & Ward, C. (2003). Care of the dying patient. British Medical Journal, 326, 30–34.

Emanuel, L., Ferris, F. D., von Gunten, C. F., & Von Roenn, J. H. (2010). The last hours of living: Practical advice for clinicians. Retrieved from http://www.medscape.org/viewarticle/716874

Ferlay, J., Shin, H. R., Bray, F., Forman, D., Mathers, C., & Parkin, D. M. (2010). GLOBOCAN 2008 v1.2: Cancer incidence and mortality worldwide. IARC CancerBase No. 10. Lyon, France: International Agency for Research on Cancer. Retrieved from http://globocan.iarc.fr

Ferrell, B. R., & Coyle, N. (2010). Oxford textbook of palliative nursing (3rd ed.). New York: Oxford University Press.

Ferris, T. G., Hallward, J. A., Ronan, L., & Billings, J. A. (1998). When the patient dies: A survey of medical housestaff about care after death. Journal of Palliative Medicine, 1, 231–239.

Ferris, F. D., von Gunten, C. F., & Emanuel, L. L. (2003). Competency in end of life care: The last hours of living. Journal of Palliative Medicine, 6, 605–613.

Field, M. J., & Cassel, C. K. (Eds.). (1997). Approaching death: Improving care at the end of life. Washington, DC: National Academy Press.

Foley, K. M., & Gelband, H. (Eds.). (2001). Improving palliative care for cancer: Report by the Institute of Medicine and National Research Council. Washington, DC: National Academy Press.

Gordon, D. B., Dahl, J. L., & Stevenson, K. K. (2000). Building an institutional commitment to pain management (2nd ed.). Madison, WI: University of Wisconsin–Madison, UW Board of Regents.

Grossman, S. A., & Nesbit, S. (2004). Symptom management and palliative care. In M. D. Abeloff, J. O. Armitage, J. E. Niederhuber, M. B. Kastan, & W. G. McKenna (Eds.), Clinical oncology (pp. 180–185). Philadelphia: Elsevier.

Gullatte, M. M., Phillips, J. M., & Gibson, L. M. (2006). Factors associated with delays in screening of self-detected breast changes in African-American women. Journal of the National Black Nurses Association, 17, 45–50.

Haylock, P. J., Mitchell, S. A., Cox, T., Temple, S. V., & Curtiss, C. P. (2007). The cancer survivor’s prescription for living. American Journal of Nursing, 107(4), 58–70.

Hewitt, M., Greenfield, S., & Stovall, E. (Eds.). (2006). From cancer patient to cancer survivor: Lost in transition. Washington, DC: National Academies Press.

Hill, C. S. (1990). Relationship among cultural, educational, and regulatory agency influences on optimum cancer pain treatment. Journal of Pain and Symptom Management, 5, S37–S45.

Howe, H. L., Keller, J. E., & Lehnherr, M. (1993). Relation between population density and cancer incidence, Illinois, 1986–1990. American Journal of Epidemiology, 138, 29–36.

Holland, J. C., & Chertkov, L. (2001). Clinical practice guidelines for the management of psychosocial and physical symptoms of cancer. In K. M. Foley & H. Gelband (Eds.), Improving palliative care for cancer: Report by the Institute of Medicine and National Research Council(pp. 7–60). Washington, DC: National Academy Press.

Hutchison, C. L., Menck, H. R., Burch, M., & Gottschalk, R. (Eds.). (2004). Cancer registry management: Principles and practice (2nd ed.). Dubuque, IA: Kendall/Hunt.

Intlekofer, R., & Michaud, F. (2007). The National Program of Cancer Registries. In H. R. Menck, L. Deapen, J. L. Phillips, & T. Tucker (Eds.), Central cancer registries: Design, management and use (2nd ed., pp. 357–369). Dubuque, IA: Kendall/Hunt.

Kaplan, B. W. (2011, May/June). The pain of surviving cancer: Coping with the lasting effects of chemo-therapy treatment. Oncology Nurse Advisor, 30, 32.

Kolata, G. (2004, June 1). New approach about cancer and survival. New York Times, pp. A1, A14.

Lynn, J., & O’Mara, A. (2001). Reliable, high-quality, efficient end-of-life care for cancer patients: Economic issues and barriers. In K. M. Foley & H. Gelband (Eds.), Improving palliative care for cancer: Report by the Institute of Medicine and National Research Council(pp. 65–95). Washington, DC: National Academy Press.

Mackay, J., Jemal, A., Lee, N. C., & Parkin, D. M. (2006). The cancer atlas. Atlanta, GA: American Cancer Society.

Max, M. B. (1990). Improving outcomes of analgesic treatment: Is education enough? Annals of Internal Medicine, 113, 885–889.

Menck, H. R. (2004). Cancer registries in other countries. In C. L. Hutchinson, H. R. Menck, M. Burch, & R. Gottschalk (Eds.), Cancer registry management principles and practice(2nd ed., pp. 403–439). Alexandria, VA: National Cancer Registrars Association.

Menck, H. R., & Bolick-Aldrich, S. (2007). Glossary of terms and concepts. In H. R. Menck, L. Deapen, J. L. Phillips, & T. Tucker (Eds), Central cancer registries: Design, management and use (2nd ed., pp. 421–439). Dubuque, IA: Kendall/Hunt.

Menck, H. R., Deapen, D., Phillips, J. L., & Tucker, T. (Eds.). (2007). Central cancer registries: Design, management and use (2nd ed.). Dubuque, IA: Kendall/Hunt.

Miller, S. E., Hager, P., Lopez, K., Salinas, J., & Shepherd, W. L. (2009). The past, present, and future of Comprehensive Cancer Control from the state and tribal perspective. Preventing Chronic Disease, 6(4), A112, Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2774626

National Cancer Institute (NCI). (2006). NCI international portfolio: Addressing the global challenge of cancer (Publication No. 06-6650). Bethesda, MD: Author.

National Cancer institute (NCI). (2011a) Cancer survivorship research. Retrieved from http://cancercontrol.cancer.gov/ocs/office-survivorship.html

National Cancer Institute (NCI). (2011b). Fact sheets: Cancer therapy. Retrieved from http://www.cancer.gov/cancertopics/factsheet/Therapy

National Cancer Institute (NCI). (2011c). Follow-up care after cancer treatment. Retrieved from http://www.cancer.gov/cancertopics/factsheet/Therapy/followup

National Cancer Institute (NCI). (2011d). Overview of the SEER program. Retrieved from http://seer.cancer.gov

National Cancer Institute (NCI). (2011e). PDQ (Physician Data Query) comprehensive cancer database. Retrieved from http://www.cancer.gov/cancertopics/pdq/cancerdatabase

National Cancer Institute (NCI). (2011f). Survivorship: Living with and beyond cancer. Retrieved from http://www.cancer.gov/cancertopics/coping/survivorship

National Comprehensive Cancer Network (NCCN). (2011a). Living with cancer. Retrieved from http://www.nccn.com/living-with-cancer.html

National Comprehensive Cancer Network (NCCN). (2011b). National Comprehensive Cancer Network (NCCN) clinical practice guidelines in oncology. Retrieved from http://www.nccn.org

Ou Shu, X., Gao, Y., Tu, J., Zheng, Y., Brinton, L., Linet, M., & Fraumeni, J. (2006). A population-based case-control study of childhood leukemia in Shanghai. Cancer, 62(3), 635–644.

Paice, J. A. & Ferrell, B. (2011). The management of cancer pain. CA: A Cancer Journal for Clinicians, 61, 157–182. (Originally published May 4, 2011, at http://caonline.amcancersoc.org/cgi/content/full/61/3/157)

Parkin, D. M. (2006). The evolution of the population-based cancer registry. Nature Reviews Cancer, 6, 603–612.

Pasero, C., Gordon, D. B., McCaffery, M., & Ferrell, B. R. (1999). Building an institutional commitment to improving pain management. In M. McCaffery & C. Pasero (Eds.), Pain: Clinical manual (2nd ed., pp. 711–744). St. Louis: Mosby.

Patrizi, P., Thompson, E., & Spector, A. (2011). Robert Wood Johnson Foundation (RWJF) retrospective series: Improving care at the end of life. Princeton, NJ: Robert Wood Johnson Foundation.

Payne, R. (2001). Palliative care for African Americans and other vulnerable populations: Access and quality issues. In K. M. Foley & H. Gelband (Eds.), Improving palliative care for cancer: Report by the Institute of Medicine and National Research Council,(pp. 153–160). Washington, DC: National Academy Press.

Pollack, L. A., Greer, G. E., Rowland, J. H., Miller, A., Doneski, D., Coughlin, S. S., . . . Ulman D. (2005). Cancer survivorship: A new challenge in comprehensive cancer control. Cancer Causes & Control, 16(suppl 1), 51–59.

Rao, J. K., Anderson, L. A., & Smith, S. M. (2002). End of life is a public health issue. American Journal of Preventive Medicine, 23, 215–220.

Renick, O. (2011). Global rise in cancer cost $300 billion in 2010, Harvard economist says. Retrieved from http://www.bloomberg.com/news/2011-06-20/global-rise-in-cancer-cost-300-billion-in-2010-harvard-economist-says.html

Reuben, S. H. (2004). Living beyond cancer: Finding a new balance. President’s Cancer Panel, 2003–2004 annual report. Bethesda, MD: National Cancer Institute.

Reuben, S. H. (2006). Assessing progress, advancing change. President’s Cancer Panel, 2005–2006 annual report. Bethesda, MD: National Cancer Institute.

Riddle, B. L., & Boeshaar, D. K. (2006). Event driven data set for cancer surveillance. Journal of Registry Management, 33, 57–62.

Rummans, T. A., Bostwick, J. M., & Clark, M. M. (2000). Maintaining quality of life at the end of life. Mayo Clinic Proceedings, 75, 1305–1315.

Shafey, O, Eriksen, M., Ross, H, & Mackay, J. (2009). The tobacco atlas (3rd ed.). Atlanta, GA: American Cancer Society.

Siegel, R., Naishadham, D., & Jemal, A. (2012). Cancer statistics, 2012. CA: A Journal for Clinicians, 62(1), 10–29.

Sloan, F. A., & Gelband, H. (2007). Cancer control opportunities in low- and middle-income countries. Washington, DC: National Academies Press.

Stewart, B. W., & Kleihues, P. (2003). World cancer report. Lyon, France: IARC Press.

Travis, L. B., Rabkin, C. S., & Brown, L. M. (2006). Cancer survivorship—genetic susceptibility and second primary cancers: Research strategies and recommendations. Journal of the National Cancer Institute, 98, 15–25.

Twycross, R., & Lichter, I. (1998). The terminal phase. In D. Doyle, G. W. C. Hanks, & N. MacDonald (Eds.), Oxford textbook of palliative medicine (2nd ed., pp. 977–992). Oxford, England: Oxford University Press.

United States Cancer Statistics Working Group (USCSWG). (2006). United States cancer statistics 2003 incidence and mortality. Atlanta, GA: Centers for Disease Control and Prevention & National Cancer Institute.

Wingo, P. A., Howe, H. L., Thun, M. J., Ballard-Barbash, R., Ward, E., Brown, M. L., . . . Edwards, B. K. (2005). A national framework for cancer surveillance in the United States. Cancer Causes and Control, 16, 151–170.

World Cancer Research Fund International. (2011). Top five most common cancers worldwide. Retrieved from http://www.wcrf.org/cancer_facts/5-most-common-cancers.php

World Health Organization (WHO). (2002). National cancer control programmes: Policies and managerial guidelines (2nd ed.). Geneva, Switzerland: Author.

World Health Organization (WHO). (2004). Better palliative care for older people. Edited by E. Davies & I. J. Higginson. Copenhagen, Denmark: Author.

World Health Organization (WHO). (2006a). Cancer control: Knowledge into action. WHO guide for effective programmes. Geneva, Switzerland: Author.

World Health Organization (WHO). (2006b). Non-communicable diseases: Cancer. Retrieved from http://www.emro.who.int/ncd/cancer.htm

World Health Organization (WHO). (2008). Cancer control: Knowledge into action: WHO guide for effective programmes. Module 4: Diagnosis and treatment. Geneva, Switzerland: Author.

World Health Organization (WHO). (2011a). WHO definition of palliative care. Retrieved from http://www.who.int/cancer/palliative/definition/en/

World Health Organization (WHO). (2011b). Cancer, fact sheet no. 297. Retrieved from http://www.who.int/mediacentre/factsheets/fs297/en

For a full suite of assignments and additional learning activities, use the access code located in the front of your book to visit this exclusive website:http://go.jblearning.com/holtz. If you do not have an access code, you can obtain one at the site.

Appendix A cancer Prevention

REDUCING TOBACCO USE AND EXPOSURE TO SECONDHAND SMOKE

Cigarette smoking and other forms of tobacco, which are collectively the largest single contributor to cancer mortality, are responsible for a large and growing global public health burden (Sloan & Gelband, 2007). Tobacco consumed in any form, but particularly when smoked, is carcinogenic (Viswanath, Herbst, Land, Leischow, Shields, Writing Committee for the AACR Task Force on Tobacco and Cancer, 2010). Tobacco is the only consumer product proven to kill half of its regular users as well as nonsmoking bystanders and is responsible for approximately 6 million deaths worldwide every year (Shafey, Eriksen, Ross, & Mackay, 2009; Warren, Asma, Lee, Lea, & Mackay, 2009). Almost three-fourths of these tobacco-related deaths occur in middle- and low-income countries (Shafey et al., 2009). As of 2004, the U.S. Surgeon-General had identified 10 cancers (lung/bronchial, pharyngeal, laryngeal, esophageal, stomach, pancreatic, kidney/renal, urinary bladder, cervical, and myeloid leukemia) for which “the evidence is sufficient to infer a causal relationship” between tobacco use and disease onset (U.S. Department of Health and Human Services [USDHHS], 2004). Building on decades of studies dating back to the 1950s, researchers have now identified the specific mechanisms by which tobacco causes disease (USDHHS, 2010).

By the year 2030, tobacco use is expected to become the leading cause of death and disability, if current trends persist. Thus, not surprisingly, the biggest single impact on cancer worldwide could be made solely by reducing tobacco use (Mackay, Jemal, Lee, & Parkin, 2006). Substantial health benefits accrue to smokers who quit, with the cessation of tobacco use reducing the risk of many cancers over time (ACS, 2011b). Passive smoking, also known as exposure to secondhand smoke or environmental tobacco smoke, causes a variety of adverse health effects in nonsmokers, and the growing evidence about the health risks related to passive smoking has led to a ban on smoking in public areas in many countries (USDHHS, 2010; WHO, 2009). In addition to public smoking bans, education/awareness activities and policy changes are being implemented worldwide, with their goal being to decrease tobacco use and thereby protect non-smokers from passive smoking (Sloan & Gelband, 2007; WHO, 2009).

The WHO’s Framework Convention on Tobacco Control (FCTC), which was developed in response to the globalization of the tobacco epidemic, is the first treaty negotiated by the member states of WHO (WHO, 2003a). It is also the world’s first internationally binding, global health treaty designed to reduce noncommunicable diseases (Mackay et al., 2006; WHO, 2003a, 2006a). This treaty was put into effect in 2003 in response to the global tobacco pandemic, with the objective of substantially reducing the worldwide prevalence of tobacco use and exposure to tobacco smoke (ACS, 2011d). The FCTC includes provisions for both reduction of the demand for tobacco and reduction of the supply of tobacco, along with the evidence of the impact of the key interventions. The key provisions of the framework are related to the following issues (WHO, 2009, 2011g):

■ Advertising, sponsorship, and promotion of tobacco products

■ Packaging and labeling of tobacco products

■ Protection from exposure to tobacco smoke

■ Illicit trade in tobacco products

From a global health perspective, the most important step toward decreasing the burden of cancer relative to tobacco is ratification of the FCTC. As of October 2010, most eligible countries (168 out of 195) had ratified the treaty (ACS, 2011d; FCTC Convention Secretariat, 2009). In response to the FCTC, the U.S. Congress passed the Family Smoking Prevention & Tobacco Control Act of 2009, which imposes strict regulation of the tobacco industry and aims to prevent smoking among youth (Carvajal, Clissold, & Shapiro, 2009). In accordance with the FCTC, the CDC’s Office on Smoking and Health developed the Global Tobacco Surveillance System (GTSS) to assess smoking prevalence and evaluate tobacco control initiatives across the world (CDC, 2011c). Experts believe that interventions to reduce tobacco use will have much broader benefits beyond the reduction of tobacco-related cancers, resulting in significant decreases in other illnesses as well, such as cardiovascular and respiratory diseases (Sloan & Gelband, 2007). The Global Tobacco Surveillance System Atlas (Warren et al., 2009) provides an overview of trends in prevalence, consumption, attitudes, and actions related to tobacco use in various parts of the world.

MAINTAINING OPTIMAL NUTRITION, PHYSICAL ACTIVITY, AND BODY WEIGHT

Nutrition, physical activity, and body weight have been linked to almost one-third of all cancer deaths (Kushi et al., 2006), with a substantial proportion of these deaths occurring in low- and middle-income countries (Sloan & Gelband, 2007). Diet, activity levels, and body weight are interrelated, and research suggests that these three factors act in complex ways to either promote or reduce the risk of cancer (Sloan & Gelband, 2007; World Cancer Research Fund [WCRF] & American Institute for Cancer Research [AICR], 2007). “For the great majority of Americans who do not use tobacco, the most important modifiable determinants of cancer risk are weight control, dietary choices, and levels of physical activity” (Kushi et al., 2012, p. 30). Worldwide, studies have suggested that the state of nutrition and extent of physical activity, along with level of alcohol consumption, may be the most important modifiable causes of cancer or cancer risk (Mackay et al., 2006).

Regarding nutrition, research to date has uncovered few definite or causal relationships between diet and cancer risk (WHO, 2011b). However, poor diet has been linked to some cancers, with the most consistent evidence connecting increased consumption of fruits and vegetables with a lower risk of developing cancers of the colon and rectum, lung, stomach, esophagus, mouth, and pharynx (Curry, Byers, & Hewitt, 2003; Sloan & Gelband, 2007; WCRF & AICR, 2007). There is also limited evidence of probable risk reduction for cancers of the larynx, pancreas, breast, and bladder (WCRF & AICR, 2007). Correspondingly, excess consumption of red and processed meat and preserved fish has been associated with an increased risk of colorectal and nasopharyngeal cancers, respectively (WCRF & AICR, 2007).

As with many other cancer risk factors, it is important that health interventions related to diet be implemented throughout a person’s life. For example, breastfeeding—a central component of most mainstream public health nutrition policy—has been shown to protect nursing mothers against breast cancer at all ages (WCRF & AICR, 2007). Exclusive breastfeeding for the first 6 months after a child’s birth is a recommended strategy in the United Nations’ document Strategy for Infant and Young Child Feeding Recommendations (WHO & United Nations Children’s Fund, 2003). It is important to note that implementation of this recommendation worldwide may be influenced by a variety of factors, such as the rising prevalence of HIV (Dop, 2002) as well as famine and/or diminishing availability of food sources. Countries affected by these two issues may need to consider alternative mechanisms for reducing cancer.

Alcohol consumption is one of the most important known risk factors for human cancers and, next to smoking, one of the largest modifiable risk factors (WHO, 2011c). Despite being a known carcinogen and dietary source of energy, alcohol is rarely discussed as a dietary risk factor for cancer (International Agency for Research on Cancer [IARC], 2011; USDHHS, 2011). Alcohol consumption is believed to increase risk of cancers of the oral cavity, pharynx, larynx, esophagus, liver, colon/rectum, and breast (Boffetta et al., 2006), with the risk varying by cancer site and increasing for all sites with greater alcohol consumption (ACS, 2011d; Baan, Straif, Grosse, Secretan, & El Ghissassi, 2007; Boffetta et al., 2006; Rehm et al., 2009; Sloan & Gelband, 2007; WCRF & AICR, 2007). The interested reader can access the literature to learn about similarities between the problems of excessive alcohol use and tobacco use, along with potentially powerful strategies to reduce individual consumption and provide public education about the harmful effects of these substances on health (Global Health Information System on Tobacco and Health, 2011, WHO, 2003a, 2011c, 2011h).

Physical activity is closely associated with nutrition and body weight factors, as it protects against overweight, weight gain, and obesity. Physical activity also protects against cancers for which the risk is increased by being overweight or having poor nutrition. Engaging in regular physical activity allows the body to function more efficiently; it complements healthy dietary practices in this sense. Urbanization, mechanization, and industrialization have significantly contributed to an increasingly sedentary lifestyle around the world. Although a sedentary lifestyle has been a public health problem in developed nations for many years, developing nations are also now experiencing this phenomenon. Given the known benefits of regular sustained physical activity, shifts in whole populations from being active to sedentary may be the most ominous public health phenomena in recent history (WCRF & AICR, 2007).

Physical activity is defined as any body movement that works a person’s muscles and uses more energy than a person uses when resting (National Heart, Lung, and Blood Institute [NHLBI], 2011). Regular, sustained physical activity appears to be protective, or may be protective, against cancers of the colon, breast (postmenopausal), and, endometrial cancers (WCRF & AICR, 2007). Research investigating a possible relationship between physical activity and cancer has focused largely on cancer of the colon, endometrium, testes, prostate, lung, pancreas, and breast. Notably, numerous studies have demonstrated an association between physical activity and colon, breast (postmenopausal), and endometrial cancers (Lund Nilsen & Vatten, 2002; Matthews et al., 2005; McTiernan et al., 2003; WCRF & AICR, 2007). There is limited evidence from prospective studies suggesting an association between physical activity and premenopausal breast cancer, lung, pancreatic, rectal, or prostate cancer (Howard, Leitzmann, Linet, & Freedman, 2009; WCRF & AICR, 2007; Yang, Berstein, & Wu, 2003).

Body weight, the third factor discussed here, is closely associated with the nutrition and physical activity factors. Excess body weight—by being either overweight or obese—is a global public health crisis affecting all age groups, races, and ethnicities, and both sexes. Obesity and overweight are distinguished from each other, as follows: Obesity is defined as having a body mass index (BMI) greater than or equal to 30.0, whereas being overweight is defined as having a BMI of 25.0 to 29.9. BMI is calculated as weight in kilograms divided by height in meters squared (kg/m2) (Garrow & Webster, 1985). Obesity is caused primarily by a combination of a sedentary lifestyle that lacks physical activity and excessive consumption of high-calorie, high-fat, and low-nutrient foods. Overweight and obesity both increase the risk of colorectal, breast (postmenopausal), endometrial, kidney, pancreas, and gallbladder cancers (WCRF & AICR, 2007). Excess body fat has also been linked to esophageal, ovarian, and gallbladder cancers (ACS, 2011c; NCI, 2004; WCRF & AICR, 2007; Wolin & Colditz, 2008).

Once considered a problem only in high-income countries, rates of overweight and obesity are now dramatically on the rise in low- and middle-income countries, particularly in urban settings (WHO, 2011d). The availability of adequate and even excess food sources coupled with reduced physical activity has led to epidemics of overweight and obesity in developed nations. As food resources have become more available in middle- and low-resource countries, the issues of obesity and overweight have emerged as major global public health concerns. Social, economic, and nutritional transitions experienced by these countries have led to changes in the health of their people. The nutritional transition, characterized by a shift from “traditional” diets that are low in fat and high in fiber to high-energy ‘Western “diets, which are high in fat and low in fiber (WCRF & AICR, 2007), has contributed substantially to the global epidemic of obesity and overweight. The full impact of this transition may not be fully understood for years; however, many of the nations now experiencing it are already reporting increases in chronic diseases related to obesity and overweight. Global recognition of these changes and their impact on resources needed to combat disease in middle- and low-resource countries has, in part, led to the development of resolutions and new plans and strategies by the United Nations and WHO to address issues of noncommunicable diseases such as cancer (United Nations, 2011; WHO, 2008).

Addressing the global obesity crisis will be essential to controlling the pandemic of chronic disease, which includes cancer. This pandemic must be addressed at every stage of life, primarily by modifying eating habits and regularly engaging in physical activity. Although diet and physical activity are clearly documented as very important determinants of cancer, interventions that are known to have a substantial effect on diet and exercise habits are not well established in high-income countries (Sloan & Gelband, 2007). The WHO report entitled Global Strategy on Diet, Physical Activity, and Health makes a series of recommendations related to establishing stronger evidence for policy, advocating for policy changes, fostering stakeholder involvement, and developing a strategic framework tailored for specific countries (Sloan & Gelband, 2007; WHO, 2004). From a global perspective, highly consistent evidence indicates that excessive calorie intake relative to an individual’s level of physical activity increases the risk of many cancers—this is the second most important avoidable cause of cancer mortality in many countries, after cigarette smoking (Willett, 2006). Given that many of the cancers linked to obesity have also been linked to diet or physical activity, it is difficult to clearly determine whether improved cancer outcomes are due solely to diet, obesity, physical activity, or a combination of these factors. For a thorough discussion of the interrelatedness of these risk factors and effects impacts on cancer, the reader is referred to the WCRF and AICR (2007) report titled Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective and the overview of “The ACS Guidelines on Nutrition and Physical Activity for Cancer Prevention” (Kushi et al., 2012).

MINIMIZING EXPOSURE TO INFECTIOUS DISEASE AGENTS

Worldwide, infectious agents, such as the hepatitis B and C viruses (liver cancer), human papillomaviruses (cervical and anogenital cancers), and Helicobacter pylori (stomach cancers), are linked to approximately 15% to 20% of cancers (ACS, 2011d; De Flora & Bonanni, 2011). In developing countries, infections can account for as many as one in five (20%) of all cancers. In 2008, two of the four leading cancers in men (stomach and liver) and women (cervix and stomach) in developing countries were related to infection (ACS, 2011d). In contrast, in the United States and other developed countries, less than 10% of all cancers are thought to be linked to infectious agents (ACS, 2011d). Preventive measures for these infections include known interventions such as vaccination, antibiotics, improved sanitation, or education (ACS, 2011d; WHO, 2011b).

H. pyloriinfection

Over the past two decades, epidemiological studies have established a strong causal relationship between H. pylori infection and gastric cancer (Cheung, Xia, & Wong, 2007; NCI, 2011d). Approximately two-thirds of the world’s population is infected with this bacterium, with infection rates being much higher in developing countries than in developed nations (CDC, 2011d; NCI, 2011d). More than 50% of all new stomach cancer cases can be attributed to H. pylori infection (Parkin, 2006).

H. pylori colonizes the stomach lining and causes chronic inflammation of and damage to the gastric mucosa, with the resulting infection placing an individual at three to six times greater risk for developing gastric cancer (Bornschein, Kandulski, Selgrad, & Malfertheiner, 2010; Sepulveda & Graham, 2003; Stewart & Kleihues, 2003). The exact mode of transmission for this infection is unclear but is thought to follow a fecal–oral or oral–oral transmission route. Improvement in hygienic conditions and treatment with antibiotics have been used to prevent or reduce infection. In developing countries and those with high rates of stomach cancer, calls for the eradication of this bacterial infection from the human stomach using antibiotics have been tempered by a concern about possible development of antibiotic resistance in H. pylori (ACS, 2011d; Suzuki, Iwasaki, & Hibi, 2009). It is important to note that while H. pylori infection is very common, most people who are colonized with these bacteria will never develop cancer (WHO, 2011b).

HPV Infection and Cervical Cancer

Persistent infections due to human papillomavirus (HPV), a common sexually transmitted virus, lead to all types of cervical cancers as well as 90% of cancers of the anus and external genitalia; to a lesser extent, HPV also causes cancers of the mouth and oropharynx and possibly also respiratory cancers (Chaturvedi, 2010; Kreimer, Clifford, Boyle, & Franceschi, 2005; Parkin & Bray, 2006; Walboomers et al., 1999). While all cases of cervical cancer are caused by oncogenic strains of HPV, 90% of women infected with HPV will clear their infections with no intervention. HPV persists in the remaining 10%, who make up the population at risk of cervical cancer (Bosch & Munoz, 2002; NCI, 2011c; Sloan & Gelband, 2007).

Based on the nearly absolute causal link between oncogenic HPV and cervical cancer, two new approaches for cervical cancer prevention have emerged: (1) primary prevention via HPV vaccination to prevent HPV infection and (2) secondary prevention via carcinogenic HPV detection for identifying and treating women with cervical precancerous lesions and early-stage cancers (Scarinci et al., 2010). Vaccines developed to prevent infection with the most prevalent oncogenic strains of HPV, types 16 and 18 (associated with 70% of cervical cancers), have shown complete efficacy in preventing persistent infection by both HPV types (Sloan & Gelband, 2007). In addition, one of the vaccines developed by Merck was also designed to protect against HPV types 6 and 11, the most common agents of genital warts (Joura, Leodolter, Hernandez-Avila, Wheeler, & Perez, 2007; Sloan & Gilband, 2007).

Cervical cancer incidence rates have historically been low in developed nations; however, several countries have experienced increases in cervical cancer incidence among younger women (ACS, 2011d). These increases were likely due in part to increases in HPV infection rates among adolescent girls. The higher rates of disease in this group have prompted many developed nations to aggressively implement HPV vaccination programs for this population. Developing nations have implemented such vaccination programs on a much smaller scale, however, because the HPV vaccine is very expensive and is not yet widely accepted (ACS, 2011d; Sankaranarayanan, 2009).

Hepatitis B and C and Liver Cancer

Chronic infection with either hepatitis B virus (HBV) or hepatitis C virus (HCV) increases the risk of liver cancer 20-fold or more (ACS, 2011d; Chuang et al., 1992; IARC, 1994; Mackay et al., 2006). Together these two infections are responsible for more than 85% of the liver cancer in the world (Mackay et al., 2006). In developing countries, 58% of liver cancers are attributable to HBV and 33% are attributable to HCV; in contrast, only 23% (HBV) and 20% (HCV) of liver cancers in developed countries are attributable to these viruses (Parkin, 2006). Globally, 350 million people have chronic (lifelong) HBV infections and are at high risk of death from liver cirrhosis and hepatocellular carcinoma; these liver conditions kill more than 1 million people each year (WHO, 2008). While inexpensive HBV vaccines have been available for 20 years, they are still not being used in areas with some of the highest liver cancer rates (CDC, 2008; Sloan & Gelband, 2007). Increasing the worldwide coverage and usage of the HBV vaccine has the potential to save lives both now and in the future and to build cancer control capacity in geographic areas where it is currently limited (CDC, 2009; Chang et al., 2009; Sloan & Gelband, 2007).

Liver cancer incidence is increasing in developed countries, which have historically had low rates of disease, likely due to increases in HCV infection or possibly obesity (El-Serag, 2007). Hepatitis C virus infection is the most common chronic, blood-borne infection in the United States; approximately 3.2 million persons are chronically infected with this pathogen (CDC, 2011e). There is currently no vaccine available to prevent hepatitis C transmission. In 2001, CDC implemented the National Hepatitis C Prevention Strategy (NHCPS) to lower the incidence of acute HCV in the United States and reduce the disease burden from chronic HCV infection (CDC, 2001). The proposed strategy includes a combination of education of healthcare providers and members of the public, counseling and testing of at-risk persons, community outreach prevention activities, and surveillance and monitoring. Copies of the strategy can be downloaded from the CDC website (CDC, 2001).

Other infection-related risk factors for liver cancer have been identified and are of particularly high interest in developing countries. These include parasitic infections (schistosomiasis and liver flukes), viruses (Epstein-Barr virus, human immunodeficiency virus [HIV], human T-cell lymphotrophic virus type 1, and human herpesvirus-8), and fungal infections (e.g., aflatoxin B) (ACS, 2011d; Liao, 2006). Epstein-Barr, HIV, and human herpesvirus-8 are each responsible for approximately 100,000 new cancer cases each year, while schistosomes, human T-cell lymphotrophic virus type 1, and liver flukes are infectious organisms that less frequently cause cancer (Mackay et al., 2006).

Positive changes in lifestyle factors have the potential to reduce a large proportion of the world’s cancer burden (Curry et al., 2003). Although specific research methods and results of analyses related to cancer prevention and early detection activities vary, the studies are all remarkably consistent in pointing to the potential benefits of reducing tobacco use, improving nutrition, increasing physical activity, maintaining a healthy body weight, keeping alcohol consumption at low to moderate levels, and getting screened regularly for cancer (Curry et al., 2003). For health professional-oriented summaries of current data on prevention for particular disease sites, the reader is referred to NCI’s Physician Data Query (PDQ) Comprehensive Cancer Database series of detailed summaries (NCI, 2011e). All of the PDQ prevention summaries are also available in patient versions, written in easy-to-understand, nontechnical language.

Appendix B Early Detection, Screening, and Education

GENERAL PRINCIPLES GOVERNING INTRODUCTION OF EARLY CANCER DETECTION PROGRAMS

The implementation of early cancer detection programs requires considerable resources. Thus it is important that national cancer control programs avoid imposing the “high technology” of the developed world on countries that lack the infrastructure and resources to use such technology appropriately or to achieve adequate coverage of their populations (WHO, 2011f). For these reasons, population-level screening programs should be undertaken as a component of early detection only in the following circumstances (WHO, 2003d, 2011g):

1. Effectiveness of the screening programs has been demonstrated.

2. Resources (e.g., personnel, equipment) are sufficient to cover a majority of the target group.

3. An effective treatment is available.

4. Facilities exist for confirming diagnoses and for treatment and follow-up of those persons with abnormal results.

5. The target disease is a common form of cancer, with high associated morbidity or mortality.

6. Testing procedures are acceptable, safe, and relatively inexpensive.

SCREENING

Some cancers can be detected before they cause symptoms. The process of checking for cancer in people who have no symptoms is called screening (Curry, Byers, & Hewitt, 2003; NCI, 2011g; Zapka, 2003). Appropriately implemented screening can help doctors find and treat certain cancers earlier and, in many cases, improve cancer outcomes. Population-level cancer screening is generally recommended only for cancers for which there is sufficient evidence that the screening test used reduces morbidity and mortality in the population being screened. To this end, population-level cancer screening is recommended only for breast, cervical, and/or colorectal cancer (NCI, 2011b, 2011g; WHO, 2011f).

Most developed and medium-resource countries have programs and/or national policies for cervical cancer screening (cytology tests) and breast cancer screening (mammography); few have programs and policies for colorectal cancer screening, specifically, the fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy (ACS, 2011d). For example, in 2009, CDC implemented the Colorectal Cancer Control Program (CRCCP), which provides funding to 25 states and 4 tribes across the United States with the goal of increasing colorectal (colon) cancer screening rates among men and women aged 50 years and older (CDC, 2011a). This program was implemented only after considerable research and sufficient demonstration that population-level screening for colon cancer was feasible and effective (CDC, 2011b). WHO recommends only cervical and breast cancer screening programs that require little technology for low-resource countries (WHO, 2011g); it does not recommend screening for colorectal cancer in resource-limited countries.

While screening methods are in use or being studied for specific cancers (e.g., lung, stomach, and prostate), the ability of the screening methods to reduce cancer mortality has not been established. Despite the lack of evidence to support full implementation of these screening methods at the population level, countries with high rates of these diseases sometimes still proceed with implementation. For example, since 1983, Japan has conducted nationwide screening for gastric cancer among all people 40 years of age and older (Hamashima et al., 2008). To learn more about the development and testing of these newer screening programs, visit the National Cancer Institute’s website: http://www.cancer.gov/cancertopics/screening/othercancers.

To be widely effective, education and screening should be accessible to all members of the population at risk. However, research indicates that members of minority ethnic groups, people living in deprived areas, and those with less education are often prevented from accessing services (von Wagner et al., 2009). Disparities in access to early detection resources contribute to differences in cancer burden. This lack of equity in terms of healthcare access is a challenge for people living in developed as well as developing countries. In the United States, issues of health disparities that plague the cancer community are, in part, associated with access to cancer screening and follow-up care. Programs such as the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), created in 1991 by the CDC, were implemented to help improve access to cancer screening for at-risk populations (CDC, 2011f). Lack of access to screening and care in developing countries is caused primarily by a lack of available resources for noncommunicable diseases and fragile health infrastructures (Sloan & Gelband, 2007). Thus considerable attention must be given to implementing cancer screening programs in developing nations.

Studies show that primary care physicians do not always comply with cancer screening guidelines (Meissner et al., 2011). One reason is that recommendations for cancer detection and screening are often fragmented, in the sense that they are developed by various medical organizations, which may make decision making more confusing regarding which recommendations to follow (Geiger & Ricciardi, 2009). Numerous national and international guidelines on cancer screening have been promulgated, including those proposed by the American College of Surgeons, American Academy of Family Physicians, U.S. Preventive Services Task Force (USPSTF), American Cancer Society, and various specialty-specific medical organizations, to name a few (Geiger & Ricciardi, 2009). Variations in recommendations developed by each organization are due to factors such as differences in interpretation of research findings (Meissner et al., 2011).

Screening for Breast Cancer

Breast cancer is the most common malignancy affecting women worldwide, with more than 1 million new cases and 400,000 deaths from this cause occurring annually (ACS, 2011d). Nearly half of these cancers occur in the developing world (ACS, 2011d; Curado et al., 2007). Worldwide, the incidence of breast cancer is increasing, with 1.7 million women predicted to be diagnosed with this disease in 2020, mostly in developing countries (“Breast Cancer in Developing Countries,” 2009). The “Westernization” of developing countries is often cited as the principal cause of this increase (Porter, 2008). This Westernization is often related to social factors such as smoking, alcohol, and obesity; also considered are hormonal risk factors such as early menarche, delayed parity, and reduced breastfeeding (Anyanwu, 2008; Porter, 2008). These factors, which are often observed in developing nations, have been related to the adoption of Western culture, diets, and lower exercise levels (Tfayli, Temraz, Abou Mrad, & Shamseddine, 2010).

Recent studies have described declines in breast cancer incidence in several developed nations. These changes have been attributed to factors such as the declining use of menopausal hormone replacement therapy and/or declines in mammography use in the age-eligible population (Banks & Canfell, 2010; Canfell, Banks, Moa, & Beral, 2008; Kumle, 2008; Ravdin et al., 2007). In North America, Western Europe, and Australia, breast cancer mortality rates have also started to decline (ACS, 2011d; IACR, 2011), likely due to improvements in early detection, treatment, and/or healthcare management (Jorgensen, Zahl, & Gotzsche, 2010).

It is important to note that debate has arisen regarding the relative contributions of screening and therapy to the decrease in mortality rates in developed countries. While this debate is ongoing, several large, observational studies in Europe have directly measured the effects of mammographic screening in large general populations, finding that most of the decrease in deaths from breast cancer is due to screening (Kopans, Smith, & Duffy, 2011). In terms of survival, rates vary but are generally higher than 70% in most developed countries. Five-year survival rates are nearly 60% in middle-income countries, but less than 40% in low-income countries (Coleman et al., 2008). These estimates generally reflect the availability of breast cancer early detection programs and access to high-quality treatment for women diagnosed with disease. The absence of these resources often results in a high proportion of women presenting with late-stage disease, and is exacerbated by the lack of adequate breast cancer diagnosis and treatment facilities (Coleman et al., 2008).

The public health impact of breast cancer has been acknowledged by members of the international community, many of which have implemented population-based mammography education and screening programs (Okonkwo, Draisma, derKinderen, Brown, & deKoning, 2008; WHO, 2011a). The United States, for example, implemented a national breast cancer screening program in the 1980s with the aim of reducing rates of breast cancer mortality (CDC, 2011f). Similar programs exist in other developed countries in North America and Europe, as well as in Japan and Australia (Okonkwo et al., 2008). In most developing countries (where breast cancer incidence rates are low and access to state-of-the-art treatment is limited), the number of deaths attributable to breast cancer is double the number in high-income countries (ACS, 2011d; Mathers, Lopez, & Murray, 2006).

Breast cancer is characterized by systemic dissemination; thus presentation of symptoms and diagnosis may not occur until the disease is advanced or metastatic. Screening tests for breast cancer include clinical breast examination and mammography (i.e., an X-ray examination of the breast) (NCI, 2011h). Mammography is the primary screening tool for early detection because it can detect a tumor before it is felt or causes symptoms. This screening tool is associated with a reduction of as much as 20% in breast cancer mortality in women at greatest risk for developing breast cancer (e.g., women aged 50–64 years) (NCI, 2011a; WHO, 2011a). Population-based screening for breast cancer occurs primarily through mammographic examination, at prescribed intervals, of all women within a specified age range (WHO, 2011a). Mammography screening is expensive, as it requires special machinery and well-trained staff to implement. Thus population-based screening programs should be undertaken only in countries with high rates of breast cancer and the infrastructure in place to provide services to eligible women (WHO, 2011a). Ideally, implementation of breast cancer screening programs should reduce the proportion of women who are diagnosed with late-stage cancer because screening should identify cancers before they progress to late stage.

Each country determines the specific age range and appropriate screening interval for its breast cancer screening program. At the minimum, programs worldwide screen all women 50 or more years of age every one to three years. Screening of women ages 40 to 49 is performed in several developed countries (e.g., United States, Australia, and Sweden). However, in 2009, the USPSTF issued new controversial guidelines regarding the appropriate screening of this population. Instead of recommending that women aged 40–49 be screened for breast cancer, the new recommendation suggested that “the decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harm” (USPSTF, 2009). Concerns that this recommendation would confuse physicians and women at risk for breast cancer prompted health officials to refrain from fully implementing these recommendations.

It is important to note that breast cancer risk is higher among women with a family history of breast or ovarian cancer (ACS, 2011c). Thus screening is initiated earlier and often in more frequent intervals for these women (ACS, 2011c). While not currently recommended at the population level, some women who are at higher risk for developing breast cancer (e.g., women of Ashkenazi Jewish descent) may also consider genetic testing to determine their risk for developing the disease. Genetic testing for breast cancer involves a blood test that looks for mutation within the BRCA1 and BRCA2 genes (breast cancer–associated tumor suppressor genes). These tests are usually reserved for women at high risk for breast cancer.

Screening for Cervical Cancer

Cervical cancer is the third most commonly diagnosed cancer and the fourth leading cause of cancer death in women worldwide (ACS, 2011a). The highest incidence rates occur in Central and South America, the Caribbean, sub-Saharan Africa, and Southern Asia (ACS, 2011a). In developing countries, cervical cancer is the leading cause of cancer death in women (Ferlay, Shin, Bray, Forman, Mathers, & Parkin, 2010). Nearly 90% of cervical cancer deaths occur in the developing part of the world, including Africa, Latin America, and Asia (ACS, 2011a). Although developing nations are reporting increasing cervical cancer rates, most developed countries have reported a decline in cervical cancer incidence and mortality in the last 30 years (ACS 2011d; WHO, 2011f). U.S. cervical cancer mortality rates declined steadily from 1975 to 2003 due to prevention and early detection due to screening with the Papanicolaou test (Pap test); since 2003, however, rates have remained stable (ACS, 2011b).

Estimates suggest as many as 80% of cervical cancer cases can be prevented through comprehensive screening programs (ACS, 2011c; Sankaranarayanan, 2009). When the disease is detected in the earliest stage, the five-year survival rate for cervical cancer is 91%; when it is detected late, the rate drops to 17% (Howlader et al., 2011). The prevention and early detection of cervical cancer is accomplished largely through timely screening using the Pap test, which identifies abnormal (cancerous or precancerous) cell changes in the cervix and is considered the gold standard. The importance of being screened regularly for cervical cancer cannot be underestimated, as survival declines rapidly when women are diagnosed in later stages (NCI, 2011b).

Many developed countries now have cervical cancer screening programs. However, the Pap test is not practical in all settings, as it requires a trained cytologist, laboratory facilities, and multiple clinical visits (WHO, 2011f). Thus, in low-resource countries, increased emphasis has been placed on increasing access to, and improvement of the quality of, screening programs for at-risk populations (ACS, 2011d). Fortunately, more cost-effective screening methods are gaining prominence in low-resource settings; these options include visual inspection using either acetic acid (VIA) or Lugol’s iodine (VILI) and DNA testing for HPV in cervical cell samples (Sherris et al., 2009). Current HPV tests may be cost prohibitive for developing nations; as a consequence, developed countries may consider implementation of these tests only as an adjunct to cytological screening (i.e., Pap test).

Screening for Colon and Rectal Cancers

Cancer of the colon and rectum is the third most common cancer in men and the second most common cancer in women worldwide (ACS, 2011d). Colon and rectal cancers are the fourth leading cause of cancer death in men and the third leading cause of cancer death in women (ACS, 2011d; Ferlay et al., 2010). Colon and rectal cancers are one of the few internal cancers that are amenable to early detection—more specifically, prevention by detection of preclinical lesions. Screening can prevent colorectal cancer and reduce the number of deaths due to disease by detecting and removing precancerous colorectal polyps (ACS, 2011c; Alberts et al., 2005). Although a small proportion of colorectal cancers occur among persons with a genetic or family history of the disease (ACS, 2011c), the primary objective of colorectal cancer screening is to detect the 90% of cases of colorectal cancer that occur sporadically, most often in patients older than the age of 50 (WHO, 2003b).

The approved screening tests for colorectal cancer are the fecal occult blood test (FOBT), flexible sigmoidoscopy, colonoscopy, and double-contrast barium enema. Colonoscopy, often considered the gold standard of screening methods, is expensive, requires a skilled examiner, is less convenient, and carries more risk for the patient (Winawer, 2007). FOBT is easy to perform and is considered the optimal screening strategy in terms of cost-effectiveness (Center, Jemal, Smith, & Ward, 2009).

Screening recommendations and guidelines for colorectal cancer vary by country, with most countries using an opportunistic approach to screening. Several nations have implemented national screening program (e.g., Japan, Germany, United States, and the Czech Republic) (CDC, 2011a; Parkin, Tappenden, Olsen, Patnick, & Sasieni, 2008). Other developing nations are conducting pilot studies to assess the feasibility of implementing colorectal cancer screening programs on a national level. Colorectal cancer screening is scarce in developing countries (ACS, 2011b) due to resource limitations.

Screening for Prostate Cancer

Prostate cancer is the second most commonly diagnosed cancer among males and the sixth leading cause of cancer mortality in men (ACS, 2011b; Ferlay et al., 2010). Prostate cancer generally develops slowly, and the risk for the disease increases with age (ACS, 2011c). Screening modalities for prostate cancer include digital rectal examination (DRE), the prostate-specific antigen (PSA) test, and transrectal ultrasound. While several developed nations use prostate cancer screening tests, it is not yet clear whether any of these screening modalities reduce the mortality from the disease.

Prostate cancer screening efficacy is currently under review by numerous organizations, and experts in major medical organizations disagree on the specifics of prostate cancer screening recommendations (National Guideline Clearinghouse [NGC], 2010). While screening tests are able to detect prostate cancer at an early stage, the lack of clarity as to whether earlier detection and treatment can lead to any change in the natural history and outcome of the disease (NCI, 2011f) continues to fuel the debate over screening for this disease. According to the USPSTF (2002), there is insufficient research evidence to recommend either using or abstaining from using PSA and DRE as prostate cancer screening modalities. The USPSTF concluded that the current evidence was insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years (USPSTF, 2008).

Early detection of prostate cancer often hinges on clinicians and patients jointly deciding to screen for disease. The American Urological Association (AUA) recommends screening for specific groups of men (AUA, 2009). The AUA, like the American Cancer Society, believes that deciding whether to be screened for prostate cancer is a personal decision that should be made by each patient after consulting with his physician and becoming informed about the advantages and disadvantages of early detection and treatment options (ACS, 2011c; AUA, 2009). Although multiple organizations in the United States and parts of Europe recommend prostate cancer screening for certain groups, the broader international cancer control community does not yet formally do so (WHO, 2011e).

PUBLIC AND HEALTHCARE PROFESSIONAL EDUCATION

The Institute of Medicine of the National Academies recommends that low-resource countries that cannot afford the infrastructure required for organized screening programs focus on increasing awareness of signs and symptoms of diagnosis in the general population, which can lead to earlier diagnosis and treatment (Sloan & Gelband, 2007). Increased education and awareness among physicians and allied healthcare workers in developing countries, in addition to increased availability of effective therapy, could have a major impact on cancer incidence, mortality, and survival (WHO, 2006b). Public health education campaigns teach people to recognize early signs of the disease and urge them to seek prompt medical attention. Health professionals, especially primary health workers who are at the forefront of the initial contact between possible cancer patients and the medical care system, should be trained to identify suspicious cases and refer them for rapid diagnosis (WHO, 2002). Professional education is essential to primary healthcare workers whose initial training may have exposed them only to advanced and often untreatable cancers. Further, it may be necessary to improve accessibility to trained healthcare workers who are competent in performing the necessary examinations (including female health workers for women) (WHO, 2002).

Cancer education programs can educate people to recognize the early signs and symptoms of cancer and emphasize the fact that cancer diagnosed early is more likely to be treatable and to respond to effective treatment. These efforts can also promote public awareness of early signs of certain cancers (e.g., those affecting the oral cavity, larynx, colon, rectum, skin, breast, cervix, urinary bladder, and prostate) as well as proper follow-up with healthcare providers if individuals experience unexplained symptoms (WHO, 2006b).

CONCLUSIONS

Early detection of cancer is part of a broad strategy that includes diagnosis, treatment of the condition detected, and follow-up. These components must work together to produce the desired outcomes (e.g., decreased mortality). Cancer screening or education programs in the absence of suitable treatment and follow-up will fail. When deciding whether to implement such programs, policy makers and cancer control planners should factor in the impact of the cancer burden in the population and the cost-effectiveness of such programs.

For interested readers, up-to-date health professional-oriented summaries containing current screening and detection information are available online from the NCI PDQ (Physician Data Query) Comprehensive Cancer Database for many cancer diagnoses (NCI, 2011e). These summaries contain current information related to screening and detection for particular disease sites, the levels of evidence for the statements included in the summaries and the significance of and evidence of benefit for the stated positions included in the summaries; supporting references to current literature are also offered. Many screening and detection summaries are also available in patient versions that are written in easy-to-understand, nontechnical language (NCI, 2011e).

The health infrastructure of each country also affects the implementation of screening and detection programs. Early detection of cancer undoubtedly contributes to increased disease burden. Thus more resources to support the health services infrastructure may be required to address the additional disease burden. Decisions to implement early screening and detection programs should be evidence based and take into account the public health importance of the specific cancer, characteristics of early-detection tests, efficacy and cost-effectiveness of early detection, personnel requirements, and the level of development of health services in a given setting.

REFERENCES

Alberts, D. S., Martínez, M. E., Hess, L. M., Einspahr, J. G., Green, S. B., Bhattacharyya, A. K., . . . Lance, P. (2005). Phase III trial of ursodeoxycholic acid to prevent colorectal adenoma recurrence. Journal of the National Cancer Institute, 97, 846–853.

American Cancer Society (ACS). (2011a). ACS guidelines on nutrition and physical activity for cancer prevention. Retrieved from http://www.cancer.org/Healthy/EatHealthyGetActive/ACSGuidelinesonNutritionPhysicalActivityforCancerPrevention/index

American Cancer Society (ACS). (2011b). Cancer facts & figures 2011. Atlanta, GA: Author.

American Cancer Society (ACS). (2011c). Cancer prevention & early detection facts & figures 2011. Atlanta, GA: Author.

American Cancer Society (ACS). (2011d). Global cancer facts & figures (2nd ed.). Atlanta, GA: Author.

American Urological Association (AUA). (2009). Prostate-specific antigen best practice statement: 2009 update. Linthicum, MD: American Urological Association Education and Research.

Anyanwu, S. N. C. (2008). Temporal trends in breast cancer presentation in the third world. Journal of Experimental and Clinical Cancer Research, 27(1), 17.

Baan, R, Straif, K, Grosse, Y, Secretan, B, & El Ghissassi, F, 2007). Carcinogenicity of alcoholic beverages. Lancet Oncology, 8(4), 292–293.

Banks, E., & Canfell, K. (2010). Recent declines in breast cancer incidence: Mounting evidence that reduced use of menopausal hormones is largely responsible. Breast Cancer Research, 12(1), 103.

Boffetta, P., Hashibe, M., La Vecchia, C., Zatonski, W., & Rehm, J. (2006). The burden of cancer attributable to alcohol drinking. International Journal of Cancer, 119(4), 884–887.

Bornschein, J., Kandulski, A., Selgrad, M., & Malfertheiner, P. (2010). From gastric inflammation to gastric cancer. Digestive Disease, 28(4–5), 609–614.

Bosch, F. X., & Munoz N. (2002). The viral etiology of cervical cancer. Virus Research, 89(2), 183–190.

Breast cancer in developing countries. (2009). Lancet, 374(9701), 1567–2131.

Canfell, K., Banks, E., Moa, A., & Beral, V. (2008). Decrease in breast cancer incidence following a rapid fall in use of hormone replacement therapy in Australia. Medical Journal of Australia, 188, 641–644.

Carvajal, R., Clissold, D., & Shapiro, J. (2009). The Family Smoking Prevention and Tobacco Control Act: An overview. Food and Drug Law Journal, 64(4), 717–732.

Center, M. M., Jemal, A., Smith, R. A., & Ward, E. (2009). Worldwide variations in colorectal cancer. CA: A Cancer Journal for Clinicians, 59(6), 366–378.

Centers for Disease Control and Prevention (CDC). (2001). National prevention strategy: A comprehensive strategy for the prevention and control of hepatitis C virus infection and its consequences. Retrieved from http://www.cdc.gov/hepatitis/HCV/Strategy/NatHepCPrevStrategy.htm

Centers for Disease Control and Prevention (CDC). (2008, November 21). Implementation of newborn Hepatitis B vaccination—worldwide, 2006. Morbidity and Mortality Weekly Report, 57(46), 1249–1252.

Centers for Disease Control and Prevention (CDC). (2009). Surveillance for acute viral hepatitis—United States, 2007. Surveillance summaries, May, 2009. Morbidity and Mortality Weekly Report, 58(SS-3), 1–27.

Centers for Disease Control and Prevention (CDC). (2011a). Colorectal cancer control program. Retrieved from http://www.cdc.gov/cancer/crccp/index.htm

Centers for Disease Control and Prevention (CDC). (2011b). Colorectal cancer screening demonstration program. Retrieved from http://www.cdc.gov/cancer/crccp/demonstration.htm

Centers for Disease Control and Prevention (CDC). (2011c). Global tobacco surveillance system. Retrieved from http://www.cdc.gov/tobacco/global/gtss/

Centers for Disease Control and Prevention (CDC). (2011d). Helicobacter pylori and peptic ulcer disease: The key to cure. Retrieved from http://www.cdc.gov/ulcer/keytocure.htm

Centers for Disease Control and Prevention (CDC). (2011e). Hepatitis C information for health professionals. Retrieved from http://www.cdc.gov/hepatitis/HCV/index.htm

Centers for Disease Control and Prevention (CDC). (2011f). National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Retrieved from http://cdc.gov/cancer/nbccedp/

Chang, M. H., You, S. L., Chen, C. J., Liu, C. J., Lee, C. M., Lin, S. M., . . . Chen, D. S. (2009, October 7). Decreased incidence of hepatocellular carcinoma in hepatitis B vaccines: A 20-year follow up study. Journal of the National Cancer Institute, 101(19), 1348–1355.

Chaturvedi, A. K. (2010). Beyond cervical cancer: Burden of other HPV-related cancers among men and women. Journal of Adolescent Health, 46(4 suppl), S20–S26.

Cheung, T. K., Xia, H. H., & Wong, B. C. (2007). Helicobacter pylori eradication for gastric cancer prevention. Journal of Gastroenterology, 42(suppl 17), 10–15.

Chuang, W. L., Chang, W. Y., Lu, S. N., Su, W. P., Lin, Z. Y., Chen, S. C., . . . Chen, C. J. (1992). The role of hepatitis B and C viruses in hepatocellular carcinoma in a hepatitis B endemic area: A case-control study. Cancer, 69, 2052–2054.

Coleman, M. P., Quaresma, M., Berrino, F., Lutz, J. M., De Angelis, R., Capocaccia, R., . . . Young J. L.; CONCORD Working Group. (2008). Cancer survival in five continents: A worldwide population-based study (CONCORD). Lancet Oncology, 9(8), 730–756.

Curado, M., Edwards, B., Shin, H., Storm, H., Ferlay, J., Heanue, M., & Boyle, P. (Eds.). (2007). Cancer incidence in five continents. IARC Scientific Publications No. 160. Lyon, France: IARC.

Curry, S. J., Byers, T., & Hewitt, M. (Eds.). (2003). Fulfilling the potential of cancer prevention and control. Washington, DC: National Academies Press.

De Flora, S., & Bonanni, P. (2011, June). The prevention of infection-associated cancers. Carcinogenesis, 32(6), 787–795.

Dop, M. C. (2002). Breastfeeding in Africa: Will positive trends be challenged by AIDS epidemic? Sante, 12, 64–72.

El-Serag, H. B. (2007, September). Epidemiology of hepatocellular carcinoma in USA. Hepatology Research, 37(suppl 2), S88–S94.

FCTC Convention Secretariat. (2009). 2009 summary report on global progress in implementation of the WHO Framework Convention on Tobacco Control. Retrieved from http://www.who.int/fctc/FCTC-2009-1-en.pdf

Ferlay, J., Shin, H. R., Bray, F., Forman, D., Mathers, C., & Parkin, D. M. (2010). GLOBOCAN 2008 v1.2: Cancer incidence and mortality worldwide: IARC CancerBase No. 10. Lyon, France: International Agency for Research on Cancer. Retrieved from http://globocan.iarc.fr

Garrow, J. S., & Webster, J. (1985). Quetlet’s index (W/H2) as a measure of fatness. International Journal of Obesity, 9, 147–153.

Geiger, T. M., & Ricciardi, R. (2009, November). Screening options and recommendations for colorectal cancer. Clinics in Colon and Rectal Surgery, 22(4), 209–217.

Hamashima, C., Shbuya, D., Yamazaki, H., Inoue, K., Fukao, A., Saito, H., & Sobu, T. (2008). The Japanese guidelines for gastric cancer screening. Japan Journal of Clinical Oncology, 38(4), 259–267.

Howard, R. A., Leitzmann, M. F., Linet, M. S., & Freedman, D. M. (2009). Physical activity and breast cancer risk among pre- and postmenopausal women in the U.S. Radiologic Technologists cohort. Cancer Causes Control, 20(3), 323–333.

Howlader, N., Noone, A. M., Krapcho, M., Neyman, N., Aminou, R., Waldron, W., . . . Edwards, B. K. (Eds.). (2011). SEER cancer statistics review, 1975–2008. Bethesda, MD: National Cancer Institute. Retrieved from http://seer.cancer.gov/csr/1975_2008/

International Agency for Research on Cancer (IARC). (1994). Hepatitis viruses: Monographs on the evaluation of carcinogenic risks to humans. IARC Scientific Publication No. 59. Lyon, France: IARC.

International Agency for Research on Cancer (IARC). (2011). Agents classified by the IARC Monographs, Volumes 1–100. Retrieved from http://monographs.iarc.fr/ENG/Classification/ClassificationsGroupOrder.pdf

Jorgensen, K. J., Zahl, P., & Gotzsche, P. C. (2010). Breast cancer mortality in organized mammography screening in Denmark: Comparative study. British Medical Journal, 340.

Joura, E. A., Leodolter, S., Hernandez-Avila, M., Wheeler, C. M., & Perez, G. (2007). Efficacy of a quad-rivalent prophylactic human papillomavirus (types 6, 11, 16, and 18) L1 virus-like-particle vaccine against high-grade vulval and vaginal lesions: A combined analysis of 3 randomised clinical trials. Lancet, 369, 1693–1702.

Kopans, D. B., Smith, R. A., Duffy, S. W. (2011). Mammographic screening and “overdiagnosis.” Radiology, 260, 616–620.

Kreimer, A. R., Clifford, G. M., Boyle, P., & Franceschi, S. (2005). Human papillomavirus types in head and neck squamous cell carcinomas worldwide: A systematic review. Cancer Epidemiology, Bio-markers, & Prevention, 14(2), 475–476.

Kumle, M. (2008). Declining breast cancer incidence and decreased HRT use. Lancet, 372, 608–610.

Kushi, L. H., Byers, T., Doyle, C., Bandera, E. V., McCullough, M., Gansler, T., . . . Thun, M. J. (2006), American Cancer Society guidelines on nutrition and physical activity for cancer prevention: Reducing the risk of cancer with healthy food choices and physical activity. CA: A Cancer Journal for Clinicians, 56, 254–281. doi: 10.3322/canjclin.56.5.254

Kushi, L. H., Doyle, C., McCullough, M., Rock, C. L., Demark-Wahnefried, W., Bandera, E. V., . . . American Cancer Society 2010 Nutrition and Physical Activity Guidelines Advisory Committee. (2012). American Cancer Society guidelines on nutrition and physical activity for cancer prevention: Reducing the risk of cancer with health food choices and physical activity. CA: A Cancer Journal for Clinicians, 62(1), 30–67.

Liao, J. B. (2006, December). Viruses and human cancer. Yale Journal of Biology and Medicine, 79(3–4), 115–122.

Lund Nilson, T. I., & Vatten, L. J. (2002). Colorectal cancer associated with BMI, physical activity, diabetes, and blood glucose. IARC Science Publications, 156, 257–258.

Mackay, J., Jemal, A., Lee, N. C., & Parkin, D. M. (2006). The cancer atlas. Atlanta, GA: American Cancer Society.

Mathers, C. D., Lopez, A. D., & Murray, C. J. L. (2006). The burden of disease and mortality by condition: Data, methods and results for 2001. In A. D. Lopez, C. D. Mathers, M. Ezzati, D. T. Jamison, & C. J. L. Murray (Eds.), Global burden of disease and risk factors (pp. 45–240). New York, NY: Oxford University Press.

Matthews, C. E., Xu, W. H., Zheng, W., Gao, Y. T., Ruan, Z. X., Cheng, J. R., . . . Shu, X. O. (2005). Cancer Epidemiology, Biomarkers, & Prevention, 14, 779–785.

McTiernan, A., Kooperberg, C., White, E., Wilcox, S., Adams-Campbell, L. L., Woods, N., . . . Ockene, J. (2003). Recreational physical activity and the risk of breast cancer in postmenopausal women: The Women’s Health Initiative Cohort Study. Journal of the American Medical Association, 290, 1331–1336.

Meissner, H. I., Klabunde, C. N., Han, P. K., Benard, V. B. & Breen, N. (2011, January 18). Breast cancer screening beliefs, recommendations and practices: Primary care physicians in the United States. Cancer 117(14), 3101–3111.

National Cancer Institute (NCI). (2004). Cancer facts: Obesity and cancer. Retrieved from http://cis.nci.nih.gov/fact/pdfdraft/3_risk/fs3_70.pdf

National Cancer Institute (NCI). (2011a). Breast cancer screening (PDQ®): Effect of screening on breast cancer mortality. Retrieved from http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/page5

National Cancer Institute (NCI). (2011b). Cervical cancer screening (PDQ®). Retrieved from http://www.cancer.gov/cancertopics/pdq/screening/cervical/healthprofessional/allpages

National Cancer Institute (NCI). (2011c). Fact sheet: Human papillomavirus (HPV) vaccine. Retrieved from http://www.cancer.gov/cancertopics/factsheet/prevention/HPV-vaccine

National Cancer Institute (NCI). (2011d). Helicobactor pylori and cancer. Retrieved from http://www.cancer.gov/cancertopics/factsheet/risk/h-pylori-cancer

National Cancer Institute (NCI). (2011e). Physician data query (PDQ®) comprehensive cancer database. Retrieved from http://www.cancer.gov/cancertopics/pdq/cancerdatabase

National Cancer Institute (NCI). (2011f). Prostate cancer screening (PDQ®). Retrieved from http://www.cancer.gov/cancertopics/pdq/screening/prostate/HealthProfessional

National Cancer Institute (NCI). (2011g). Screening and testing to detect cancer. Retrieved from http://www.cancer.gov/cancertopics/screening

National Cancer Institute (NCI). (2011h). Screening and testing to detect cancer: Breast cancer. Retrieved from http://www.cancer.gov/cancertopics/screening/breast

National Guideline Clearinghouse (NGC). (2011). Guideline synthesis: Screening for prostate cancer [Originally published December 1998; revised May 2010]. Retrieved from http://www.guideline.gov

National Heart, Lung, and Blood Institute (NHLBI). (2011). Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/phys

Okonkwo, Q. L., Draisma, G., derKinderen, A., Brown, M. L., & deKoning, H. J. (2008). Breast cancer screening policies in developing countries: A cost-effectiveness analysis for India. Journal of the National Cancer Institute, 100, 1290–1300.

Parkin, D. M. (2006). The global health burden of infection-associated cancers in the year 2002. International Journal of Cancer, 118, 3030–3044.

Parkin, D. M., & Bray, F. (2006). HPV vaccines and screening in the prevention of cervical cancer. Chapter 2: The burden of HPV-related cancers. Vaccine, 24(suppl 3), S11–S25.

Parkin, D. M., Tappenden, P., Olsen, A. H., Patnick, J., & Sasieni, P. (2008). Predicting the impact of the screening programme for colorectal cancer in the UK. Journal of Medical Screening, 15(4), 163–174.

Porter, P. (2008). “Westernizing” women’s risks? Breast cancer in lower-income countries. New England Journal of Medicine, 358(3), 213–216.

Ravdin, P. M., Cronin, K. A., Howlader, N., Berg, C. D., Chlebowski, R. T., Feuer, E. J., . . . Berry, D. A. (2007). The decrease in breast-cancer incidence in 2003 in the United States. New England Journal of Medicine, 356, 1670–1674.

Rehm, J., Mathers, C., Popova, S., Thavorncharoensap, M., Teerawattananon, Y., & Patra, J. (2009). Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet, 373(9682), 2223–2233.

Sankaranarayanan, R. (2009). HPV vaccination: The promise and problems. Indian Journal of Medical Research, 130(3), 322–326.

Scarinci, I. C., Garcia, F. A., Kobetz, E., Partridge, E. E., Brandt, H. M., Bell, M. C., . . . Castle, P. E. (2010, June 1). Cervical cancer prevention: New tools and old barriers. Cancer, 116(11), 2531–2542.

Sepulveda, A. R., & Graham, D. Y. (2003). Role of Helicobacter pylori in gastric carcinogenesis. Hematology Oncology Clinics of North America, 17, 505–523.

Shafey, O., Eriksen, M., Ross, H., & Mackay, J. (2009). The tobacco atlas (3rd ed.). Atlanta, GA: American Cancer Society.

Sherris, J., Wittet, S., Kleine, A., Sellors, J., Luciani, S., Sankaranarayanan, R., & Barone, M. A. (2009). Evidence-based alternative cervical cancer screening approaches in low-resource settings. International Perspectives on Sexual and Reproductive Health, 35(3), 147–154.

Sloan, F. A., & Gelband, H. (2007). Cancer control opportunities in low- and middle-income countries. Washington, DC: National Academies Press.

Stewart, B. W., & Kleihues, P. (2003). World cancer report. Lyon, France: IARC Press.

Suzuki, H., Iwasaki, E., & Hibi T. (2009). Helicobacter pylori and gastric cancer. Gastric Cancer, 12(2), 79–87.

Tfayli, A., Temraz, S., Abou Mrad, R., & Shamseddine, A. (2010, December 15). Breast cancer in low-and middle-income countries: An emerging and challenging epidemic. Journal of Oncology, 2010, 490631.

U.S. Department of Health and Human Services (USDHHS). (2004, May–June). The 2004 United States Surgeon General’s report: The health consequences of smoking. New South Wales Public Health Bulletin, 15(5–6), 107.

U.S. Department of Health and Human Services (USDHHS). (2010). The 2010 United States Surgeon General’s report: How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease: A report of the Surgeon General. Rockville, MD: Author.

U.S. Department of Health and Human Services (USDHHS). (2011). Public Health Service, National Toxicology Program: Report on carcinogens (12th ed.). Retrieved from http://ntp.niehs.nih.gov/ntp/roc/twelfth/roc12.pdf

U.S. Preventive Services Task Force (USPSTF). (2002). Screening for prostate cancer: Recommendations and rationale. Annals of Internal Medicine, 137(11), 915–916.

U.S. Preventive Services Task Force (USPSTF). (2008). Screening for prostate cancer. Retrieved from http://www.uspreventiveservicestaskforce.org/uspstf/uspsprca.htm

U.S. Preventive Services Task Force (USPSTF). (2009). Screening for breast cancer: U.S. Preventive Task Force recommendation statement. Annals of Internal Medicine, 151, 716–726.

United Nations (UN). (2011). Prevention and control of non-communicable diseases. Report of the Secretary-General. Retrieved from http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/64/265&Lang=E

Viswanath, K., Herbst, R. S., Land, S. R., Leischow, S. J., Shields, P. G., & Writing Committee for the AACR Task Force on Tobacco and Cancer. (2010, May 1). Tobacco and cancer: An American Association for Cancer Research policy statement. Cancer Research, 70, 3419.

von Wagner, C., Good, A., Wright, D., Rachet, B., Obichere, A., Bloom, S., & Wardle, J. (2009). Inequalities in colorectal cancer screening participation in the first round of the national screening programme in England. British Journal of Cancer, 101, S60–S63.

Walboomers, J. M. M., Jacobs, M. V., Manos, M. M., Kummer, J. A., Shah, K. V., Snijders, P. J. F., . . . Munoz, N. (1999). Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. Journal of Pathology, 189(1), 12–19.

Warren, C. W., Asma, S., Lee, J., Lea, V., & Mackay, J. (2009). Global Tobacco Surveillance System: The GTSS atlas. Atlanta, GA: CDC Foundation.

Willett, W. C. (2006). Diet and nutrition. In D. Schottenfeld, & J. F. Fraumeni, Jr. (Eds.), Cancer epidemiology and prevention (3rd ed., pp. 405–421). New York: Oxford University Press.

Winawer, S. J. (2007). The multidisciplinary management of gastrointestinal cancer: Colorectal cancer screening. Best Practice & Research Clinical Gastroenterology, 21(60), 1031–1048.

Wolin, K. Y., & Colditz, G. A. (2008, October 7). Can weight loss prevent cancer? British Journal of Cancer, 99(7), 995–999.

World Cancer Research Fund (WCRF) & American Institute for Cancer Research (AICR). (2007). Food, nutrition, physical activity, and the prevention of cancer: A global perspective. Washington, DC: AICR.

World Health Organization (WHO). (2002). National cancer control programmes: Policies and managerial guidelines (2nd ed.). Geneva, Switzerland: Author.

World Health Organization (WHO). (2003a). Framework Convention on Tobacco Control. Retrieved from http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf

World Health Organization (WHO). (2003b). World cancer report. Geneva, Switzerland: Author. Retrieved from http://www.who.int/cancer/prevention/en/

World Health Organization (WHO). (2004). Global strategy on diet, physical activity and health. Retrieved from http://www.who.int/dietphysicalactivity/goals/en

World Health Organization (WHO). (2006a). Cancer control: Knowledge into action. WHO guide for effective programmes. Geneva, Switzerland: Author.

World Health Organization (WHO). (2006b). Non-communicable diseases: Cancer. Retrieved from http://www.emro.who.int/ncd/cancer.htm

World Health Organization (WHO). (2008). Prevention and control of non-communicable diseases: Implementation of the global strategy. Report by the Secretariat. Retrieved from http://apps.who.int/gb/ebwha/pdf_files/A61/A61_8-en.pdf

World Health Organization (WHO). (2009). Report on the global tobacco epidemic, 2009: Implementing smoke-free environments. Retrieved from http://whqlibdoc.who.int/publications/2009/9789241563918_eng_full.pdf

World Health Organization (WHO). (2011a). Breast cancer: Prevention and control. Retrieved from http://www.who.int/cancer/detection/breastcancer/en/index3.html

World Health Organization (WHO). (2011b). Cancer prevention. Retrieved from http://www.who.int/cancer/prevention/en/

World Health Organization (WHO). (2011c). Global status report on alcohol and health 2011. Retrieved from http://www.who.int/substance_abuse/publications/global_alcohol_report/msbgsruprofiles.pdf

World Health Organization (WHO). (2011d). Obesity. Retrieved from http://www.who.int/topics/obesity/en

World Health Organization (WHO) (2011e). Prostate cancer. Retrieved from http://www.who.int/cancer/detection/prostatecancer/en/index.html

World Health Organization (WHO). (2011f). Screening for various cancers. Retrieved from http://www.who.int/cancer/detection/variouscancer/en/index.html

World Health Organization (WHO). (2011g). WHO report on the global tobacco epidemic, 2011: Warning about the dangers of tobacco. Retrieved from http://www.who.int/tobacco/global_report/2011/en/index.html

World Health Organization (WHO) & United Nations Children’s Fund. (2003). Global strategy for infant and young children feeding. Geneva, Switzerland: Authors.

Yang, D., Berstein, L., & Wu, A. H. (2003). Physical activity and breast cancer risk among Asian American women in Los Angeles: A case-control study. Cancer, 97, 2565–2575.

Zapka, J. (2003). A framework for improving the quality of cancer care: The case of breast and cervical cancer screening. Cancer Epidemiology, Biomarkers, & Prevention, 12, 4–13. (Holtz 283)

Holtz, Carol. Global Health Care: Issues and Policies, 2nd Edition. Jones & Bartlett Learning, 05/2012. Vital Book file.

The citation provided is a guideline. Please check each citation for accuracy before use.