Reducing the Burden of Disease

Cancer Prevention and Control

Alabama (REACH Program): Using Community Health Advisors to Encourage Women to Obtain Cancer Screening Services

Public Health Problem
In 2000, nearly 2,700 women were diagnosed with breast cancer in Alabama. In selected counties, there were more breast cancer deaths among African American (30/100,000) than among white (20/100,000) women.

Evidence That Prevention Works
Mammography is the most effective method for detecting breast cancer early. Timely mammography screening could prevent 15%–30% of all deaths from breast cancer among women aged 40 or older. Additionally, detecting precancerous lesions by a Pap test and treating them can prevent cervical cancer and therefore prevent virtually all cervical cancer deaths.

Program Example
The University of Alabama at Birmingham Breast and Cervical Cancer Coalition involves a variety of community-based, religious, grassroots, and health care organizations that serve the target population. The community action plan is designed to reduce disparities in breast and cervical cancer screening and outcomes between African American and white women through the use of community advisors. Core working groups of community health advisors, nurses, and church representatives disseminate information to support, encourage, and help women obtain cancer screening services and navigate the health care system. This approach is based on the Multilevel Approach Toward Community Health (MATCH) framework. Using health advisors, MATCH seeks to eliminate barriers that women face when trying to access health services.

Implications
Using community-based health advisors as agents for behavioral change lends credibility to interventions to reduce the risk for breast and cervical cancer and increases the reach of the program in the community. This approach can extend lifesaving prevention programs and screening services across cultural divides to communities that would not likely be reached by traditional means.

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California: Broadening Access to Asian Populations Through a Breast Cancer Hot Line

Public Health Problem
In California in 2002, an estimated 19,900 cases of breast cancer were diagnosed, and 3,900 women died of breast cancer. Racial and ethnic minorities are disproportionately affected by cancer. For Asian American women, cancer has been the leading cause of death since 1980. A variety of factors, including cultural differences, language barriers, and logistical barriers such as lack of transportation to and from a clinic, contribute to these women never or rarely having been screened for breast and cervical cancer.

Evidence That Prevention Works
Interventions based on cultural sensitivity and trust are effective in promoting the early detection of breast cancer in racial and ethnic minority populations. For those populations who speak little to no English, eliminating language barriers is often a first step in successful outreach and education efforts.

Program Example
The California Department of Health's Every Woman Counts program launched the first statewide breast cancer hot line in the United States for Asian American women. As a way of reaching this population, the department broadened its hot line to offer information in Chinese (Mandarin and Cantonese dialects), Korean, and Vietnamese, in addition to the information already offered in English and Spanish. Through its 2000 public awareness campaign, Every Woman Counts...Every Year, the department sponsored radio and print ads in Chinese, Korean, and Vietnamese to let Asian American women know about the hot line. Because of the campaign, the number of calls to the hot line increased from 24 in April 2000 to 576 in June 2000. On average, the hot line continues to receive approximately 60 to 80 calls per month, three times the number received prior to the campaign.

Implications
As a result of the hard work and sensitivity of the outreach workers, access to potentially lifesaving information was improved. Hundreds of women learned about available cancer screening services because of linguistically and culturally appropriate outreach efforts. This program demonstrates the importance of reaching special populations through a targeted public awareness campaign.

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California (REACH Program): Creating Customized Community Action Plans: Responding to the Needs of the Community

Public Health Problem
In California, an estimated 20,000 women are diagnosed with breast cancer each year, and, on average, 13 women die of breast cancer each day. The incidence of cervical cancer is more than five times greater among Vietnamese women in the United States than among white women.

Evidence That Prevention Works
Early detection and appropriate treatment could prevent virtually all cervical cancer deaths and about 15%–30% of breast cancer deaths among women older than age 40. The initial costs for breast cancer care, if diagnosed early before it has spread, may be as much as 32% lower than the initial care costs for breast cancer diagnosed after it has spread.

Program Example
The California Endowment funds the Special Services for Groups (SSG) Inc.'s Promoting Access to Health (PATH) for Women, a Los Angeles-area collaboration that focuses on reducing disparities in rates of breast and cervical cancer among Asian American and Pacific Islander women. SSG held focus groups and interviewed 2,100 Pacific Islander (Chamorro, Samoan, and Tongan) and Southeast Asian (Cambodian, Laotian, Thai, and Vietnamese) women in Los Angeles and Orange counties. SSG works with seven ethnic populations (Cambodian, Laotian, Thai, Vietnamese, Chamarro, Samoan, and Tongan) and draws on the leadership of its Pacific Islander and Southeast Asian community members and health care providers to develop customized community action plans and materials for each ethnic group. Each ethnic group implements its community action plan at its own level of readiness. The Samoan National Nurses Association is an example of one group that has been executing almost all facets of PATH for Women, including offering community outreach and education services, promoting a cancer ministries program with local Samoan pastors, establishing a cancer support group, and setting up mobile screening programs for community women.

Implications
Community-based programs that seek community input are responsive in meeting the needs of a particular community. This program demonstrates the importance of giving communities the materials and plans to implement an effective intervention while allowing them to execute these plans in a manner and at a pace that resonates with their own culture and community. This approach can extend lifesaving prevention programs and screening services across a variety of cultures to communities that would not likely be reached by traditional means.

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Colorado: Examining New Partnerships and Innovative Educational Approaches for a Comprehensive Cancer Control Program

Public Health Problem
Malignant melanoma (the deadliest form of skin cancer) causes more than 75% of all deaths from skin cancer in the United States. Diagnosed at an early stage, malignant melanoma can usually be cured, but if diagnosed at a late stage, it is more likely to spread and cause death. During 1993–1997, Colorado's incidence rate for melanoma was 31% higher than the overall U.S. rate. The incidence rate for non-Hispanic white males climbed 9% between 1993 and 1997.

Evidence That Prevention Works
Exposure to the sun's ultraviolet (UV) rays appears to be the most important risk factor in the development of skin cancer; therefore, when sun protection measures are used consistently, skin cancer is largely preventable.

Program Example
A public education campaign that included the brochure "Sun Smart Tips" was launched in June 2001. This campaign resulted from a unique partnership between the state health department's Comprehensive Cancer Prevention and Control Program and Mesa Verde National Park, which has about 600,000 visitors annually. National park officials educated Colorado residents, as well as visitors from all over the world, about the steps they can take to be safer in the sun. The goal of this campaign was to educate park visitors about the need to protect themselves from the damaging rays of the sun and how best to prevent skin cancer. In addition to park staff handing out thousands of brochures at the park entrance gates, the rangers incorporated "Sun Smart Tips" into their regularly scheduled talks, which are held frequently throughout the year.

Implications
This project was so well received that plans are under way to make the skin cancer brochures and information available at Colorado's highway visitors' centers. Thousands of travelers can potentially be reached with important sun safety messages. This effort also underscores the added value of coordinated partnerships to disseminate consumer-oriented information on cancer prevention.

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Connecticut: Using Peer Communication to Create an Early Detection Program

Public Health Problem
In 2002, an estimated 2,600 cases of invasive breast cancer and 100 cases of cervical cancer were reported in Connecticut; approximately 500 women died of breast cancer in Connecticut.

Evidence That Prevention Works
Interpersonal strategies, those that involve communication with a family member or a person in one's social network, are effective in promoting early detection and treatment of breast and cervical cancer. Using peers to encourage women to be screened for cancer may eliminate language barriers and can help a program better address cultural and community factors.

Program Example
Connecticut's Breast and Cervical Cancer Early Detection Program focuses on providing screening services to the state's uninsured or underinsured older women who are from racial or ethnic minority groups. As of 2001, more than 18,000 of the state's uninsured, low-income women had received services through this program. This number represents 45% of the state's program-eligible population. Nearly 18% of these women are African American, and 20% are Hispanic. At enrollment, women receiving program services were asked how they heard about the program. Twenty-four percent (24%) of these women said that they heard about it through outreach educators who were members of the local community and employed by the Connecticut program to recruit women for screening services.

Implications
Without this program and the commitment and work of the outreach educators, these Connecticut women may not have received potentially lifesaving early detection services. This program emphasizes the importance of using peer communication as an effective way to reach underserved populations.

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Idaho: Creating an Innovative Visual Aid to Help Communicate the Importance of Early Detection

Public Health Problem
In Idaho in 2002, an estimated 900 women were diagnosed with breast cancer, and approximately 200 women died of breast cancer.

Evidence That Prevention Works
Studies show that early detection of breast cancer and a comprehensive follow-up program save lives. Timely mammography screening could prevent 15% to 30% of all deaths from breast cancer among women over the age of 40. Studies show that early detection is the best protection against breast cancer deaths. When breast cancer is diagnosed at a local stage, 96% of women are still alive 5 years later. If the cancer spreads regionally, this rate is reduced to 78%, and if diagnosed after spreading to distant sites, the 5-year survival rate is reduced to 21%.

Program Example
Idaho's Breast and Cervical Cancer Early Detection Program, Women's Health Check, developed an innovative way to teach women about breast cancer using a visual tool. The program is called "Ask Me," and it uses wooden beads to illustrate the various tumor sizes that can be detected by mammography. This visual image helps women understand the importance of getting regular exams and demonstrates how early a tumor can be detected, even when it is very small. A curriculum also was developed for the program. The program was launched in conjunction with McCall Memorial Hospital, the Idaho Breast and Cervical Cancer Alliance, and the American Cancer Society. Sorority groups, cancer centers, Idaho's Hispanic women's group, local jewelry stores, and health insurance companies implemented the program.

Implications
By using a visual aid to support its early detection message, this program illustrates the importance of early detection and screening and demonstrates the impact that a visual aid can have on promoting prevention.

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Illinois (REACH Program): Reaching Out to Low-Income Women to Prevent Breast and Cervical Cancer

Public Health Problem
In the United States, African American woman are more likely to die of breast cancer than women of any other racial or ethnic group. Cervical cancer death rates are more than twice the national average among African American women and are higher than average among Hispanic women. In the United States, more than 40,000 women will die of breast cancer, and more than 2,000 of them will be from Illinois. Currently, only about 9% of breast cancers in Illinois are detected at the earliest, most curable stages, and in 1998, Illinois was in the top 25% of states for women aged 50 or older who had not had a mammogram in the last 2 years.

Evidence That Prevention Works
Timely mammography screening could prevent approximately 15%–30% of all deaths from breast cancer among women over the age of 40. According to the American Cancer Society, between 1955 and 1992, the number of deaths from cervical cancer declined by 74%, and the main reason for that decline was the use of the Pap test to detect cervical cancer early.

Program Example
Reach Out is a broad-based Chicago-area collaboration that draws on the leadership of local churches to encourage low-income African American and Hispanic women to seek early breast and cervical cancer screening. Reach Out held focus groups of female members of seven African American and two Latino churches and learned that participants wanted relevant information about how breast and cervical cancer could affect them as individuals and as a community. Led by health educators in the community, each church used a standard education intervention in addition to other outreach methods such as incorporating health information and reminders about the importance of screening and early detection in Sunday sermons, developing support groups, and sponsoring health fairs.

Implications
Community-based programs like Reach Out that seek community input are more likely than other programs to be responsive to the needs and the culture of the community. This approach can extend lifesaving prevention programs and screening services across cultural divides to communities that would not likely be reached by traditional means.

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Indiana: Screening Underserved Populations Through Collaboration Among Government Agencies and Nonprofit Organizations

Public Health Problem
In Indiana in 2002, an estimated 4,600 women were diagnosed with breast cancer and 300 with cervical cancer, and 900 women died of breast cancer. Underserved populations include those people who are least likely to be screened for breast and cervical cancer. As a result, these populations also are at the greatest risk of dying of these types of cancer. Many women in correctional facilities are underserved because they often have low incomes, little or no health insurance, and no routine health care. In addition to these socioeconomic factors, free breast and cervical cancer screenings are not readily available in most jails.

Evidence That Prevention Works
Through collaborative efforts by federal and state government agencies and nonprofit organizations, the disparities that exist in cancer prevention and control for women who are uninsured or underinsured can be reduced. Studies show that early detection of breast and cervical cancer and a comprehensive program, including case management and community collaboration, save lives. Timely mammography screening could prevent 15% to 30% of all deaths from breast cancer among women over the age of 40. Having a Pap test as recommended could prevent nearly all deaths from cervical cancer.

Program Example
The Indiana State Department of Health Breast and Cervical Cancer Program (BCCP) collaborated with the University of Southern Indiana Nurse Practitioner Program and the Vanderburgh County Jail and Safe House to reach the low-income, uninsured population of incarcerated women and provide them with ongoing access to cancer screenings. BCCP staff members educated women at the Vanderburgh County Jail and Safe House about breast and cervical cancer and enrolled them in the program. A nurse practitioner performed Pap tests on-site for the inmates, and mammography screening was scheduled at a local breast center. Follow-up procedures for abnormal results also were provided. Further partnerships are being pursued with parole offices to help maintain contact and facilitate rescreenings after the women are released from prison.

Implications
Without this innovative program and the hard work of the outreach workers, this unique population of women would not have received lifesaving early detection services. This program demonstrates the importance of working within special populations to identify both the people and the existing systems that would be most likely to reach them. This program also demonstrates the importance of providing these underserved women with access to routine screening both during and after their incarceration.

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Missouri: Providing Resources and Support to Breast Cancer Patients Through Community Collaboration

Public Health Problem
Breast cancer is the second leading cause of cancer death for Missouri women. In Missouri in 2002, an estimated 4,000 women were diagnosed with breast cancer, and 800 died of breast cancer.

Evidence That Prevention Works
Timely mammography screening could prevent 15% to 30% of all deaths from breast cancer among women over the age of 40. Studies show that early detection is the best protection against breast cancer death. When breast cancer is diagnosed at a local stage, 96% of women still are alive 5 years later. If the cancer has spread regionally, this rate is reduced to 78% of women, and if diagnosed after spreading to distant sites, the 5-year survival rate is reduced to 21%.

Program Example
The Missouri Department of Health and Senior Services' Breast and Cervical Cancer Control Program (BCCCP) case managers collaborated with community organizations such as the Breast Cancer Foundation of the Ozarks (BCFO) and the American Cancer Society to provide resources and support for women affected by breast cancer and their families. In one case, the BCCCP case manager acted as a liaison for Susan, a woman diagnosed with breast cancer who needed chemotherapy and a mastectomy. Susan was unemployed and depressed. The case manager helped Susan get in touch with the BCFO, who paid her rent and utilities for 3 months. The American Cancer Society provided a wig and other types of support. Susan has now completed her treatment and is doing well in her own home. She continues to express gratitude to the BCCCP for helping to save her life.

Implications
The Missouri BCCCP case management service enhances the quality of life of women diagnosed with breast cancer. By educating women on the scope of available services from diagnosis through treatment and recovery, the BCCCP helps increase the number of women who use the program and take advantage of the available diagnostic and treatment services.

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North Carolina: Addressing Cancer Concerns From a Comprehensive and Family Health-Oriented Perspective

Public Health Problem
Colorectal cancer is the second leading cause of cancer death among North Carolinians. In 2001, about 1,700 adults in North Carolina died of colorectal cancer. Because people are not participating in routine screenings, only about 35% of colorectal cancers are detected in the curable, early stages.

Evidence That Prevention Works
The state's 11 years of experience in conducting the Breast and Cervical Cancer Control Program (BCCCP) through local health departments provide a successful model for reducing deaths from cancer by using a comprehensive approach to cancer control. This approach involves integrating and coordinating various cancer control activities at the community level, including public and professional education, early detection services, monitoring, and evaluation.

Program Example
To address the colorectal cancer control goals included in the state's cancer plan, the North Carolina Division of Public Health's Comprehensive Cancer Unit (CCU) applied "lessons learned" in implementing the BCCCP. The CCU designed a pilot project to conduct colorectal cancer screening in 10 local health departments encompassing 15 counties in diverse regions of the state. The project specifically targeted low-income women with little or no health insurance and raised awareness about the importance of early detection. Already participating in the state's BCCCP, these women were encouraged to participate and to invite their husbands to take advantage of the colorectal cancer screening program. The CCU provided educational materials, an in-service educational program on colorectal cancer for the local staff, fecal occult blood test (FOBT) kits for all participants aged 50 or older, funding for staff time and administrative costs (including transportation), and funds to cover additional diagnostic testing of positive results. Participants received information on colorectal cancer and were offered FOBT kits. A total of 1,478 participants (including more than 240 men) were counseled and offered FOBT kits; 1,226 took the kits home, and 706 (including more than 100 men) completed and returned the test kits. Of these, 148 tests were positive, resulting in 107 successful referrals for follow-up testing. (Some clients declined further testing.) Ten precancerous polyps (three among men) were found, and four cancers (two among men)
were diagnosed.

Implications
This pilot program demonstrates the feasibility of screening in a local health department setting and the potential value of addressing cancer concerns from a comprehensive and family health-oriented perspective. Because of the extensive reach these agencies have in the community, they can be helpful in raising public awareness about the importance of early cancer detection and in encouraging people to use screening programs.

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Texas: Improving Data Collection for a Comprehensive Cancer Control Program

Public Health Problem
In the process of gathering data for program planning, the Texas Comprehensive Cancer Control Coalition (TCCCC), working with the Texas Department of Health, recognized various gaps and deficiencies in cancer data for the state. In part, these gaps were a result of outdated registry software systems and the lack of specific case reporting requirements in the state registry regulations.

Evidence That Prevention Works
Data collected by state central cancer registries enable public health professionals to better understand and address the cancer burden. Cancer data are used to determine cancer patterns among various populations, monitor trends over time, and advance research.

Program Example
The TCCCC facilitated a review of the various cancer data resources for Texas, as well as the processes and systems involved in collecting data. This review resulted in the publication of Information Management Enhancements to Improve Texas Cancer Data for Comprehensive Cancer Control. This publication and a companion report (The Cost of Cancer in Texas) also produced for the Coalition were critical resources used by the Coalition to document the extent of the data problems. More importantly, the Texas Cancer Council, the Texas Medical Association, the American Cancer Society Texas Division, and other Coalition members used these reports to educate the health commissioner and state legislators about the need for changes in the rules governing cancer-reporting regulations and for improvements in the state's data management systems. The Texas State Legislature subsequently passed a bill (effective September 1, 2001) that updates the state's cancer registry law. This legislation requires reporting of cancer cases to the state central cancer registry by physicians, dentists, and outpatient facilities, including surgical centers. It also strengthens the language that requires hospitals and other reporting facilities to reimburse the Texas Department of Health for the costs of identifying or documenting unreported cancer cases. The Texas Department of Health also asked legislators for increased funding for the cancer registry and other health registries to purchase updated computer software in order to process data more efficiently.

Implications
Improved coordination of cancer control activities, including monitoring, is a key benefit of comprehensive cancer control planning. Passing this bill is an important first step in addressing the problem of incomplete cancer data. This effort by the TCCCC demonstrates the potential health agencies and organizations have to mobilize collective support for a statewide cancer monitoring system.

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Vermont: Providing Vital Cancer Screening Programs to Women Who Face Special Barriers to Accessing Health Services

Public Health Problem
In 2002, an estimated 400 women were diagnosed with breast cancer, and approximately 100 women died of breast cancer in Vermont. About 40 women in Vermont were diagnosed with cervical cancer in 2002.

Evidence That Prevention Works
Early detection cancer screening services need to be available and accessible to all women. Studies show that early detection of breast and cervical cancer and a comprehensive follow-up program save lives. Timely mammography screening could prevent 15% to 30% of all deaths from breast cancer among women over the age of 40. Having a Pap test as recommended could prevent nearly all deaths from cervical cancer.

Program Example
Ladies First is Vermont's Breast and Cervical Cancer Screening Program. This program makes special efforts to reach out to women with special needs (e.g., women who are blind, hearing impaired, in wheelchairs) who face special barriers to accessing health care services. Ladies First has been a big help for Natalie, who is blind. The program helped her fill out the necessary forms to get screened for breast and cervical cancer, helped her choose a doctor, and made certain she got to her appointment. Ladies First also provided Natalie with an audiotape of all the available educational materials on breast and cervical cancer. The program also provides educational materials in alternative formats, including braille and large type print. Ladies First recently purchased wheelchair-accessible examining tables for 10 hospitals throughout the state and for one correctional facility to help ensure that disabled women get thorough exams. Often, the typical exam table is too high and not wheelchair accessible.

Implications
Through practical steps like these, Ladies First works hard to make sure women like Natalie have access to vital health information and cancer screening services. Since its launch in 1995, the Vermont Department of Health has provided cancer screening and diagnostic services to 6,000 Vermont women through its Ladies First program, many of whom benefitted from special services for women with disabilities. As a result of Ladies First screening efforts, 70 cancers have been detected, most in the earliest, most treatable stage. This program demonstrates the importance of reaching uninsured and underinsured women and women who face physical challenges in a way that addresses their particular needs.

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Washington: Creating a Native American Women's Wellness Program to Promote Cancer Screening and Education

Public Health Problem
Cancer is the second leading cause of death for American Indian/Alaska Natives, even though cancer incidence is often lower for this group. Five-year survival rates are significantly lower for racial and ethnic minority populations, in part because of the late stage at diagnosis and problems with access to follow-up care. For American Indian/Alaska Native populations in Washington, the age-adjusted breast cancer mortality rate is 28.6 per 100,000, considerably higher than the national rate of 15.0 per 100,000.

Evidence That Prevention Works
Older women and those from culturally or geographically isolated communities or racial and ethnic minority groups (including Native American/Alaska Native women) are priority populations for the National Breast and Cervical Cancer Early Detection Program. Within these populations, public health providers should involve the community and open the lines of communication to build an environment of trust.

Program Example
With support from Avon and the Susan G. Komen Foundation, the South Puget Intertribal Planning Agency's Native Women's Wellness Program hired outreach workers in 2000 in the five tribal communities in Washington State. The program has five American Indian outreach workers and five tribal health care providers (one for each tribe) to encourage women to use available health services. Because they are highly respected and well known in their communities, the American Indian outreach workers have built a level of trust with the women in their communities. This rapport has enabled outreach workers to better educate and encourage the women to take advantage of the health services that are offered to them. They also have increased turnout rates by providing incentives, holding special events such as mother and daughter teas, and offering transportation and day care to make it easier for the women to be screened. In 2000, only 136 women were newly enrolled. In 2001, after hiring American Indian outreach workers, the number of newly enrolled women almost doubled to 251. In 2001, the program delivered the highest number of services in its history: 1,218 Pap tests, mammograms, and clinical breast exams combined. Since its inception, the South Puget Intertribal Agency's Native Women's Wellness Program has provided 1,600 mammograms, 2,330 clinical breast exams, and 2,473 Pap tests.

Implications
Without this program, late diagnoses of breast and cervical cancer would have continued in this population that faces higher than average cancer death rates. This outreach program demonstrates the importance of identifying the right community leaders who can help influence the behaviors within a special population.

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