Emerging Issues:
Cancer in New Hampshire
Executive Summary
February 2008
New Hampshire Comprehensive Cancer Collaboration
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Development and publication of this report was supported by: the Centers
for Disease Control and Prevention (PA02060) under cooperative
agreement number U55/CCU-121912, the New Hampshire Division of Public
Health Services(DPHS), the New Hampshire Comprehensive Cancer
Control Program, the NH Comprehensive Cancer Collaboration, and the
Foundation for Healthy Communities.
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VISION
The vision of the New Hampshire Comprehensive Cancer Collaboration is for
cancer incidence, morbidity, and mortality to be significantly reduced or
eliminated and for the people of New Hampshire to enjoy health and quality of
life.
MISSION
The mission of the Comprehensive Cancer Collaboration is to reduce
significantly the incidence of, suffering from, and mortality due to cancer for
people in New Hampshire through prevention, early detection, treatment,
rehabilitation, and palliation. We will accomplish this goal by means of an
integrated and coordinated alliance of stakeholders that will utilize available
epidemiological data and evidence based research to set priorities for action.
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EXECUTIVE SUMMARY
This report was prepared for the New Hampshire Comprehensive Cancer
Collaboration Emerging Issues in Cancer workgroup by the Plymouth State
University Center for Rural Partnerships in collaboration with researchers at
Keene State College. The purpose of the report is to detail emerging issues
related to cancer, which can be introduced to health care providers, policy
makers, health care advocates, and the general public in New Hampshire. The
information in this literature review will also be provided to the other New
Hampshire Comprehensive Cancer Collaboration workgroups to inform and help
in the development of their education and media campaigns.
The World Health Organization Cancer Control Programme describes cancer’s
worldwide reach.
“Cancer affects everyone – the young and old, the rich and poor, men,
women and children – and represents a tremendous burden on
patients, families and societies… Yet, many of these deaths can be
avoided. Over 40% of all cancers can be prevented. Others can be
detected early, treated and cured. Even with late stage cancer, the
suffering of patients can be relieved with good palliative care (WHO
2006).”
Cancer is a generic term for a group of more than 100 diseases that affects all
body parts. What all cancers have in common is unrestrained cell growth and
division caused by damage to the genes regulating the cell division and repair
cycle. This rapid growth of abnormal cells can grow beyond their usual
boundaries and invade adjoining body parts. Cancer is caused by internal and
external factors. Internal factors include inherited mutations, hormones, immune
conditions, and mutations caused by metabolism, etc. External factors include
tobacco, radiation, chemicals, or infectious agents, etc. (ACS 2007). Much time
may pass in-between exposure to an external factor and detectable cancer, but it
all starts with one abnormal cell (ACS 2007; WHO 2006). Research into all
aspects of cancer is ever-growing causing an ever-growing understanding of the
disease.
Research into all aspects of cancer is ever-growing, causing an evergrowing understanding of the disease. However, people want to know what is
their risk of getting cancer? Every person can develop cancer, but some people
have varying risks that decrease or increase this chance. Risk is a mathematical
probability of something occurring. Scientists calculate cancer risk estimates by
studying large groups of people to discover the probability that a person or
category of people will develop cancer over a certain time-period (Mayo Clinic
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2007). According to the American Cancer Society publication Cancer Facts &
Figures- 2007 American men have a lifetime risk of slightly less than 1 in 2 of
developing cancer. The lifetime risk for an American woman developing cancer
is slightly more than 1 in 3. Lifetime risk is a term that describes the probability
that a person will develop or die from cancer over the course of a lifetime.
Lifetime risk is a type of absolute risk- the actual numeric chance or probability of
developing cancer during a specified time period. There is another type of
calculated cancer risk- relative risk. Relative risk is a comparison of a certain
risk factor and the people exposed to that specific risk factor. Relative risk looks
at the strength of relationship between a risk factor and the heightened or
lessened chance of cancer (ACS 2007; Mayo Clinic 2007).
In 2005, New Hampshire Comprehensive Cancer Collaboration (NHCCC)
released its plan, Cancer in New Hampshire: A Call to Action 2010. The first
priority is to ensure that it not just be a report on cancer but “function as a clearly
defined action plan to reduce the incidence, morbidity and mortality of cancer.”
Incorporated into the NHCCC plan in the spring of 2005, the Emerging Issues
(EI) workgroup was charged with the goal of identifying emerging issues in
cancer in New Hampshire and developing an action plan that will benefit New
Hampshire residents and health care providers. Towards that aim, the EI
workgroup identified a priority objective to increase public and provider
awareness regarding emerging issues in cancer in New Hampshire. The EI
workgroup proposes to achieve that goal in two phases. This report comprises
part of Phase One.
Phase One of the EI workgroup action plan includes a strategy to identify
existing national and local resources that contain evidence-based research on
emerging issues in the following areas: primary prevention, early detection,
treatment, survivorship, and palliation; environmental factors that may lead to
cancer; and emerging studies and data relevant to New Hampshire residents and
providers. Phase Two will include a plan for the dissemination of “emerging
issues” information in order to increase awareness of the public and providers,
with a specific emphasis on prevention and environmental factors relevant to
New Hampshire residents and providers.
This report is intended to inspire additional conversation and research on
the emerging issues in cancer. The authors hope that the report will become a
“living document” that will grow and develop with more input. In its current form,
it is comprised of a literature review, internet-based research, and
correspondence with scientists and health care providers. Students at Plymouth
State University and Keene State College1 conducted research for this report
1
Stacy Luke and Casey Doyle at Plymouth State University and Jaime Ingalls at Keene State College
conducted this research. Stacy Luke was the project leader with support and oversight from Thaddeus
Guldbrandsen, Director of the Center for Rural Partnerships at Plymouth State University. Work was done
in dialogue with the NHCCC EI Workgroup, especially Laura Holmes and Martha Hill.
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with oversight by the director of the Plymouth State University Center for Rural
Partnerships.
Emerging issues include new scientific discoveries, new developments in
health care, and topics of renewed public interest. Data collection for this
document proved challenging in that many scientists and health care providers
were unable to provide information about the latest emerging issues for
identifiable reasons. Therefore, not all emerging issues in New Hampshire are
included. In some instances, scientists were unable to report on emerging issues
prior to undergoing a rigorous peer review process and publication. Some
information was proprietary in nature, and researchers were unwilling to report it
to the authors of this report. Finally, busy schedules of scientists and health care
providers made it challenging to collect information within a specified time frame.
Once this report is made public, the authors hope that additional information will
be forthcoming.
For the most part, emerging issues in New Hampshire are the same as
those in the rest of the country, with some exceptions. There are a few
differences due to our geography, rural areas, cultural make-up, and geology.
For example, because of the state’s unique geology, radon and arsenic can pose
significant cancer hazards for New Hampshire residents. The uneven distribution
of health care providers, hospitals, and palliative care providers within the state
also impacts outcomes associated with cancer and its treatment. Social
inequality and poverty pose challenges for cancer diagnosis and treatment in
New Hampshire, as it does elsewhere in the United States. Finally, because
many of the state’s employers are small businesses, access to health insurance
is a particular concern for the population.
This document focuses on the predominant forms of cancer in New
Hampshire; therefore, information on certain types of cancer, such as leukemia
and brain cancer, are underrepresented.
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KEY TOPICS: AN OVERVIEW OF EMERGING ISSUES
This section highlights prominent emerging issues noted in the literature
review and conversations with scientists and health professionals.
Tobacco Use
The negative health impacts of tobacco use are well established; however,
current research focuses on the effects of tobacco advertising, behavioral
counseling, and the methods best used to reduce smoking (smoking bans,
smoking cessation programs, etc.). This section of the literature review focuses
on emerging issues regarding the effects of advertising on tobacco use and the
methodology used in smoking cessation programming and behavior counseling.
The types of advertising researched include those made by smoking
companies as well as public service announcements geared toward reducing
tobacco use. In the studies cited, advertising of tobacco products was found to
have a direct effect on teens’ use of tobacco products and that reducing the
exposure to tobacco product advertising reduces the number of young smokers.
These studies recommend that restrictions on tobacco advertising be increased,
and tobacco-warning labels be made more effective.
Studies also indicate that one-on-one behavior counseling with numerous
meeting points over a sustained time period are extremely beneficial in helping
mothers reduce their smoking, and therefore, the exposure of Environmental
Tobacco Smoke (ETS) to their children.
Exposure to Radiation
Studies show that radiation is both a cause of and treatment for cancer.
Ionizing radiation has recently been linked as a cause of several cancers,
including childhood leukemia, breast cancer, and skin cancer (Belson et al. 2007;
Cardis et al. 2007; Lichter et al. 2000). As the effects of therapeutic ionizing
radiation become better known, the role of ionizing radiation in cancer screening
is inevitably affected. New screening tools are sought, such as ultrasound for
breast cancer screening. Scientific studies have shown that ultraviolet radiation
is a well-known cause of skin cancer though the exact role on the human body is
still incompletely known. Emerging issues related to ultraviolet radiation include
gene-environment interactions related to skin cancer susceptibility, peoples’
behaviors regarding sun safety, and the possible therapeutic role it plays in
reducing the risk of non-Hodgkin’s Lymphoma, breast, colon, ovary, and
prostate cancers.
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A study of the Portsmouth Naval Shipyard indicates that there has been a
connection to higher levels of exposure to ionizing radiation and an increase in
leukemia cases (Yiin et al. 2005). However, researchers conclude that more
research needs to be conducted to definitively conclude the findings because of
the small population size of the study. Therapeutic radiation has been connected
to an increased risk for developing basal cell carcinoma (BCC) and squamous
cell carcinoma (SCC).
Studies indicate that education programs about proper skin protection
against ultraviolet radiation (UV) exposure have been beneficial in improving the
skin protection habits of individuals. In addition, providing multiple points of
contact for education reinforcement has been found to be most effective (Olsen
et al. 2007).
Cumulative Exposure to Pollutants
Growing evidence shows that the human body is exposed to numerous
toxicants at low levels. Though each individual pollutant is encountered at
assumingly “safe” levels, the cumulative effects of many pollutants may cause
numerous diseases, including cancer. Citations include the environmental
pollutants arsenic, radon, MtBE, pesticides, dioxins, coal tar, and more. An
additional source of cumulative exposure may also include the chemical
ingredients in some personal care products. Our research also indicates that
human biomonitoring is a growing field by the Centers for Disease Control and
Prevention (2001, 2003, 2005) and others such as Angerer et al. (2007) that is
being used to detect and track cumulative exposure to pollutants.
Arsenic
There is current and on-going research regarding arsenic in drinking
water. The United States Geological Survey (USGS) is working to document
areas where high levels are present (Ayotte et al. 2006). This research
concludes that the use of well water from private sources may correlate with
excess bladder cancer mortality in New England. Analytical studies are underway
to clarify the relation between suspected water contaminants, particularly arsenic,
and raised bladder cancer rates in northern New England. Ayotte et al. (2006b)
also created a model to predict the probability of arsenic levels beyond the
recommended levels.
MtBE
The United States Geological Survey (USGS) is mapping areas with high
levels of MtBE. Whether or not MtBE is a carcinogen is not yet clear. The
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research on MtBE in the state is not tied to any health effects. Current focus is
on mapping the occurrences of MtBE in public and private wells in New
Hampshire. A study for Rockingham County is completed (Ayotte et al. 2005),
while another statewide study is currently undergoing peer review (Ayotte, pers.
comm.).
Air Quality
There is significant research on the dangers of occupational and
environmental exposures to a variety of airborne contaminants (radon, particulate
matter, arsenic), in addition to smoking, that may have a connection to lung
cancer. Some of the most important emerging and ongoing concerns for
exposure in New Hampshire are indoor radon levels, outdoor ambient air
particulate matter (PM) concentrations, and exposure to cigarette smoke. The
studies cited in this report indicate that there is a need for increased education
about indoor radon exposure risks for homeowners in particular. Studies also
show that PM exposures of size cut less than or equal to 2.5 microns comprised
of metals and other volatile organic compounds are gaining the attention of
regulators nationwide; however, the need for more analytical data has been
stated. Research at Keene State College identifies diesel exhaust as a possible
factor in lung cancer in occupational settings and possibly for the general
population.
Diet and Nutrition
Scientific debates about the role of nutrition in cancer risk and prevention
are on-going. There are several citations on the benefits of a Mediterranean diet
on cancer prevention. There are new studies on Vitamin D deficiency and
cancer (Grant 2006; Giovannucci et al. 2006; Meyer 2004; Schwartz and Skinner
2007). According to Giovannucci & Michaud (2007), metabolic disruptions
caused by obesity increase occurrences of certain cancers such as colon,
prostate, and pancreatic cancer. Obesity may also reduce the effectiveness of
treatment (Stroup et al. 2007; Dignam et al. 2006; Pierce et al. 2007).
Healthcare Access
In the interviews conducted with health care providers for this review,
equitable access to high-quality health care was identified as a recurring theme.
Interviewees believed that before cancer incidence and deaths can be reduced,
New Hampshire residents must have access to healthcare for preventative
education, screening, and, if needed, treatment. The literature review indicates
that there are many barriers to healthcare access in New Hampshire: cost,
insurance, distance, personal beliefs, and disparities due to gender, race,
ethnicity, primary language spoken, or socio-economic status.
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Cancer Prevention And Screening
Information on cancer prevention was not readily available on all kinds of
cancers. In the case of colorectal cancer, there was information on screening,
which remains a significant concern. Emerging issues in colorectal screening
include issues found in other cancer screening programs: risk assessment,
genetic testing, patient-health care provider communication, access to health
care, social disparities, and cultural beliefs. Citations found in this section
discuss these issues and areas of improvement.
Currently, there are no evidence-based guidelines for colorectal screening
(Marcella et al. 2007). The other topic of interest in screening has been about
prostate cancer, The symptoms and signs of prostate cancer usually manifest
after it is too late to 'cure' the condition, making screening for the cancer
essential to reduce prostate cancer deaths (Frydenberg & Wijesinha 2007).
Screening usually takes two forms: prostate specific antigen (PSA) and digital
rectal examination. Many barriers exist to screening, particularly cultural beliefs,
patient-health care provider communication, and perceived risk. Citations in this
section address these barriers and others with discussions on improving prostate
screening for all men.
Cancer Treatment
Emerging issues in cancer treatment include targeted therapies aimed at
the biochemical pathways or gene interactions in the development of cancer.
Early studies of targeted cancer treatments show promising results. With these
studies, researchers are led to believe that generalized treatment for the body
part the cancer is affecting may be replaced by a treatment based on the
molecular biology of the mutated cells. Such studies include targeted treatment
of non-small cell lung cancer (Zalcman et al. 2007), multiple myeloma (Anderson,
2007), and nucleotide-based targeted therapies for prostate cancer (Sowery et
al. 2007). Additional studies and clinical trials are underway, such as the
TailorX Trial, which is using molecular profiling to determine who will benefit the
most from chemotherapy.
This review found that many patients struggle with the decision to use
surgery, chemotherapy, radiation, or other “traditional” treatments for cancer.
Some patients are choosing complementary therapies, in part or in whole, to
treat their cancer. According to studies cited, complementary/alternative
therapies are becoming increasingly popular and research into their use, their
effectiveness, and their relationship with traditional therapies are emerging
issues worldwide. This section includes citations on general use of
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complementary therapies with several references specifically on dietary
supplements.
Palliation
Palliation is care given to patients and families who face life-threatening
illness by providing pain and symptom relief, spiritual and psychosocial support
from diagnosis to the end of life and bereavement (WHO 2006). This review
suggests a general misperception about palliation as being only hospice care for
the end-stage of life. Emerging issues in palliation include the use of behavioral
interventions (Redd et al. 2001) and mind-body therapies (Astin et al. 2003) in
symptom management versus an emphasis on medications. The research work
on the role of chemotherapy and radiation in palliation is also reviewed in this
document.
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