© Oxford University Press 2006.
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Control Plans Help States Fight Cancer Locally
In 1999, only six states had a blueprint to reduce the cancer burden in their regions by improving primary prevention, early detection, and the quality of treatment. By this summer, the District of Columbia, several tribal organizations, and every state except Oklahoma and Alaska had approved their own comprehensive cancer control plan.
These documents are as diverse as the areas they represent. Some have independent funding and are already being implemented. Delaware, for example, has established a fund that pays for cancer treatment for residents who can't, even though its plan is relatively new. Others plans are, at this point, little more than elaborate to-do lists that have not been acted upon.
What the control plans have in common is that they ask their citizens—everyone from the schoolhouse nutritionist and rural physician to local businesses and priority-setting state legislators—to participate in a collective push against cancer.
These plans represent a reversal in how many view effective cancer control. Rather than directing efforts to reduce cancer incidence and mortality from the national level, experts now believe these efforts are best tackled at the local and regional level, with guidance and limited "prime the pump" funding from the federal government. They have seen how successful locally driven cancer control initiatives can be, such as the grassroots movement to adopt local workplace smoke-free ordinances.
"Everyone wants to do something about cancer, but we have come to recognize that we can't do it by ourselves," said Leslie S. Given, the point person for state-level comprehensive cancer control at the Centers for Disease Control and Prevention (CDC). "Now we are involving everyone."
The effort to draft and adopt state comprehensive cancer control plans reflects a change in how the country's primary cancer organizations work together. After President Richard Nixon declared a "war on cancer" in 1971, the National Institutes of Health, CDC, and the American Cancer Society (ACS) launched largely independent initiatives that barely nudged the cancer death toll. Now they are working with each other and with other organizations to take on cancer.
Before, "we were driving in individual cars all trying to reach the same destination, but we have been working hard together for the past 6 years and are now on the same bus, which can help carry a lot more state and local partners than we could in the past," said Jon F. Kerner, Ph.D., who coordinates the National Cancer Institute's collaboration with other federal agencies to help states draft and implement their plans.
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"The perception we have is that the states appreciate the fact that the national partners are now working together, instead of waving our individual banners as we have historically done," said Kerner, who came to NCI in 2000 after working for 20 years as a researcher in two major cancer centers.
Collaborative Planning
To draft a cancer control plan, each state sets up its own consortium of local experts and citizens, which usually includes state health officials and academic leaders. They contribute to a detailed breakdown of the top cancers in their area—usually lung, breast, and colorectal—and different interventions designed to screen and treat each of these cancers. An executive committee usually makes the final decisions about what goes into the plan, and they are approved within the state. The federal government does not mandate what goes into the plans, and the CDC "approves" them only by funding their implementation. There are no federal sticks, just carrots, and it was peer pressure among the states that pushed many to draft their plans.
Asking states to help control cancer rates in their regions is not new, Given said. The effort has its roots in 1980, after the 1979 Surgeon General's Report laid the foundation for a national prevention agenda. The resulting Healthy People program, established by the U.S. Public Health Service, set national health objectives and served as the basis for the development of state and community health plans.
During that time, the ACS, CDC, and NCI initiated many new research and community initiatives, including programs for tobacco control (COMMIT and ASSIST), dietary change (the 5-a-Day program), and cancer screening (National Breast and Cervical Cancer Early Detection Program). After consulting with public health, primary care, and oncology experts, the NCI produced Cancer Control Objectives for the Nation: 1985–2000 with the ambitious goal of reducing the age-adjusted cancer mortality rate by 50% by 2000.
Although many aspects of the program showed promise, such as tobacco use reduction and increased breast and cervical cancer screening, they achieved few of even the intermediate goals in the NCI program, according to Given and Kerner. And they didn't even get near the mortality reduction goals.
"We realized we needed to involve everyone, including all different kinds of partners and disciplines, and private, public, and not-for-profit interests, and other existing coalitions and programs," Given said. "We started talking with the NCI and ACS, and they too were interested in this concept."
In 1994, these new partners began to define comprehensive cancer control as an emerging public-health need. Meanwhile, some state health departments had already invested in state-based cancer control measures, such as tobacco cessation and cancer screening. To help support this effort, the CDC provided funding in 1998 to five states and one tribal health board with existing cancer control plans to demonstrate that further building the program could help cancer control efforts. Congress then allocated the CDC $15 million annually to help the rest of the states and other entities develop their plans.
In April 2003, the NCI, in collaboration with CDC, ACS, and other national partners, launched the Cancer Control PLANET (Plan, Link, Act, Network with Evidence-based Tools) Web site (http://cancercontrolplanet.cancer.gov) to "ensure that the plans, as developed and implemented, are informed by science," Kerner said.
The PLANET site contains the critical information states need to develop, implement, and evaluate their plans, including statistics on cancer incidence and mortality, program and research partners, research evidence, and examples of evidence-based cancer control programs, he said. It also links to all the plans so the states can learn from each other. "For example, Alaska can find a colorectal screening program that has already been tested somewhere else with similar geographic challenges and can figure out how to adapt it. States don't each have to recreate the wheel," Kerner said. "The PLANET really is a five-step program to help break the addiction to making up everything from scratch."
The result is that 53 targeted cancer control plans have been adopted, Given said. That includes 48 states, the District of Columbia, and four of six tribal programs that are part of the CDC's National Comprehensive Cancer Control Program. Alaska's plan will be released in 2006, and Oklahoma's in January 2007. The 12 U.S. associated territories are working on plans, but none are completed.
Challenges to Implementation
Now the CDC and NCI are holding workshops to help states implement their plans, and this is where the rubber meets the road, many say. "When you implement it, you have to do it at the local level, and the question is how do you get communities to buy into it?" Kerner said. Success at the local level will make the difference in whether state cancer plans die or thrive, he said, "but how do you move a statewide approach into the local level, with over 3,000 counties in the U.S.?"
"Many of us think that when this thing starts flying at the local level, it will drive communities to start pushing the state, demanding directions and resources," said Bruce Black, Ph.D., ACS director of cancer control and planning. "But the worry is now that the plans in place will fall flat once attempts are made to implement them. The critical issue is to keep the momentum going, and with the ACS's strong community volunteer base, we hope to be able to provide an infrastructure to keep things from falling apart."
Including rural residents in the cancer control effort is one of the problems facing Nevada, which is emphasized in the plan the state approved in April. "What I worry about most is that we won't reach the populations that are most affected by cancer," said Charlene Herst, who manages Nevada's plan from the Nevada State Health Division. "We don't have access to care like a lot of states do. We don't have a comprehensive cancer center, and, outside of Las Vegas, the state is mostly rural and frontier, with a large minority population,"
On top of that challenge is the state's existing cancer burden: Nevada ranks ninth in the nation for cancer mortality—in part because it residents are the nation's 11th highest users of tobacco—and its burgeoning population, with 6,000 new residents moving in each month.
But there are several factors on Nevada's side, Herst said, including that the state is young and can start fresh mobilizing its residents to take on the cancer challenge. "We are a state that has been ignored for years because many think of us just in terms of negative behaviors," she said. "When they realize that we have a population that is not drinking, gambling, and smoking 24/7 and that our issues are the same as everyone else's, it gives us a chance to show our stuff."
Herst said that among the strategies Nevada is pursuing is one to beef up the inroads that local ACS chapters have already made in the state's rural areas. "The society has done a lot of rural outreach; they are our major partner in this."
"That has been the historic role of the American Cancer Society," said Black. "Now, working with the states and moving their plans into communities fits in line with our goals."
A Funding Focus
Perhaps the biggest issue facing many states is where resources will come from to implement the plans. "It is the problem," Black said.
"Cancer control will not work as an unfunded mandate because forcing states, tribes, or territories to do something without some guidance and resource support leads nowhere," Kerner said. "Rather, federal government agencies must work together, and with ... the private sector, to provide incentives and encouragement, listen to their needs, and help them to find resources."
For example, the Michigan Cancer Consortium has revised its plan twice since it was first implemented in 1998, and it has already met three of its top 10 goals. But the consortium continues to search for new ways to attract private-sector funds to supplement public-sector dollars. "The current economic environment in Michigan makes this even more challenging," said Patti Brookover, Michigan's control plan program director at the state's Department of Community Health.
"It is helpful that in the late 1980s, Michigan became a leader in addressing mammography quality-control issues, and we built a platform of credibility from which we could easily move into comprehensive cancer control," Brookover said. "Success, experience, skilled leadership, and committed partners have helped to keep the plan afloat."
One funding route being tried by many cancer control planners is pressing their states to dedicate tobacco money, either from the Master Settlement Agreement or increased excise taxes on cigarettes.
Colorado, for example, recently passed a constitutional amendment that instituted a permanent $0.64 tax on a pack of cigarettes, which is expected to raise $175 million a year. More than one-third of those funds will go toward tobacco education and cessation programs and competitive grants to reduce the burden of cancer and other chronic disease.
"It took 10 years, but this is huge for us," said Sara Miller, director of the comprehensive cancer program at the Colorado Department of Public Health and Environment. "Before this, we had to cobble together resources that didn't meet all of our needs."
Colorado was one of the first states to develop a comprehensive cancer control plan, and it is now seeing a reduction in cancer rates. Now the biggest challenge is "continuing to manage the vast amount of work that needs to be done," Miller said.
The state also has a unique burden, she added with a laugh. "We don't want to catch up with the rest of the nation," Miller said. By most measures, Colorado is home to the nation's healthiest residents, she explained, and the skin cancer (including melanoma) that comes from enjoying outdoor life is one of its biggest cancer issues.
"Keeping a cancer control plan going in the state is both complicated and simple at the same time," Miller said. "Managing the plan is a lot of work, and knowing if the things we put in place are being used is difficult. But what is simple is the knowledge that people in Colorado are suffering from cancers, and they don't need to. That provides the passion that keeps us going."
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