Friday, April 21, 2017

Reaching the Goal of 80% Colon Cancer Screening by 2018: Practical Lessons from Community Clinics

A great interview this week with Belma Andrić, MD, MPH on the 80% by 2018 blog highlights successful approaches that can boost colon cancer screening rates at community clinics with underserved populations.

During her tenure as Medical Director with C. L. Brumback Primary Care Clinics in Florida, colon screening rates increased from 21 percent in 2013 to 82 percent in 2016 - meeting and surpassing the National Colorectal Cancer Roundtable's goal of an 80 percent screening rate by 2018.

How did they do this?  By tackling the issue at multiple levels and developing creative ways to work around barriers.  Some lessons from their experience include:

Collaborate.  Groups within the clinic not only worked together to improve screening rates but the clinics also worked with the Florida state primary care health systems manager and an American Cancer Society local liaison.

Staff a patient navigator.   "This proved to be one of the best decisions we made," Andrić says. The navigator was key to addressing the needs and concerns of the patients while also making sure screening efforts synched within the clinic system.  One key aspect of the navigators' work was to walk patients through the steps of colonoscopy bowel prep and to check in with them during the process.

Make the offer of screening "second nature."  One initial top barrier to screening was the fact that many patients were simply not being offered screening at their clinic visits.  They addressed this problem through a combination of provider/team education, weekly check-ins, and some friendly competition between care teams - "doctors are very competitive." 

Make it easy and immediate.  Clinics implemented a "Poop on Demand" program that asked patients if they wanted to provide a stool sample for testing while they were at the clinic.  This boosted rates of FIT testing by 30 - 40 percent.

"Don't get discouraged."  Barriers of all kinds pop up with any program.  Expect that they will come up, even if the specific barriers are unexpected.  Most can be overcome.

Seek extra funding.  The clinics applied for - and received - an American Cancer Society Community Health Advocates implementing Nationwide Grants for Empowerment and Equity (CHANGE) grant, which helped them explore and implement strategies for improving screening rates.



Tuesday, April 18, 2017

Looking for a Good Return on Investment? Fund Public Health Programs


In a recent New England Journal of Medicine Sounding Board article, Karen Emmons and Cancer News in Context's Graham Colditz detailed the well-established health and economic benefits of disease prevention programs.   One example they highlighted was the more than double return on investment (ROI) of dollars put towards a tobacco cessation program in Massachusetts.


Now, a new systematic review by Rebecca Masters and fellow researchers in the United Kingdom shows that that very good doubling of ROI may actually be on the low end of returns when it comes to the positive economic benefits of many public health interventions.  Looking at published studies on interventions as varied as speed limits, needle exchange, soda taxes, vaccination, medication adherence, and tobacco cessation, the researchers found that the average ROI across all such interventions was 14.  This means that for every dollar invested in the reviewed public health programs, 14 dollars (plus the initial dollar invested) was saved.  

While a small number of individual studies in the review showed a negative ROI, the vast majority found positive results, with some very large, such as the ROI for sugary soda tax legislation.  The table below highlights some of the individual studies used to calculate the overall ROI for the public health interventions.

Selected interventions (single study results) ROI
Sugar-sweetened beverage tax $55.00
Tobacco cessation (pregnant women) $6.72 - 17.18
Workplace health management $4.51
Cycling & walking trails $2.94
Universal Hepatitis B vaccination $2.98
Tobacco cessation (general) $2 - 2.25


With such large and consistent findings of economic benefit, it is hard to understand why such health programs need to fight so hard for adequate funding.  As the authors write, "even with the most rudimentary economic evaluations, it was clear that most public health intervention are substantially cost saving."

Unfortunately, success in public health can take time and it can feel muted next to flashier news items - both of which can hamper funding efforts.  To capitalize on these numbers - to realize the potential of their great return on investment - we need to find a way to effectively tell our stories, to build public interest, and to garner the political will to fund public health appropriately.  The economic and health benefits could be enormous.  We should not leave them on the table.

The Coeur d'Alene Tribe Promotes Physical Activity Through a Program of Traditional Dance

National Public Radio aired a really nice piece yesterday about a fitness program developed by the Coeur d'Alene Tribe of northern Idaho that focusses on traditional American Indian dance.  With funding from the Centers for Disease Control and Prevention, the program uses exercise classes and a series of fitness videos based on powwow dances to get tribal members moving.

Featuring both men's and women's dances, the "Powwow Sweat" videos have engaging whimsical touches and interlace dancers in standard workout clothes and those in traditional dress. Similar exercise classes are also offered at the Tribe's wellness center.





As reported in the piece, the traditional, cultural approaches of the program may help it reach and engage people to a greater degree than one solely based on physical activity alone.
"It's this combination of tradition and exercise that keeps tribal member Ryan Ortivez and his neighbors coming to class each week, to watch the videos and dance alongside each other. 
'It's a lot more attractive than doing jogging or the bicycle for me, because it also relates to my culture,' says Ortivez."

This kind of tailored approach and support is key to improving health behaviors in all populations.  We respond to messages that resonate with us, and that are supported within our broader communities.    "Powwow Sweat" is a great example of a program working to do just that.

It is also of particular interest to us as we've had the opportunity to partner with the Buder Center for American Indian Studies at Washington University on health outreach.  And we've recently tailor two of our 8 Ways to Prevent Cancer series titles to American Indian and Alaska Native populations (Breast Cancer & Colon Cancer), each of which was distributed at the Center's 27th Annual Powwow this past March.







Thursday, April 13, 2017

Large Study Further Confirms Overweight & Obesity Increase Risk of Premature Death

 A "normal" weight - with BMI between 22.5 and 24.9 - was linked to lowest risk

by Hank Dart

It turns out that a healthy weight is a healthy weight. That's the essential conclusion of a large and well-designed new study looking at long term weight and its relation to premature death.

What makes this seemingly common sense finding especially newsworthy is that it runs counter to some recent high-profile studies that have concluded that being overweight or slightly obese may actually provide the best protection against premature mortality, even more so than being at what is classified as a "normal" or "healthy" weight.

Not surprisingly, these past "obesity paradox" studies made a splash in both the media and scientific circles, grabbing headlines the world over.

Yet, many researchers had concerns about the design of these studies, and therefore the

trustworthiness of their findings. The main issue was that the studies did not seem to adequately take into account smoking status and pre-clinical disease, which can have an important impact on both weight and the risk of death. Pre-clinical disease is an illness that has not yet been diagnosed but that can lead to weight loss and increased risk of dying. And weight loss from such illness can happen many years before it is diagnosed. Likewise, smokers also tend to weigh less and have a higher risk of dying. Unless a study is designed correctly, each of these factors can incorrectly sway results to show that being a normal weight increases the risk of death, and being overweight lowers risk.

This new study, performed by researchers at the Harvard School of Public Health and Harvard Medical School, was design to address such issues by using participants' maximum weight over a 16-year period. This way, the impact of weight loss due to pre-clinical disease could be limited. A participant with a maximum weight in the "normal" category, for example, would not have gotten there by losing weight -- such as due to an unknown illness.

 

Following 225,000 middle-aged men and women for another 8 - 20 years, the researchers found a steady increase in risk of premature death with overweight and obesity, compared to normal weight (see figure). Underweight also increased risk in women. The lowest risk of premature death was with a body mass index (BMI) between 22.5 - 24.9, which is a weight of 148 - 164 pounds for someone 5 feet, 8 inches tall.


While these findings are not necessarily surprising - since they fall in line with the guidelines for healthy weight and unhealthy weight - they are quite an important counter to the widespread "obesity paradox" coverage. Next to smoking, weight is the most important health issue in the nation - and increasingly the globe. In addition to lowering quality of life, overweight and obesity increase the risk of heart disease, diabetes, stroke, osteoarthritis, liver disease, and thirteen different cancers. 

Working to maintain a healthy weight remains one of the best things people can do for their health and well-being.  While it's not easy, it's certainly worth it. 


See our recent post for simple tips to help keep weight in check.

 

http://www.cancernewsincontext.org/2017/03/12-little-things-that-can-put-hitch-in.html

Photo: Mini-me-7 by Marcel Oostervijk (CC License, CC BY-SA 2.0) (Edited: Cropped)

Thursday, March 23, 2017

Another Look at Luck and Cancer: Risk Accumulation & Prevention

by Graham Colditz

The debate regarding luck, prevention, and cancer risk is in the media again today (see Science, NPR, Forbes, and many others).

The authors of this new paper -- a follow-up of their original published two years ago and which caused such stir -- make a clear effort too classify cancer risk as due to H - hereditary (our parents - who we cannot change), E - environmental exposures (modifiable risk factors, such as cigarette smoking, weight gain in adult years, and lack of physical activity) and R - rate of DNA damage accumulated as cells divide.  By taking this approach, however, we continue to focus on the underlying rate of division and DNA damage, not the factors that modify this rate and certainly are known to modify cancer risk.

Doll and Armitage showed in 1954 that 5 to 6 mutations were needed to generate cancer in lung, colon, and numerous other organ sites. Yes, the multistage model proposed in 1954 was largely correct based only on assessment of age and cancer mortality in the UK. Of course, back then, treatment did not change outcomes to any great extent.

Today, we have more evidence that the rate of DNA damage varies by age.  For example, breast cancer shows this clearly in animal models and through incidence in women. The stages of a woman's life are associated with different rates of cell division - faster from the time a woman has her first menstrual period to the time she has her first baby, then more slowly after each baby, to even slower after menopause (unless a women uses hormone therapy that consists of estrogen-plus-progestins).

We wrote on this some time ago, (see below) as have many others.



While risk accumulates through cell divisions, we know that avoiding smoking and other major risk factors dramatically reduces the risk of specific cancers.



As the cancer burden continues to increase globally, using what we know from decades of cancer research lets us as a society reap benefits now.  Our return on investment on what we already know is waiting to be collected.  We just need the foresight and political will to do it.

12 Little Things That Can Put a Hitch in Your Efforts to Keep Weight in Check - And Ways to Fix Them


by Hank Dart

Even in the middle of the roiling media cycle we're in, diet has still managed to break through and make headlines the past couple weeks. Probably the biggest recent story was the release of a paper in the Journal of the American Medical Association that found that around 40 - 50 percent of deaths in the United States from heart disease, stroke, and diabetes could be linked to unhealthy eating. Big culprits were eating too much sodium and processed meat, and not enough nuts, seeds, and fish rich in healthy fats.

Following on the heels of this was a paper in the journal Cancer Causes and Control by Isabelle Romieu of the International Agency for Research on Cancer (IARC), which detailed the key drivers of energy imbalance that leads to obesity. Energy imbalance, when it comes to weight gain, simply means consuming more calories than you need, which over time can lead to becoming overweight and possibly obese.

And, as many of us have frustratingly found, it doesn't take too many of these extra calories to put on weight, something Romieu and her co-authors highlight -
"Very small deviations from energy balance, on the order of 1 - 2% of daily energy intake, can result in large long-term change in body weight (~20kg)[Ed: ~44lbs]."
For a moderately active adult woman, for example, 1 - 2 percent is only about 20 - 40 extra calories a day. That's the splash of cream in a morning coffee, three ounces of sugary soda, or half a small cookie. Or looking at it from the other end, that's the calories burned by walking less than half a mile. Not much at all.

Clearly, the little things we do in relation to how we eat and how active we are can really matter, especially over time. So, let's take a look at some of the little things that can put a hitch in our best efforts to keep in energy balance.

 Most likely, we all have at least one or two -- and probably more -- that we do regularly. The good news: because they're little, or at least little-ish, they're sometimes not too hard to start to tackle. 

Why not begin today?

Eating too fast
It's a go, go, go world these days, and that mindset can transfer to our eating, too. But eating food fast can easily lead to overeating because our minds and stomachs need some time to synch up. You can quickly down two hot dogs, a shake, and large fries before your mind has had a chance to register the first hot dog and tell you you've had enough. Before you know it, you feel stuffed and may have eaten a 1,000 calories more than your body actually wanted.

The fix: Simply try to slow down at each meal. Take time between bites. Enjoy your food. This slower pace can put your stomach and mind in better synch and help you feel satisfied with less food.


Ordering "the works"
Steer clear of ordering anything with "the works." Along with "stuffed crust" and "extra whip," "the works" are two terrible words to utter when you're working to keep calories in check. Whether on a potato, hamburger, or dessert, "the works" is usually just a vehicle for extra calories you may not even enjoy all that much.

The fix: Try low-calorie toppings instead, like fresh fruit, tomatoes, or salsa.


Being swayed by advertising
Most food companies want to get us to eat and drink - and the more the better. And they spend billions of dollars a year on advertising to get us to do just that. So, it's important to try to develop a bit of media savvy when it comes to advertising, so we can make clear, objective choices about the food we eat.

The fix: When you see a food ad, just take a moment and ask yourself: Why is the company paying for this ad? Is the ad a true depiction of what buying and eating the food is like? Is the food a healthy choice for me and my family? Most of the time, the answers will speak for themselves.


Driving a lot
Many of us need to spend way too much time in cars -- or on buses or subways. It's just a fact of life. We have to get to and from work, pick up the kids, and run errands. But many times, we also take the car or other transportation when we could just as easily walk or ride a bike. And this cuts out a great opportunity to easily add some physical activity to our days.

The fix: If it's safe, try to do some errands on foot or by bike a couple times a week. Then, build from there.


Eating mindlessly
Most of us do some amount of automatic eating -- eating without really thinking about it because there's food in front of us, our favorite TV show is on, or it's a certain time of day. But such mindless eating, usually when we're not even hungry, can add a lot of extra calories to our days.

The fix: Just take a moment and think before you eat. Ask yourself: Am I actually hungry? If you're not, try to do something other than eating for while. Go for a quick walk, play a game, even do some chores or errands you've been putting off.


Throwing in the towel 
Set-backs are natural. We're human. But don't let set-backs frustrate you into abandoning your health goals - even for a day. Yes, you ate five pink cookies you hadn't plan to and missed your workout. That's OK. Keep the long view.

The fix: Stay positive and know that health is a journey. And journeys are rarely straight lines to a destination. There can be twists and turns. Just get back on track and keep moving forward -- knowing you can get where you want to be.


Drinking calories
A lot of beverages are packed with calories -- sugary soda, sweet tea, and many types of blended coffee drinks. On top of this, it's been shown that our bodies don't register these liquid calories as readily as those from food. So, we often don't compensate for beverage calories by eating fewer food calories. The result: extra calories in our day.

The fix: Choose water or unsweetened tea and coffee instead of sugary drinks. Start with just one or two days a week, but eventually try to get down to zero sugary drinks. It's probably not as hard as you think.


Being too refined
Being refined in life is wonderful, but eating too many refined grains is not. Refined grains -- which make up foods like white bread, white rice, and regular pasta -- have had most of their fiber and nutrients stripped out in processing. Diets rich in less-processed whole grains -- like, 100% whole wheat bread, brown rice, and old-fashioned oatmeal -- have been shown to help keep weight in check.

The fix: Try to start buying more whole-grain foods. There are a lot of options these days. Look for foods with "whole" or "whole-grain" as a first ingredient and not too much sugar (7grams/serving or less).


Avoiding the bathroom scale
Not many people enjoy stepping on the bathroom scale. But avoiding it for long periods can lead to unwelcome surprises. Weight gain has a way of sneaking up on people. An extra pound here and an extra pound there can really add up over time. Stepping on the scale weekly, even daily, can help us keep track of our weight and adjust how much we're eating and how active we are.

The fix: Set a date with your scale -- every Tuesday at 7am, say -- and keep it. Want to go a step further? Keep track of your weight with a paper log or smartphone app.


Ignoring calorie labels
One thing's clear by now: calories matter. And although it's not essential to painstakingly track how many calories are in the food we eat, it can be helpful to have a general idea. Some meals, especially when we're eating out, can have a surprisingly large number of calories, at times bordering on a whole day's worth.

The fix: Many restaurants and fast food places post calorie-counts on menus, so they're pretty easy to find. Given them a quick read before you order, so you know what you're getting, and adjust if you need to.


Eating out for lunch - a lot
Eating lunch out -- whether at a restaurant, fast-food place, or food truck -- is often fun, tasty, and easy. But there can be downsides, too. It can be unhealthy, expensive, and calorie-packed.

The fix: Try to brown-bag it more often. Packing your lunch with healthy foods, in modest portions, means you're more likely to keep calories in check.


Waiting 'til tomorrow
Trying to get on a healthier path -- whether it's walking more or eating more fruits and vegetables -- isn't always easy. So, it's natural to want to put things off. And a day here or a day there may not make much difference, but the more you put things off, the more likely you are to keep putting things off. The sooner you get started on a healthier path, the sooner it'll become second nature to you, and the sooner you'll start getting benefits.

The fix: Try a new healthy behavior today, no matter how small it may seem. It can be buying a banana at lunch or walking to a bus stop that's further away than usual. Then keep it up, building over time with other healthy changes. 

You've got this.

Thursday, March 9, 2017

Ready for the Taking: The Economic & Health Benefits of Implementing Cancer Prevention

For a topic that always gets a lot of news coverage, health and healthcare has been in the media even more than usual since the 2016 election. While it’s unclear exactly where the current debates on Obamacare and the American Health Care Act will lead, a Sounding Board article in today’s New England Journal of Medicine by Karen Emmons, PhD and Washington University’s Graham Colditz, MD, DrPH makes one thing clear: we could drastically cut the burden of cancer if we invest appropriate health resources to successfully implementing the things we already know could prevent more than half of all cancers. 


In the sweeping article, Emmons and Colditz detail the often large disparities between states in rates of healthy behaviors that can lower cancer risk. In the nation as a whole, for example, 15 percent of people smoke, but rates vary by 17 percentage points between Utah (9.7 percent) and West Virginia (26.7 percent). Rates of obesity vary by 16 percentage points between Colorado (20.2 percent) and Louisiana (36.2 percent). And rates of physical inactivity vary 15 points between Colorado (16.4) and Mississippi (31.4 percent). Such inequality can be parsed further, with rates varying within states by county and socioeconomic groups, for example.  Vulnerable populations — those in poverty, or with mental health issues, or in minority groups — often have worse health profiles and health outcomes compared to others.

The effort to combat smoking — one of the greatest public health success stories of the past 50 years — still has great room for improvement. State cigarette taxes on a pack of cigarettes, which demonstrably leads to lower smoking rates, vary from less than 25 cents a pack to over four dollars. And evidence-based programs to help people quit smoking are unevenly implemented and unevenly funded not only between states but across town. Devoting enough resources to fully realize the benefit of controlling tobacco use nationwide will have large health and economic benefits.

 Emmons and Colditz write as an example:
“Every $1 expended on a comprehensive smoking-cessation program in Massachusetts was associated with a return on investment of $2.12.”

This Massachusetts program, MassHealth, expanded evidence-based tobacco-cessation coverage in low-income smokers and included effective pharmacological approaches. The program lowered rates of smoking in this group by 26 percent — a group with typically static cessation rates, and the annual rate of admissions for heart attacks dropped 46 percent, and admissions for coronary atherosclerosis dropped 49 percent.

Other cancer-prevention approaches — increasing activity, controlling weight, improving diet, and getting youth vaccinated against HPV, say — also have vast potential for health benefits nationwide.  If they get implemented and implemented effectively.  Yet, efforts to determine the best way to get people and communities to adopt such behaviors — and then to put these into practice — are under-resourced. As Emmons and Colditz write:
“Simply put, as a nation, we continue to underinvest in primary prevention and screening and fail to adopt strategies to ensure that all population groups benefit equally from our knowledge of cancer prevention.”

Yet, as with tobacco cessation, we know certain approaches work with these other risk factors. Rates of HPV vaccination lag significantly between the US and Australia. The US lacks a comprehensive, effective vaccination program, which leads to lower rates overall and large variability between states, with 68.0 percent of girls fully vaccinated in Rhode Island but only 24.4 percent in Mississippi. Australia, on the other hand has an overall rate of 74 percent for girls and one nearly as high for boys.

The difference? HPV vaccination in Australia is mandated for boys and girls and is paid for by the Australian government. The high vaccination rates have led to a substantial drop in positive Pap tests and the need for women to return for after-test follow-up. The future drop in rates of cervical cancer because of HPV vaccination should be substantial.

We should build on such lessons and learn what works best in the US for implementing cancer-prevention strategies. Research should focus on the patient, provider, organization, and policy levels to increase cancer prevention interventions to lower healthcare costs and patient mortality. Such as,
  • Funding for safety net clinics (at-risk populations). Health equity is key. We must be sure to focus on preventing cancer in the most vulnerable populations. 
  • Implementing environment and policy changes. Talking multiple levels of society works, such as smoking bans at work, schools, and restaurants; and required HPV vaccinations for school children. 
  • Fostering a focus on prevention in clinical settings. This can include: Patient education and provider interaction about smoking cessation, lifestyle factors, and recommended screening. 
While learning to effectively put into practice those things we already know can prevent cancer may not be as flashy or newsworthy as the discovery of a new treatment or previously unidentified gene mutation, this doesn’t mean it doesn’t deserve the same attention and the same resources.

The real power of prevention has yet to be realized - or even really appreciated. Yet, prevention has been shown to work in public health interventions, to be cost effective, to lower mortality, and to have a high return on investment.  It is an opportunity that should not be squandered.

As Emmons and Colditz conclude:
“ Although many efforts are under way to maximize our knowledge about the causes and treatments of cancer, we can achieve reductions in the cancer burden right now by doing what we already know works. Enhanced investment in research that increases our understanding of how to implement the knowledge we have is needed. Our moonshot is right here — ready for the taking.”