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Montana Comprehensive Cancer Control Plan, 2006-2011
Montana Cancer Control Coalition: Working Together.
Cover Letter:
May 2006
We are pleased to present you with a copy of this newly released Montana
Comprehensive Cancer Control Plan 2005-2011. If you have received more than one
copy, please pass the extra to a friend or colleague.
Montana’s Comprehensive Cancer Control Plan is a living document designed to
guide a unified and collaborative effort covering the five-year period between
2006 and 2011. It offers a framework for statewide cancer prevention and
control, utilizes evidence-based strategies and sets priorities for public and
private cancer-control activities. The intent is to implement the plan by
engaging individuals and organizations to work together to control cancer.
Cancer has affected us long enough. Working together, we can ensure a healthier
Montana.
The Montana Cancer Control Coalition (MTCCC) represents a broad spectrum of
partners who want to reduce the burden of cancer in our state. They have worked
together for over two years to develop Montana’s Comprehensive Cancer Control
Plan. The MTCCC includes cancer survivors, caregivers, medical professionals,
hospital administrators, legislators, and representatives of nonprofits, the
Department of Public Health and Human Services (DPHHS), private and public
organizations, and other health advocates – all sharing their knowledge,
experience and expertise.
We look forward to sustaining and expanding participation as the MTCCC moves
forward toward implementation. For more information or to access the Plan
online, visit www.cancer.mt.gov or call
406-444-3624. To help control cancer in our state, join the MTCCC in
implementing the Plan by completing and returning the Member Information Form or
submit the form online.
Sincerely, Montana Cancer Control Coalition
Montana Comprehensive Cancer Control Plan, 2006-2011
Vision: A comprehensive, statewide, evidence-based approach to reduce the burden
of cancer in Montana, motivated by compassion...an investment in the future.
Mission:
1. To reduce cancer incidence, morbidity, and mortality in Montana through a
collaborative partnership of private and public individuals and organizations.
2. To develop, implement, promote, and advocate for a statewide, coordinated,
integrated approach to control cancer for all Montanans.
3. To ensure quality of life through prevention, early detection, treatment,
research, rehabilitation, and palliation.
Purpose: The Comprehensive Cancer Control (CCC) Plan will serve as a guide for a
Comprehensive Cancer Control Program for Montana. This is a participatory model
that allows the involvement of all touched by cancer, and encourages statewide,
community level participation. It has been designed to evolve with changing
circumstances, and to allow flexible and creative responses to emerging issues.
This plan will promote the collaboration needed to achieve comprehensive cancer
control in
Montana.
Guiding Principles: Best practices; comprehensive; cost sensitive; culturally
sensitive; data driven; evidence based; evolutionary and responsive; outcome
oriented; respectful of the individual's rights, dignity, privacy, and safety.
My Fellow Montanans: It’s likely that every one of us has been impacted by the
burden and tragedy of cancer. It affects fathers and mothers, children,
grandparents…and it could strike any of us tomorrow, next week, or a year from
now.
The medical field has made great progress in the fight against cancer over the
last decade, and I believe we are on the verge of breakthroughs on a number of
social, medial and scientific fronts. Effective cancer prevention and control
requires thorough, collaborative planning and coordination. The Montana Cancer
Control Coalition has taken on that task. Over the last two years, this
coalition has brought together hundreds of people from around our state.
Together they have created a plan that will help prevent, reduce, and control
cancer. These committed people shared their collective knowledge and expertise
for the good of all. The result is this five-year Comprehensive Cancer Control
Plan for Montana.
The plan is a living document, and one that will change and evolve over time. It
is also a plan that honors our ability to make progress in our efforts to
control a deadly disease. This is a process that can – and – should give us hope
for the future. By working together, we can truly ensure a healthier Montana.
(signed) Governor Brian Schweitzer.
This plan reflects the work of dozens of organizations and over 150 Montanans.
They came together to share their time, knowledge and resources. Each and every
one deserves our heartfelt appreciation for their unselfish investment in a
healthier Montana.
Contents:
Executive Summary and Introduction
The Burden of Cancer
Prevention
Early Detection
Treatment
Quality of Life & Survivorship
Research
Data, Registry & Surveillance
Advocacy
Implementation, Evaluation & Evolution
Resources & Glossary
Member Information Form
Executive Summary: Montana’s CCC Plan 2006-2011
Cancer accounts for more than one in five Montana deaths.
Who: The Montana Cancer Control Coalition (MTCCC) is a diverse group of
individuals and organizations working together to reduce cancer incidence,
morbidity, and mortality for all Montanans through a statewide, coordinated,
integrated approach to controlling cancer and ensuring quality of life and
survivorship. The MTCCC has developed this Montana Cancer Control Plan with
broad public involvement throughout the process and from public comments.
What: The CCC Plan is a guide for achieving the following overarching goals:
1. Work to prevent the incidence of cancer by reducing risk factors.
2. Detect cancer at the earliest stage possible.
3. Promote access to quality comprehensive cancer care.
4. Optimize the quality of life and survivorship for those affected by cancer.
5. Support research to best improve cancer control.
6. Monitor, disseminate and utilize cancer data while improving the consistency,
coordination, and compliance of reporting and surveillance.
7. Monitor, document, and work to eliminate disparities across the cancer
continuum.
8. Develop and support policies and initiatives that enable cancer control.
How: The CCC Plan describes priorities for cancer prevention and control
activities in the following sections: Burden; Prevention; Early Detection;
Treatment; Quality of Life and Survivorship; Research; Data, Registry and
Surveillance; Advocacy; and Implementation, Evaluation and Evolution. In
addition to the goals, objectives and strategies in each section, please note
the “What You Can Do” lists.
This plan has a purpose beyond the identified goals and objectives. It is a
living document that represents Montana's determination to prevent and control
cancer. The objectives delineated in this plan are far-reaching and complex. The
MTCCC is in the process of implementing this CCC Plan. No one individual or
organization has the capacity to carry out all of the activities. Please take
this opportunity to help put the Montana CCC Plan into action by joining the
MTCCC in preventing and controlling cancer. The member information form is at
the end of this printed document and on the webpage at
www.cancer.mt.gov .
Why:
1. Montana’s Central Tumor Registry records approximately 5,000 new cancer case
per year. In 2003, there were 4,632 new cancer cases.
2. The overall annual cost of cancer to Montana is about $588 million.
3. The American Cancer Society reports that more than 60 percent of all cancer
deaths in the United States could be prevented.
4. National Cancer Institute predictions indicate that if current trends
continue, 1/3 of all Americans will be diagnosed with cancer in their lifetimes.
The Plan: History and Next Steps.
Comprehensive Cancer Control (CCC) is "an integrated and coordinated approach to
reduce cancer incidence, morbidity and mortality through prevention, early
detection, treatment, rehabilitation and palliation." (CDC, 2002.)
The burden of cancer on Montana is tremendous. On average, 5,000 new cancer
cases will be diagnosed annually in Montana. Cancer also stands as the second
leading cause of death, taking approximately 1,800 Montana lives each and every
year. No one is exempt from developing cancer, though age is a primary risk
factor. About 77 percent of all cancers diagnosed will be among people aged 55
or older. The good news is that advances in screening, early detection, cancer
treatment, and follow-up care are allowing more people to live "beyond" cancer
each year. While progress has been made to reduce cancer incidence and
mortality, significant challenges still lie ahead. At the same time, fiscal
constraints are driving cancer-related programs and organizations at all levels
to find smarter, more effective and efficient ways to fight the disease.
There is a strong national initiative to include cancer control in public health
activities. This dialogue on cancer began several years ago, and has grown into
a national movement to initiate formal, state-level comprehensive cancer control
planning efforts, primarily funded by the Center for Disease Control and
Prevention (CDC). Cancer control plans become the stepping stones for advancing
cancer prevention and control. State and tribal governments have been encouraged
to develop their own plans to address their own unique cancer burdens and
resources.
In October 2003, Montana began creating its Comprehensive Cancer Control Plan.
The people who came together became the Montana Cancer Control Coalition, which
is comprised of survivors, medical professionals, hospital administrators,
representatives of nonprofits, staff from the Cancer Control Section of the
Department of Public Health and Human Services (DPHHS), organizational
representatives, and others. This planning group recognized common threads.
These included the need to enhance education, communication, survivorship,
knowledge of resources, and to identify
barriers to availability, accessibility, and utilization of services. Defining
the burden of cancer and healthcare disparities were considered key first steps
to the prevention and reduction of cancer. The MTCCC recognizes the special
circumstances of American Indians with regard to cancer disparities, access to
healthcare, self governance, and cultural uniqueness. The language of the plan
is deliberately broad; references to patients, healthcare providers, and health
facilities are intended to be inclusive of all residents of Montana.
The MTCCC has been working together to identify and prioritize areas of need and
challenge in Montana's efforts to prevent and control cancer. In 2004, on behalf
of the Montana Cancer Control Coalition, the Montana Department of Public Health
& Human Services (DPHHS) entered into a cooperative agreement with the Centers
for Disease Control and Prevention. Funds were provided to Montana to develop
this Comprehensive Cancer Control (CCC) Plan.
The MTCCC prioritized cancer-control issues for Montana. Goals, measurable
objectives and data sources were established for each issue. Coalition members
reviewed, revised, and approved a draft plan. The public was then invited to
review the plan and to submit their comments. A summary is available online at
www.cancer.mt.gov .
A Guide for Statewide Cancer Prevention and Control.
The Plan…Next Steps:
Montana's CCC Plan covers the five-year period between 2006 and 2011. It offers
a framework for statewide cancer prevention and control, utilizes evidence-based
strategies, and sets priorities for public and private cancer control
activities.
The goals, objectives, and strategies are provided for each section of this plan
are designed to serve as a guide and a call to action. No one document can cover
all cancer sites, treatment protocols, or emerging best practices, but this plan
attempts to include the sites, interventions, and issues that research suggests
will impact cancer incidence, morbidity, mortality, and quality of life. The
intent is to engage individuals and organizations involved in any aspect of
cancer control in the process of implementing this plan.
The CCC Plan is designed to serve as a living document that can guide unified
and collaborative action. It will be modified as the state moves into
implementation, as evidence and needs change, and as new issues emerge.
The success of this document and Montana’s efforts to prevent and control cancer
depends on translating strategies into action. To do so will require substantial
indivudal and organizational involvement throughout the state.
We welcome your active involvement in implementing this plan and in breathing
life into a sustainable effort. We’ve set some lofty goals, but they are
achievable if we work together. We can turn this plan into reality.
A membership form is included at the end of the printed plan and on the Cancer
Control webpage www.cancer.mt.gov .
Please complete and return it. The comprehensive approach to cancer control is
an emerging strategy that seeks to ensure that all of a state's cancer-fighting
resources, from government programs to private organizations, are working
together to fight cancer in every community, on all fronts, from prevention and
early detection to treatment, rehabilitation, and end-of-life care. (The Council
on State Governments).
The Benefits of Comprehensive Cancer Control:
1. Maximizes resources
2. Reduces duplication of efforts
3. Enables changes in systems and policies
4. Enables multi-level, simultaneous interventions
5. Maximizes impact on reducing incidence and mortality, and improving quality
of life.
Montana's CCC Plan Goals at a Glance:
1. Prevention: Reduce the risk factors that lead to cancer, e.g., tobacco, poor
nutrition, inactivity, obesity, ultraviolet light exposure, and environmental
carcinogens.
2. Early Detection: Broaden coverage, increase utilization, and promote
compliance with cancer-screening guidelines.
3. Treatment: Ensure prevailing standards of care, accessibility, availability,
and utilization of cancer treatment services for all. Promote optimum
patient/provider communication.
4. Quality of Life & Survivorship: Promote quality of life for cancer patients;
empower patients and families; ensure age-appropriate services for children; and
ensure opportunities for safe and effective use of complementary medicine.
5. Research: Provide access to cancer research information and ensure
high-quality cancer research.
6. Data, Registry & Surveillance: Collect, analyze, and disseminate quality
cancer-related data.
7. Advocacy: Implement Montana's Comprehensive Cancer Control Plan.
The Burden of Cancer:
Rates: According to the National Cancer Institute, cancer incidence rates in
Montana continue to rise, as they have since 1990. In 2003, the Montana
incidence rate was 472.0 per 100,000, as compared to the United States incidence
rate, which was 471.4 per 100,000. The actual number of cancer incidences are
converted to age-adjusted rates per 100,000. This allows comparison of Montana
data with that of other states and the nation.
Disparities: As is clear from the graph described below, there are grave
disparities between the Montana cancer rates for American Indian and White
populations and between men and women. In general, rates among men tend to be
higher than those among women, and higher among American Indians than among
Whites. American Indian men exhibit the highest cancer incidence rates of all
four groups.
Description of figure: Montana Cancer Incidence Rates: White and American Indian
by Gender. (Please note that actual data for this line graph were unavailable,
so this description estimates each data point. In 1991-1993, the incidence of
cancer for White females was about 362 per 100,000. The incidence of cancer for
Native American females was about 442 per 100,000. The incidence of cancer for
White males was about 512 per 100,000. The incidence of cancer for American
Indian males was about 618 per 100,000. In 1994-1996, the incidence of cancer
for White females was about 380 per 100,000. The incidence of cancer for
American Indian females was about 510 per 100,000. The incidence of cancer for
White males was about 511 per 100,000. The incidence of cancer for American
Indian males was about 759 per 100,000. In 1997-1999, the incidence of cancer
for White females was about 412 per 100,000. The incidence of cancer for
American Indian females was about 556 per 100,000. The incidence of cancer for
White males was about 530 per 100,000. The incidence of cancer for Native
American males was about 709 per 100,000. In 2000-2002, the incidence of cancer
for White females was about 418 per 100,000. The incidence of cancer for
American Indian females was about 530 per 100,000. The incidence of cancer for
White males was about 559 per 100,000. The incidence of cancer for American
Indian males was about 730 per 100,000. End of description.
National studies suggest that poverty may be one of the root causes of this
inequity and that disparities in cancer incidence rates are driven by a complex
set of social, economic, cultural, and health system factors. Disease always
occurs within the context of human circumstances, including social position,
economic status, culture, and environment. Poverty, culture and social injustice
are believed to be the three principle determinants of cancer disparities. These
factors are interrelated and, to some extent,
superimposed. (Source: Poverty, Culture, and Social Injustice: Determinants of
Cancer Disparities. Harold P. Freeman, MD. CA: A Cancer Journal for Physicians.
Online: http://amcacersoc.org ).
Incidence: The average incidence of cancers in Montana, grouped according to
anatomical site, reveals that the four most common types of invasive cancer are
prostate, breast, lung/bronchus, and colorectal. Cumulatively, these four
cancers account for 56.8 percent of all diagnosed invasive cancers in Montana.
Adding cancer of the bladder (including in-situ cases), non-Hodgkin lymphoma,
uterus, and all leukemia brings the cumulative total to 70.7 percent. (Montana
Central Tumor Registry: 1999- 2003.)
Five-year averages for Montana males (1999 to 2003) reveal that three cancer
sites: prostate (33.2%), lung/bronchus (14.3%), and colorectal (10.4%), account
for 57.9 percent of all cancer incidences, as compared to 56.8 percent for males
in the U.S. (CDC, 2001). Five-year averages for Montana females reveal that
three cancer sites: breast (30.8%), lung/bronchus (13.6%), and colorectal
(11.0%), account for 54.4 percent of all incidences, as compared to 56.0 percent
for females in the U.S. (CDC, 2001).
Stage: Stage at the time of cancer diagnosis is an important predictor of the
outcome of treatment. The earlier cancer is diagnosed, the better the chances of
survival. Between 1999 and 2003, 46 percent of all cancers diagnosed in Montana
residents were at a local stage, 22 percent were regional (spreading beyond the
organ of origin but remaining within the anatomical region), and 18 percent were
diagnosed at a distant (metastasized) stage. The majority of prostate (70%) and
breast (63%) cancers were
diagnosed at a local stage. With colorectal cancer, 37 percent were diagnosed at
a local stage. With colorectal cancer, 37 percent were diagnosed at a local
stage; with lung cancers, only 16 percent were diagnosed at a local stage.
Five-Year Cancer Survival in Montana: The five-year relative survival rate is
the percent of patients surviving five years after diagnosis. The description of
the following table shows the Montana survival rate in comparison with the
United States rate. Survival rates are for all sites, as well as for prostate,
breast, colorectal and lung.
Description of Table: Five-year Survival Rates in Montana. Survival rate for all
stages and all sites was 66%. For all stages of prostate cancer, survival rate
was 98.7%. For all stages of breast cancer, survival rate was 90.6%. For all
stages of colorectal cancer, survival rate was 66.8%. For all stages of
lung/bronchus cancer, survival rate was 14.3%. Survival rate for localized
cancer of all sites was 94.8%. Survival rate for localized prostate cancer was
100%. Survival rate for localized breast cancer was
97.7%. Survival rate for localized colorectal cancer was 92.7%. Survival rate
for localized lung/bronchus cancer was 46.6%. Survival rate for regional cancer
of all sites was 62.8%. Survival rate for regional prostate cancer was 100%.
Survival rate for regional breast cancer was 86.9%. Survival rate for regional
colorectal cancer was 69.7%. Survival rate for regional lung/bronchus cancer was
16.8%. Survival rate for distant cancer of all sites was 20.9%. Survival rate
for distant prostate cancer was
29.4%. Survival rate for distant breast cancer was 20.9%. Survival rate for
distant colorectal cancer was 10.8%. Survival rate for distant lung/bronchus
cancer was 2.1%.
Five-year Survival Rates in the U.S.. Survival rate for all stages and all sites
was 66.3%. For all stages of prostate cancer, survival rate was 99.9%. For all
stages of breast cancer, survival rate was 89.1%. For all stages of colorectal
cancer, survival rate was 65.6%. For all stages of lung/bronchus cancer,
survival rate was 15.7%. Survival rate for localized cancer of all sites is
unavailable. Survival rate for localized prostate cancer was 100%. Survival rate
for localized breast cancer was 97.7%. Survival rate for localized colorectal
cancer was 90.4%. Survival rate for localized lung/bronchus cancer was 49.5%.
Survival rate for regional cancer of all sites is unavailable. Survival rate for
regional prostate cancer was 100%. Survival rate for regional breast cancer was
81.3%. Survival rate for regional colorectal cancer was 67.9%. Survival rate for
regional lung/bronchus cancer was 16.2%. Survival rate for distant cancer of all
sites is unavailable. Survival rate for distant prostate cancer was 33.5%.
Survival rate for
distant breast cancer was 26.1%. Survival rate for distant colorectal cancer was
9.7%. Survival rate for distant lung/bronchus cancer was 2.1%. U.S. rates are
from SEER (Statistics, Epidemiology, and End Results) 1995-2001. Five year
survival for all sites by stage at diagnosis is not available for the U.S. End
of description.
Stages of Cancer:
1. A localized cancer is limited to the site of origin. There is no evidence of
metastasis elsewhere in the body.
2. A regional cancer extends beyond the limits of the site of origin into
surrounding organs or tissues or regional lymph nodes.
3. A distant cancer extends beyond adjacent organs, metastasizes to distant
sites, or to distant lymph nodes.
Mortality: Cancer is the second leading cause of death in Montana, and accounted
for 21.8 percent of all 2003 deaths in Montana. Nationally, cancer accounted for
22.8 percent of all deaths in 2002. There are approximately 1,880 cancer deaths
annually in Montana. These include cancers of the lung, bronchus and trachea
(30%), colon and rectum (9%), prostate (6%), and breast (6%), which together
accounted for 50 percent of Montana's 2003 cancer deaths. The age-adjusted
cancer mortality rate
(1999 . 2003) for all cancer sites (including prostate, breast, lung,
colorectal, and
others) combined was 190.8 per 100,000. This is relatively consistent with
national
rates of 197.8 per 100,000.
Description of figure: Montana Observed Mortality Rates. This line graph shows
deaths per 100,000 resident population by year for all races and ages. Figures
for breast cancer are for females only. Figures for prostate cancer are for
males only. Figures for lung/bronchus and colorectal cancers are for both
genders. Data source is
http://statecancerprofiles.cancer.gov . In 1978, the rate of deaths from
lung/bronchus cancers was 38.0. In 1980, it was 43.9. In 1985, it was 44.6. In
1990, it was 50.4. In 1995, it was 50.5. In 2000, it was 49.5. In 2002, it was
51.9. In 1978, the rate of deaths from breast cancer was 29.5. In 1980, it was
26.2. In 1985, it was 28.1. In 1990, it was 34.1. In 1995, it was 33.9. In 2000,
it was 24.8. In 2002, it was 27.1. In 1978, the rate of deaths from prostate
cancer was 43.5. In 1980, it was 34.7. In 1985, it was 43.4. In 1990, it was
40.6. In 1995, it was 35.7. In 2000, it was 27.8. In 2002, it was 27.6. In 1978,
the rate of deaths from colorectal cancers was 26.6. In 1980, it was 26.9. In
1985, it was 26.4. In 1990, it was 21.5. In 1995, it was 19.0. In 2000, it was
20.1. In 2002, it was 17.7. End of description.
Heart disease remains the leading cause of death in Montana, at 23.4 percent in
2003.
The Financial Burden of Cancer
In 2002, cancers cost this country over $179 billion overall. This includes more
than $110 billion for lost productivity and over $60 billion for direct medical
costs (CDC, 2003). Each year breast cancer treatment costs nearly $7 billion;
colorectal cancer treatment costs about $6.5 billion; and cervical cancer
treatment costs about $2 billion. Overall, cancer costs Montana
approximately $588 million annually (2002).
"Half of all bankruptcies in the United States are the result of a medical
diagnosis." (Mary Zapor, Pancreatic Cancer Action Network.)
Description of table: Montana men, 2003 cancer cases and cancer deaths. Total
number of cancer cases was 2,539. Total number of cancer deaths was 961.
Prostate cancer accounted for 34% of cancer cases and 11% of cancer deaths. Lung
& bronchial cancer accounted for 14% of cancer cases and 31% of cancer deaths.
Colon & rectal cancer accounted for 8% of cancer cases and 8% of cancer deaths.
Urinary bladder cancer accounted for 8% of cancer cases and 4% of cancer deaths.
Leukemia
accounted for 3% of cancer cases and 5% of cancer deaths. Non-Hodgkin lymphoma
accounted for 3% of cancer cases and 4% of cancer deaths. Kidney cancer
accounted for 3% of cancer cases and 3% of cancer deaths. Melanoma skin cancer
accounted for 3% of cancer cases and 3% of cancer deaths. Oral cavity cancer
accounted for 3% of cancer cases and 2% of cancer deaths. Pancreatic cancer
accounted for 2% of cancer cases and 5% of cancer deaths. Esophageal cancer
accounted for 1% of cancer cases and 4% of cancer deaths. Liver & bile duct
cancer accounted for 1% of cancer
cases and 3% of cancer deaths. Cancer of all other sites accounted for 17% of
cancer cases and 17% of cancer deaths. End of description.
Description of table: Montana women, 2003 cancer cases and cancer deaths. Total
number of cancer cases was 2,093. Total number of cancer deaths was 877. Breast
cancer accounted for 31% of cancer cases and 13% of cancer deaths. Lung &
bronchial cancer accounted for 14% of cancer cases and 27% of cancer deaths.
Colon & rectal cancer accounted for 11% of cancer cases and 10% of cancer
deaths. Uterine cancer accounted for 5% of cancer cases and 2% of cancer deaths.
Non-Hodgkin
lymphoma accounted for 4% of cancer cases and 5% of cancer deaths. Thyroid
cancer accounted for 4% of cancer cases and no cancer deaths. Melanoma skin
cancer accounted for 3% of cancer cases and 2% of cancer deaths. Ovarian cancer
accounted for 3% of cancer cases and 6% of cancer deaths. Pancreatic cancer
accounted for 2% of cancer cases and 5% of cancer deaths. Leukemia accounted for
2% of cancer cases and 4% of cancer deaths. Kidney & renal pelvic cancer
accounted for 2% of cancer cases and 2% of cancer deaths. Urinary bladder cancer
accounted for 2% of cancer cases and 1% of cancer deaths. Multiple myeloma
accounted for 1% of cancer cases and 2% of cancer deaths. Brain and other
nervous system cancer accounted for 1% of cancer cases and 3% of cancer deaths.
Cancer of all other sites accounted for 15% of cancer cases and 18% of cancer
deaths. End of description.
Note: For both men and women, the data exclude basal and squamous cell skin
cancers and in-situ carcinomas except urinary bladder. Data Source: Montana
Central Tumor Registry, 2005.
On an individual level, the foundation for effective cancer prevention and
control is a trusting relationship with a personal primary care physician or
healthcare provider.
Table of Contents
Prevention: Many cancers are preventable. Scientists
estimate that as many as 50 to 75 percent of cancer deaths in the United States
are caused by various environmental factors. Environmental causes include
lifestyle choices as well as exposure to agents in the air and water. Cancer is
linked to some behavioral choices such as smoking, physical inactivity and poor
diet. Although some cancer prevention takes place at the individual level, it is
our society' s responsibility to prevent public exposure to environmental
carcinogens and to help facilitate healthy lifestyles for all citizens. It is
also important to acknowledge the interplay among behavior and economic,
environmental, social, and cultural factors when looking at cancer prevention.
The Top Six Ways to Prevent Cancer:
1. Avoid the use of tobacco.
2. Choose a diet rich in fruits and vegetables.
3. Decrease exposure to environmental carcinogens
4. Engage in regular physical activity.
5. Maintain a healthy body weight.
6. Protect your skin from ultraviolet exposure.
Each year, at least one-third of all cancer deaths and one-fifth of all deaths
can be attributed to tobacco use. Smoking is the single most preventable cause
of death in the United States, yet one in five adult Montanans currently smokes
cigarettes. Another six percent use smokeless tobacco. Nationally, about 170,000
people died of cancer because of tobacco use in 2002. This number represents at
least 30 percent of all estimated cancer deaths in the United States.
People whose diets are rich in fruits and vegetables are likely to have a lower
risk of cancer of the colon, mouth, pharynx, esophagus, stomach, lungs, and
possibly prostate. Experts recommend between five and nine servings of fruits
and vegetables daily. These choices can hinge on more than good intentions:
dietary choices may come down to the ability to afford fruits and vegetables.
An estimated 20 to 30 percent of the most common cancers may be related to
excess weight and physical inactivity. Recent studies indicate that overweight
and obesity may also increase the risk of death from many cancers, accounting
for up to 14 percent of cancer deaths in men and 20 percent in women. Obesity
prevention can also reduce the risk for many of the most common cancers,
including colon, uterine, renal cell, and postmenopausal breast cancers. Regular
physical activity is also associated with reduced risk of heart disease, high
blood pressure, diabetes, obesity, and some
cancers. Despite the benefits, only one in four children engages in the
recommended level of daily physical activity (30 minutes of moderate activity or
20 minutes of vigorous activity).
The self-reported rate of overweight adults in Montana increased from 41.7
percent in 1990 to 56.9 percent in 2003. The self-reported rate of obesity
increased from 8.7 percent in 1990 to 18.8 percent in 2003. Both rates remained
steady between 2001 and 2003.
Skin cancer is the most common cancer in the United States. Rates are increasing
despite the fact that the greatest risk factor for skin cancer is avoidable,
unprotected exposure to ultraviolet (UV) rays. Reducing long-term exposure to
the sun and artificial light from tanning beds, booths, and sun lamps reduces
the risk of non-melanoma skin cancer. Avoiding burns and other damage from these
sources, especially during childhood and adolescence may also reduce the chances
of developing melanoma
skin cancer. White people have the highest risk of contracting melanoma skin
cancer, with white males the highest risk group of all. Death rates from
melanoma skin cancer are twice as high in males as in females.
Other cancer prevention involves social responsibility and the prevention of
public and occupational exposure to environmental carcinogens. The National
Cancer Institute regularly updates the Report on Carcinogens, which lists more
than 200 chemicals known or suspected of causing cancer. For more information,
visit: http://ntp-server.niehs.nih.gov or
http://progressreport.cancer.gov
.
Goal I: Reduce the impact of tobacco use and exposure to secondhand smoke on the
burden of cancer in Montana.
Objective I.1: Decrease the prevalence of tobacco use among adults and youth.
Baseline:
Adults: Smoking (21%); smokeless (6%)
Youth: Smoking (19%); smokeless (9%)
Outcomes, by 2011:
Adults: Smoking (12%); smokeless (3%)
Youth: Smoking (16%); smokeless (7%).
Data Sources: Behavioral Risk Factor Surveillance System (BRFSS) 2004; Youth
Risk Behavior Survey (YRBS) 2003; Prevention Needs Assessment (PNA) 2004
Strategy 1: Plan, develop, and implement statewide public awareness and
education campaigns on the need for increased tobacco product prices; to reduce
tobacco-industry sponsorship of community events; and to remove preemption
related to tobacco product placement.
Strategy 2: Educate and encourage Tribal governments to adopt tobacco tax and/or
revenue sharing agreements to reduce tobacco sales and use.
Strategy 3: Determine and implement appropriate policies to increase the tobacco
tax.
Strategy 4: Collaborate with Office of Public Instruction (OPI) and individual
school districts to develop and implement comprehensive tobacco-free school
policies.
Strategy 5: Increase cessation attempts by designing and implementing strategies
to increase utilization of the Montana Tobacco Quit Line (1-866-485-QUIT).
Strategy 6: Increase the number of healthcare providers who integrate the U.S.
Public Health Department's Clinical Guidelines: “Treating Tobacco Use and
Dependence” into their healthcare systems.
The American Cancer Society estimates there will be 168,140 cancer deaths in the
United States annually that can be directly attributed to tobacco use. This
number represents about 30% of all estimated U.S. cancer deaths. Annually,
approximately 1,400 Montanans will die of diseases directly attributable to
tobacco use. Approximately 90% of current adult smokers became addicted at, or
before, age 18.
Profile: Penny Patterson started smoking in 1951, at age 16. No one objected.
Her father and mother were smokers. When she got married at 18, her husband was
a smoker, too. Years passed. Children came along and grew up. Cigarettes were a
constant part of the everyday woof and warp of life, their legacy evident in
burn marks on furniture, yellowed walls that only became obvious next to fresh
paint, the sound of her husband's cough. Then one day, an old friend was
diagnosed with cancer. If she
got out of the hospital, her children would always have to care for her. Sitting
in the hospital room, it occurred to Penny that if she became old and sick and
her children had to care for her, she wouldn't be able to live with herself if
it was because of something she'd done to herself. She threw away her cigarettes
as she left the hospital. "I still miss smoking sometimes, but this was the
greatest gift I could give my kids."
Objective I.2: Reduce Montanans' exposure to secondhand tobacco smoke.
Baseline:
Children: 17 percent of children under 18 are potentially exposed to secondhand
tobacco smoke at home.
Schools: 29 percent of schools are tobacco free (2002).
Workplaces: 82 percent of worksites have formal policies that prohibit smoking
(2001).
Nonsmokers: A percent to be determined of nonsmokers are regularly exposed to
secondhand tobacco smoke.
Outcomes: By 2007, determine the percentage of nonsmokers, including children,
who are regularly exposed to secondhand tobacco smoke. By 2011, less than 10
percent of children will be regularly exposed to tobacco smoke at home (Healthy
People 2010 target); all schools will be tobacco free; all worksites will have
formal policies that prohibit smoking; less than 45 percent of nonsmokers will
be regularly exposed to secondhand tobacco smoke (Healthy People 2010 target).
Data sources: Behavioral Risk Factor Surveillance System, 2002 (BRFSS); Youth
Risk Behavior Survey, 2003 (YRBS); Montana Adult Tobacco Survey (MT-ATS) 2004.
Strategy 1: Determine the percentage of nonsmokers who are regularly exposed to
secondhand tobacco smoke.
Strategy 2: Plan, develop, and implement a statewide public education and
awareness campaign regarding the hazards of exposure to secondhand smoke.
Strategy 3: Increase the number of community-based public education and
awareness campaigns delineating the hazards of exposure to secondhand smoke.
Strategy 4: Increase the number of policies and laws eliminating exposure to
secondhand smoke by supporting:
A. the limited 2005 statewide Secondhand Smoke Free Law to become all inclusive
in 2009.
B. self-governing community/county secondhand smoke free ordinances.
C. tribal nation’s secondhand smoke-free policies.
D. voluntary secondhand smoke-free policies.
E. comprehensive tobacco-free school policies.
Strategy 5: Support the Montana Tobacco Use Prevention Strategic Plan.
According to the American Cancer Society, approximately 38,000 nonsmoking
Americans die every year as a result of exposure to secondhand smoke . 120 of
them are Montanans. Nonsmokers exposed to secondhand (environmental) tobacco
smoke absorb nicotine and other compounds just as smokers do. The U.S.
Environmental Protection Agency (EPA) has classified secondhand smoke as a Group
A carcinogen, which means that evidence exists that it causes cancer in humans
(American Cancer Society).
Objective I.3: Increase the total funding for the Montana Tobacco Use Prevention
Program (MTUPP) and expand the program to meet national standards.
Description of table: Baselines and Outcomes. Baseline: 2006 state funding level
is $6,889,920. CDC funding is $285,000. Total is $7,174,920. 2007 state funding
level is $6,804,480. CDC funding is $616,500. Total is $7,420,980. Outcomes: In
2009, $9.35 million (CDC recommended minimum) will be available. In 2011, MTUPP
will meet national recommendations for a comprehensive, evidence-based program
as in the Guide to Community Preventive Services: Tobacco Use Prevention and
Control. Data source: MTUPP 2005. End of description.
"Today's teenager is tomorrow's potential regular customer...the smoking
patterns of teens are particularly important to Phillip Morris." (Philip Morris
Companies, Inc.,1981
www.who.int/tobacco/en/atlas7.pdf ).
Strategy 1: Advocate for allocation of a larger percent of tobacco settlement
funds for a comprehensive tobacco use prevention and control program.
Strategy 2: Plan, develop, and implement a campaign to educate the public and
decision-makers on the need for a comprehensive tobacco use prevention and
control program.
Strategy 3: Determine and implement the appropriate policy vehicle to increase
the total funding available for implementation of a comprehensive tobacco use
prevention program to at least the minimum level recommended by the Centers for
Disease Control and Prevention (CDC).
Strategy 4: Expand the MTUPP as funding allows. Increase:
A. the number of public education and awareness campaigns on tobacco issues.
B. the number of school-based interventions.
C. training and technical assistance to community-based programs and their
coalitions. D. services provided by the Montana Tobacco Quit Line to meet the
needs of a greater number of tobacco users.
E. surveillance on tobacco issues.
F. evaluation of all components of the MTUPP.
Strategy 5: Collaborate with the Office of Public Instruction, the Addictive and
Mental Disorders Division, the Department of Revenue, and the Department of
Justice to address various tobacco-related issues in Montana, and add a chronic
disease prevention component to tobacco use prevention efforts.
Tobacco Industry Influence in Montana: The tobacco industry spends more than
$12.4 billion per year B over $34.1 million a day B marketing its deadly
products in the United States alone, much of this advertising reaches kids. The
annual tobacco industry marketing expenditures for Montana are $40.7 million.
Research has found that: kids are three times more sensitive to tobacco
advertising than adults; kids are more likely to be influenced to smoke by
cigarette marketing than by peer pressure; and one-third of underage
experimentation with smoking is attributable to tobacco company advertising
( http://www.tobaccofreekids.org
).
Goal II: Reduce the impacts of poor nutrition, physical inactivity and obesity
on the burden of cancer in Montana.
Objective II.1: Increase the percentage of youth and adults who consume the
recommended number of servings of fruits and vegetables per day
Baseline: 16.7% of students in grades 9-12 and 22% of adults reported eating
five or more servings of fruits and vegetables per day during the past seven
days.
Outcomes: By 2011, 19% of students in grades 9-12 and 25% of adults will report
eating five or more servings of fruits and vegetables per day.
Data sources: YRBS 2003; BRFSS 2003 .
Strategy :1 Promote inclusion of cancer risk reduction diets in school health
education curriculums, nutritional and meal programs, and health promotion
information.
Strategy 2: Promote and support environmental changes in school and child care
programs to increase the availability and promotion of fruits and vegetables.
Strategy 3: Promote and support school, home, and community garden projects.
Strategy 4: Support community wide campaigns and projects geared to youth and
families that promote the consumption of fruits and vegetables.
Strategy 5: Support the Women, Infants and Children (WIC) Farmer's Market
Nutrition Program to increase access to fruits and vegetables for families.
Strategy 6: Support worksite programs designed to increase fruit and vegetable
consumption.
Strategy 7: Promote community education and public awareness campaigns on
healthy eating for cancer risk reduction and cancer prevention; distribute the
Cancer Research and Prevention Foundation's “Progress Through Prevention”
educational materials.
Strategy 8: Collaborate with industry partners to increase access to, and
availability of, fruits and vegetables on a communitywide level.
Five to Nine a Day for Better Health is a national program that seeks to
increase the number of daily servings of fruits and vegetables Americans eat to
five or more. Diets rich in fruits and vegetables may reduce the risk of cancer
and other chronic diseases. Fruits and vegetables provide essential vitamins and
minerals, fiber, and other substances that are important for good health.
(Source: www.5aday.gov )
Description of Table: Fruits and vegetables....how many times a day do you eat
fruits and vegetables? In 2002, compared to 4.7% of all Americans, 4.1% of
Montanans never ate fruits and vegetables or ate fewer than one per day.
Compared to 35.9% of all Americans, 34.1% of Montanans ate one to two servings
of fruits and vegetables per day. Compared to 36.1% of all Americans, 39.1% of
Montanans ate three to four servings of fruits and vegetables per day. Compared
to 22.6% of all Americans, 22.7% of Montanans ate five or more servings of
fruits and vegetables per day. Source:
http://apps.nccd.cdc.gov/5ADaySurveillance . End of description.
For more information on healthy diet, go to
http://MyPyramid.gov .
Objective II.2: Increase:
1. the percentage of adults and youth who engage in moderate and vigorous
physical activity.
2. the amount of leisure time activity pursued by adults.
3. the percentage of youth spending less than 2 hours per school day watching
television.
Baseline: BRFSS 2003; YRBS 2003.
Youth:
1. 22.3 percent of 7th and 8th graders participate in moderate physical
activities; 71.8 percent participate in vigorous physical activities.
2. 24 percent of 9th-12th graders participate in moderate physical activities;
62.1 percent engage in vigorous physical activities.
3. 69 percent of 7th-8th graders watch less than 2 hours of television on an
average school night.
4. 49.5% of 9th-12th graders watch less than 2 hours of television on an average
school night
Adults:
1. 58.5% engage in moderate physical activities
2. 33.2% engage in vigorous physical activities
3. 79.8% report engaging in leisure time physical activity
Outcomes: By 2011,
Youth:
1. 35 percent of 7th-12th graders will participate in moderate physical
activities; 85 percent will participate in vigorous physical activities (Healthy
People 2010 target).
2. 75 percent of 7th-12th graders will watch less than 2 hours of television on
an average school night (Healthy People 2010 target).
Adults:
1. 60% will engage in moderate physical activities
2. 35% will engage in vigorous physical activities.
3. 82% will report engaging in leisure time physical activity
Data sources: BRFSS, 2003; YRBS, 2003; Healthy People 2010.
Strategy 1: Support and promote the development and implementation of community
wide campaigns:
A. to increase physical activity in youth and adults, and to include education
on cancer risk reduction and prevention activities.
B. geared to parents that focus on limiting total television screen time for
children to two hours or less per day.
C. to increase private and public sector opportunities for adult physical
activities with Apoint of decision prompts.
Strategy 2: Support policies for school wellness and physical education
programs.
Strategy 3: Promote and support school, after school, youth-based, and childcare
programs that increase opportunities for physical activity.
Strategy 4: Support partnerships with community leaders and stakeholders that
support physical activity policies in schools, childcare programs, community
organizations and worksites. Support local campaigns to create safe walk, run
and bike paths.
Strategy 5: Identify communities and worksites promoting cancer risk reduction
by providing health education and physical activity programs.
Strategy 6: Promote fitness activities in employee work site wellness programs
and increase work sites offering wellness programs.
Strategy 7: Identify barriers and implement strategies to promote policies
promoting physical activity.
Strategy 8: Work with healthcare professionals, local health departments, and
community clinics to support exercise counseling and distribution of exercise
plans.
Objective II.3: Maintain the current rate of self-reported overweight and
obesity in Montana.
Baseline: Adults: 57% are overweight; 18.8% are obese.
Youth: 8.1% are overweight; 11.6% are at risk for becoming overweight.
Outcomes: By 2011, there will be no rise in the percentage of overweight or
obese
adults, or in the percentage of overweight or at-risk youth.
Data sources: YRBS 2003; BRFSS 2003.
Strategy 1: Design a strategy to educate healthcare providers to screen all
adult patients for obesity and offer intensive weight management counseling and
behavioral interventions for those who are.
Strategy 2: Collaborate with the Montana Cardiovascular Disease/Obesity
Prevention Task Force to study obesity control and to formulate statewide
policies and strategies for children, youth, and adults. Support implementation
of their statewide plan.
Strategy 3: Support surveillance of Body Mass Index (BMI) changes in Montana for
adults, youth, and children.
Strategy 4: Support employers in the development of worksite wellness programs.
Strategy 5: Educate healthcare providers and the public on the link between
cancer and obesity.
Strategy 6: Support the development of community coalitions and networks to
assess, monitor and develop strategies for obesity prevention in local
communities and to promote healthful eating and physical activity.
Goal III: Reduce the incidence of skin cancer in Montana.
Objective III.1: Reduce the percentage of adults who report sunburn during the
past 12 months.
Baseline: 41.1% of adults report having had a sunburn during the past 12 months.
Outcomes: By 2011, less than 35% of adults will report having had a sunburn
during the past 12 months.
Data sources: BRFSS 2004
Strategy 1: Distribute educational and culturally relevant materials on skin
cancer prevention at parks and other recreational areas throughout the state.
Distribute materials on sun cover-up behaviors that include photos of skin
cancers, sun-safety guidelines, and other information.
Strategy 2: Promote the increase of shaded areas at public recreational sites.
Strategy 3: Add questions to the BRFSS every other year dealing with the
protective effects of limited sun and UV light exposure, wearing protective
clothing, and using sun screen.
Objective III.2: Increase the number of school programs that educate students on
decreasing exposure to UV light and skin cancer prevention.
Baseline: To be determined.
Outcomes: By 2008, establish the number of school programs addressing skin
cancer prevention. By 2011, increase the number of programs by a percentage to
be determined.
Data sources: To be established.
Strategy 1: Establish how many school programs on skin cancer prevention there
are in Montana (consider adding a question to the School Administrators Self
Assessment Survey).
Strategy 2: Support school, preschool, and youth programs designed to increase
sun protective knowledge, attitudes, intentions, and behaviors among children
and youth.
Strategy 3: Promote family-based interventions such as “Together for Sun
Safety”.
Tips for Safe Fun in the Sun:
1. Avoid the sun between 10 a.m. and 3 p.m., even on cloudy days.
2. Kids should wear photo-protective clothing and wide-brimmed hats. Sit in the
shade when outdoors.
3. Use waterproof sunscreen and lip balm with an SPF of 15 or higher routinely
on yourself and your children, and reapply it every two hours.
4. Babies under six months of age should not spend much time in the sun.
(source: http://www.PreventCancer.org)
Goal IV: Reduce the risk of cancer from exposure to environmental carcinogens.
Objective IV.1: Increase compliance with new arsenic standards in public
drinking water and private wells.
Baseline: In 2004, the levels of arsenic were above 10 parts per billion (ppb)
in 29 of 2,050 public water supplies, affecting 5,075 people. In a sampling of
private wells, 10% of 3,541 had arsenic levels above 10 ppb (Montana Bureau of
Mines, March 2005).
Outcomes: By 2009, all public water supplies in Montana will comply with the
standard of 10 ppb arsenic maximum, and there will be an increase in arsenic
testing by private well owners.
Data sources: Public water supplies: Department of Environmental Quality (DEQ)
Public Water Supplies Program; well tests, Montana Bureau of Mines.
Strategy 1: Work with the DEQ and the Water Quality Testing program to monitor
compliance with arsenic standards in public water supplies and encourage private
well users to test their drinking water for exposure.
Strategy 2: Support the Heavy Metals Workgroup to increase knowledge about
arsenic exposure in drinking water and to establish regional baselines for
exposure levels.
Strategy 3: Promote education on testing water for arsenic and inform the public
about methods to reduce their exposure to arsenic.
Objective IV.2: Increase awareness of the potential danger of high radon
exposure in homes and workplaces; decrease the proportion of homes with radon
levels in excess of 4pCi/L.
Baseline: Level of awareness to be determined.
Outcomes: By 2006, establish baseline estimates of public awareness of radon.
By 2011, increase the level of awareness of radon by a percentage to be
determined. Data sources: BRFSS.
Radon found in homes may contribute to as many as 20,000 lung cancer deaths in
the U.S. annually. Reducing indoor radon exposure could prevent about 30 percent
of lung cancer deaths from radon. Of these, 86 percent would be smokers or
former smokers. Forty-seven percent of homes in Montana have radon levels in
excess of >4pCi/L. [U.S. Environmental Protection Agency guidelines for maximum
exposure] (1997 Radon Study, Montana State University).
Strategy 1: Work with Montana labs or the National Institute for Occupational
Safety and Health at CDC to determine number of houses and workplaces tested for
radon each year and to document the percent of homes and workplaces with
exposure to elevated radon >4pCi/L.
Strategy 2: Work with existing agencies and organizations to determine the
number of existing homes with elevated radon levels that have undergone
mitigation, and newly built homes with radon-resistant new construction
features.
Strategy 3: Design and implement strategies to increase public awareness of the
potential dangers of high radon levels in homes and workplaces. Promote
education on how to remedy this issue through public service announcements and
other programs.
Strategy 4: Work with the Montana Indoor Air Quality Program, tribal
environmental departments, and other associated organizations to distribute
educational materials on radon in the home. Promote the Radon Hotline:
1-800-546-0483.
Strategy 5: Promote indoor radon testing on sale of homes and in new
construction where there is high radon potential; encourage distribution of EPA
materials to realtors.
Objective IV.3: Improve public knowledge and awareness of common environmental
carcinogens and promote methods to reduce exposure.
Baseline: To be determined.
Outcomes: Increased availability of educational opportunities, reduced exposure,
and increased public awareness of environmental carcinogens.
Data sources: BRFSS; website visit counts; conference attendance; distribution
of published materials.
Strategy 1: Design a tool to measure baseline public awareness of carcinogens,
such as adding a question to BRFSS.
Strategy 2: Develop and maintain communication among agencies including the
Environmental Public Health Tracking (EPHT), Department of Environmental Quality
(DEQ), Department of Public Health and Human Services, Extension Service,
Montana State University, University of Montana and others relative to issues
pertaining to environmental carcinogens.
Strategy 3: Participate in and/or host conferences, seminars and other
educational opportunities to further public awareness of environmental
carcinogens that provide information on preventing exposure at home and in the
workplace.
Strategy 4: Develop materials (written and/or web-based) discussing commonly
encountered environmental carcinogens and provide information on preventing
exposure.
Strategy 5: Support policies and programs designed to decrease exposure to
environmental carcinogens.
Lifetime risk is the probability that someone, over the course of his or her
lifetime, will develop cancer. In the United States, men have nearly a one in
two lifetime risk of developing cancer; for women, the risk is a little more
than one in three. (American Cancer Society 2003)
Prevention: What You Can Do
Avoid:
1. Tobacco use
2. Secondhand smoke
3. Too much alcohol (one drink a day for women, two for men)
Make healthy food choices:
1. Eat five or more servings of fruits and vegetables daily.
2. Maintain a low-fat diet.
3. Balance total calorie intake with calories expended through physical
activity.
Maintain a healthy weight or body mass index: Ask your healthcare provider to
measure this at least yearly.
Be physically active:
1. Increase your moderate and vigorous activity per week.
2. Watch less than 2 hours of TV per day.
Protect your skin from sunlight, UV light exposure and tanning lights.
Discuss:
1. Cancer prevention and risk factors with your primary healthcare provider.
2. Your risk for cervical cancer with your healthcare provider.
3. Occupational exposure to carcinogens with your employer.
Become knowledgeable:
1. About environmental carcinogens and your exposure to them.
2. Check your home's radon level and take measures to decrease it if over
4pCi/L.
Support:
1. Increasing the tobacco tax.
2. Policies reducing exposure to tobacco products and secondhand smoke.
Advocate:
1. For increased funding for the Montana Tobacco Use Prevention Program.
2. For cancer prevention policies with your school board, workplace, state and
local governments.
A Montana Epidemic: Obesity and Overweight:
1. 57 percent of Montana adults are overweight or obese. (BRFSS 2002)
2. 17 percent of non-Hispanic white adults and 39 percent of American Indian
adults in Montana are obese (BRFSS, 2002; Montana American Indian Behavioral
Risk Survey, 2003).
3. The obesity rate among Montana adults increased by 115 percent between 1990
and 2002 (BRFSS, 1990, 2002).
4. 18 percent of Montana high school students are overweight or at risk of
becoming overweight (YRBSS, 2001).
What does "overweight" and "obese" mean? Overweight and obesity are labels for
weight ranges greater than those generally considered healthy for a given
height. The terms also identify weight ranges shown to increase the likelihood
of certain diseases and other health problems.
For adults, overweight and obesity ranges are determined by using weight and
height to calculate a number called the "body mass index" (BMI). BMI is used
because, for most people, it correlates with their amount of body fat. Although
BMI correlates with the amount of body fat, it does not directly measure body
fat. As a result, some people, such as athletes, may have a BMI that identifies
them as overweight even though they do not have excess body fat.
Calculate BMI using the following formula: BMI = [(Weight in pounds) + (Height
in inches)2] x 703. For more information about BMI, visit
www.cdc.gov/nccdphp/dnpa/bmi
.
Description of table: A person with a BMI of <18.5 is underweight. A person with
a BMI of 18.5 -24.9 is normal. A person with a BMI of 25-29.9 is overweight. A
person with a BMI of 30 or greater is obese. End of description.
Table of Contents
Early Detection: Detecting cancers early through
screening can lead to more effective treatment with fewer side effects.
A statewide program emphasizing early detection and prevention of cancer through
screening and healthful living would reduce the rate of cancer in Montana. The
use of screening tests to detect cancers in the early stages often leads to more
effective, less expensive treatment with fewer side effects. Patients whose
cancers are found early are more likely to survive than those whose cancers are
not found until symptoms appear.
1. Screening mammograms every 12-33 months for women over age 40, followed by
timely treatment when breast cancer is diagnosed, reduce the chances of dying
from breast cancer.
2. Regular Pap smear tests followed by appropriate and timely treatment reduce
death from cervical cancer. Women who have never been screened or who have not
been screened in the past five years face a greater risk of developing invasive
cervical cancer than their screened counterparts.
3. Colorectal cancer can be prevented and detected early through screening. The
primary screening modalities include the fecal occult blood test, flexible
sigmoidoscopy and colonoscopy. Precancerous polyps can be identified and may be
removed during sigmoidoscopy or colonoscopy to prevent the development of
cancer; cancers can also be detected at an early and curable stage.
4. Information should be provided to all men starting at the age of 50 about
what is known and what is uncertain about the benefits and limitations of early
detection and treatment of prostate cancer, so that they can make informed
decisions. Prostate-specific antigen testing (PSA) and digital rectal
examination (DRE) are the two primary methods used to screen for prostate
cancer. PSA testing in combination with DRE is currently the best approach
available for the early detection of prostate cancer.
Early Detection: We believe individuals will be more likely to access screening
tests for cancer if urged to do so by their healthcare providers. Such
discussions between provider and patient can result in partnerships for informed
decision making relative to cancer risk, early detection and risk reduction. It
is important for providers to discuss cancer risks and the tests available for
early detection, as well as make referrals for screening tests. They are an
invaluable resource for patients who need to make informed decisions in order to
reduce their risk of cancer. Likewise, it is essential for individuals to be
aware of cancer-screening guidelines so that they can initiate discussions with
their healthcare providers.
Profile: Destiny Boyd has a strong family history of cancer. Her grandmother
died of cancer, which scared Destiny's mother enough that she went in at 35 for
a colonoscopy. Just in time, as it turns out: doctors found a teardrop-sized
cancer during the procedure. Destiny is very thankful that her mother has had
follow-up treatment and is doing well. She's also become a firm believer in the
importance of routine cancer screenings. Destiny will be 25 this year -- ten
years younger than her mother was when her cancer was discovered. Her plans for
the year include her first colonoscopy. "So many things are preventable and
colon cancer is one of them. People need to know that you just have to do
this...for yourself and for your family."
Goal I: Promote compliance with cancer-screening guidelines.
Objective I.1: Increase compliance with the American Cancer Society (ACS) Cancer
Detection Guidelines.
Baseline:
1. Breast: Women over 40 who have had a mammogram within the past two years:
71.9 percent
2. Cervical: Women over 18 who have had a PAP test in past three years: 86.1
percent
3. Colorectal: Adults over 50 who have ever received a sigmoidoscopy or
colonoscopy exam: 52.6 percent
4. Prostate: To be determined
Outcomes: By 2011,
1. Breast: 75 percent of women over 40 will report having had a mammogram within
the past two years.
2. Cervical: 90 percent of women over 18 will report having had a PAP test
within the past three years (Healthy People 2010 goal: 90%)
3. Colorectal: 55 percent of adults over 50 will have had a sigmoidoscopy or
colonoscopy exam (Healthy People 2010 goal: 50%).
4. Prostate: By 2008, identify the programs that offer education on informed
decision-making for prostate cancer screening; identify the number of healthcare
providers who offer informed decision making. By 2011, increase the number of
providers and programs promoting informed decision-making on prostate cancer
screening by a percentage to be determined.
Data source: Behavioral Risk Factor Surveillance System (BRFSS) 2004 and a
healthcare provider survey.
Strategy 1: By 2008, identify the programs that offer education on informed
decision-making for prostate cancer screening; identify the number of healthcare
providers who offer informed decision making.
Strategy 2: Market the ACS Cancer Detection Guidelines to the healthcare
provider community and the public.
Strategy 3: Provide the media with Center for Disease Control and Prevention
(CDC) programs on cancer screening, including “Screen for Life”.
Strategy 4: Inventory local community locations for all cancer-screening
facilities and providers, including those serving Montana's American Indian
population. Promote a cancer type-specific community-level list to healthcare
providers and the public; add to the “Cancer Resource Roster” on the Cancer
Control web page.
Strategy 5: Analyze the inventory list for gaps in services and promote
increased screening service capacity as needed.
Strategy 6: Promote and incorporate colorectal cancer information into workplace
wellness programs and other community-based health-related education programs.
Strategy 7: Use existing or develop new culturally competent and medically
appropriate materials on prostate cancer that healthcare providers and men can
utilize to facilitate informed decision-making on prostate cancer screening.
Strategy 8: Increase the number of healthcare providers who discuss and
recommend appropriate screening for breast, cervical, colorectal, and prostate
cancers.
Strategy 9: Analyze available data on the scope of cancer screening among
specific populations, including Medicaid and Medicare recipients. Implement
strategies to rectify any identified disparities. Determine the best strategies
for improving access to screening.
Strategy 10: Review, revise and promote the clinical cancer screening protocols
used for federally funded clinics, Indian Health Service facilities, and tribal
health clinics.
For more information, visit www.cancer.org
and go to "Prevention and Early Detection" or go to
http://progressreport.cancer.gov
and go to "Early Detection."
Objective I.2. Reduce barriers to cancer screening services.
Baseline: Barriers have not been identified.
Outcomes: Barriers are defined and corrective strategies implemented.
Data sources: Process evaluation results.
Strategy 1: Identify barriers to access, availability, and utilization of
cancer-screening services; study and describe at the local level.
Strategy 2: Implement strategies to address identified barriers.
Early detection could substantially reduce the billions of dollars spent on
cancer treatment each year. Not only does cancer screening save lives by
detecting breast, cervical, and colorectal cancer early, it is also the first
step in preventing some colorectal and cervical cancers from developing.
Screening for colorectal cancer, as recommended by the U.S. Preventive Services
Task Force, can reduce the number who die of this disease by at least 30
percent. Regular mammograms (every 1-2 years) can reduce the risk of dying of
breast cancer for women age 40 and older by about 16 percent. Cervical cancer
can be prevented by using the Pap test to detect precancerous lesions, which can
be treated before cancer develops. Researchers in many countries found that
rates of cervical cancer death dropped by 20 to 60 percent after screening
programs began (CDC 2003).
Goal II: Healthcare providers will promote high-quality cancer screening and
diagnostic services.
Objective II.1: Increase the accredited professional education available to
Montana healthcare providers on state-of-the-art cancer screening, diagnosis,
risk factors and prevention.
Baseline: To be determined.
Outcomes: By 2007, determine the baseline number of continuing education credits
providers report that include cancer screening, diagnosis, and prevention. By
2011, increase the number of accredited courses on state-of-the-art cancer
prevention, screening and diagnosis by a percentage to be determined.
Data sources: Healthcare provider survey.
Strategy 1: Conduct a healthcare provider survey to determine the accredited
education courses available to Montana healthcare providers that include cancer
prevention, screening, and diagnosis. Determine provider needs relative to
cancer prevention, screening, and diagnosis.
Strategy 2: Develop a method to increase the number of accredited professional
education opportunities available to Montana healthcare providers.
Strategy 3: Implement strategies to address the needs identified through the
healthcare provider survey.
Your chances of developing colon cancer increase tremendously after age 50,
but you are in the driver's seat. Colon cancer starts with a growth that has not
yet developed into cancer. Testing can help your doctor find and remove these
growths before they become cancerous. Even if the test finds colon cancer, you
have a much better chance if it's found early.
Ensuring that people of all races, ethnicities, geographic locations, and
socioeconomic levels have equal access to screening services will help achieve
control of cancer in Montana.
Goal III: Broaden coverage and utilization for cancer-screening services in
Montana.
Objective III.1: Increase the proportion of insured Montanans screened for
breast, cervical, colorectal, and prostate cancer.
Baseline:
1. Breast: Insured women over 40 who have had a mammogram within the past two
years: 75.5 percent
2. Cervical: Insured women over 18 who have had a Pap test in the past three
years: 87.8 percent
3. Colorectal: Insured adults over 50 who have ever received a sigmoidoscopy or
colonoscopy: 55.5 percent
4. Prostate: Insured men over 40 who have had a PSA test in the past two years:
57.3 percent
Outcomes: By 2011:
1. Breast: 80 percent of insured women over 40 will have had a mammogram within
the past two years
2. Cervical: 90 percent of insured women over 18 will have had a PAP test within
the past three years (Healthy People 2010 goal: 90 percent)
3. Colorectal: 60 percent of insured adults over 50 will have received a
sigmoidoscopy or colonoscopy,
4. Prostate: 60 percent of insured men over 40 will have had a PSA test within
the past two years.
Data source: BRFSS 2002; insured respondents.
Strategy 1: Identify additional data sources and analyze baseline data needs.
Strategy 2: Collect and evaluate utilization data for major health plans in
Montana; analyze utilization and coverage gaps.
Strategy 3: Work with healthcare plans to promote and increase the utilization
of cancer screening and diagnostic services. Monitor, promote, and protect
existing private and public health insurance coverage for cancer screening.
Strategy 4: Address known underutilization (e.g., colorectal and breast in
Medicare) and promote culturally competent patient education.
Profile: Five generations of a Crow family come together for Messengers for
Health.
The best method for delivering female health education on the Crow Indian
Reservation is through women respected by the Tribe. Messengers for Health, a
four-year-old program on the Apsaalooke (Crow) Reservation, successfully uses
this technique. The program is based at Montana State University and funded by
the American Cancer Society.
Alma Knows His Gun McCormick, Messengers for Health Project Coordinator, speaks
the Crow language as fluently as she speaks English. She needs both in her work
with 32 Crow women who have been trained to provide grassroots cancer outreach
for Messengers for Health. Crow women have learned about health and life in
familiar settings from tribeswomen they trust and respect. The Messengers for
Health outreach workers are dispensing information on cervical cancer in the
traditional way: by visiting with friends and relatives. "We have been able to
encourage women for health (issues) and for other things," McCormick said. "We
are working for a good purpose. Women here are beginning to feel empowered,
comfortable enough even to schedule their own (cancer) screening appointments.
They are beginning to know the importance of a Pap test. We are overcoming
barriers."
That is important because Northern Plains Indians have a statistically higher
mortality rate from cervical cancer than their White neighbors. Screenings are
vital because most women who develop cervical cancer do not have symptoms. When
a Pap test reveals cervical cancer early, close to 100 percent of women survive.
The first 25 Messengers, recruited in July 2002, had all been identified as
women others naturally sought out for advice. Initially, their work focused on
cervical cancer, but from the beginning, the program became a clearinghouse for
all manner of health-related information.
"This program gives women information on many health topics and sends the
message that it's important for women to take care of themselves so that we can
be there for our families," McCormick said. (Gratefully adapted from "Messengers
for Health Uses Traditional Crow Relationships to Teach About Contemporary
Health" by Carol Schmidt. MSU News, 6/30/05.
Reducing Mortality Through Screening and Early Detection: Many deaths from
breast and cervical cancers could be avoided by increasing cancer screening
rates with mammography and Papanicolaou (Pap) tests. Deaths from breast and
cervical cancer occur disproportionately among women who are uninsured or
underinsured.
Timely mammography screening among women aged 40 years or older could prevent
approximately 16 percent of all deaths from breast cancer. Mammography is the
best available method to detect breast cancer in its earliest, most treatable
stage. an average of one to three years before a woman can feel a lump. Women
aged 40 years or older should have a screening mammogram every 12 to 24 months.
Except for skin cancer, breast cancer is the most commonly diagnosed cancer
among women in the United States, and second to lung cancer as the leading cause
of cancer-related death among women. If detected early, the U.S. five-year
survival rate for localized breast cancer is 97 percent.
Cervical cancer screening using the Pap test detects cancer as well as
precancerous lesions. Women should begin getting a Pap test within three years
of onset of sexual activity or age 21, whichever comes first. Pap tests can find
cervical cancer at an early stage when it is most curable, and can actually
prevent the disease if precancerous lesions found during the test are treated.
The incidence of invasive cervical cancer has decreased significantly over the
last 40 years, in large part because of screening for, and treatment of,
precancerous cervical lesions. Routine screening for cervical cancer can prevent
the disease.
For more information, visit the Center for Disease Control and Prevention (CDC):
www.cdc.gov/cancer/nbccedp .
American Cancer Society Guidelines:
The following cancer screening guidelines are primarily recommended for people
at average risk for cancer who do not have any specific symptoms. People who are
at increased risk for certain cancers may need to follow a different screening
schedule recommended by their primary healthcare provider.
Cancer-Related Checkup: A cancer-related checkup should include health
counseling and depending on age, might include examinations for cancers of the
thyroid, oral cavity, skin, lymph nodes, testes, and ovaries, as well as for
some non-malignant diseases.
Breast Cancer: The American Cancer Society recommends yearly mammograms starting
at age 40, which continue for as long as a woman is in good health. Clinical
breast exams (CBE) should be part of periodic health exams, about every three
years for women in their 20s and 30s, and annually for women age 40 and over.
Women should report breast changes promptly to their healthcare providers.
Colon and Rectal Cancer: Beginning at age 50, men and women at average risk for
developing colorectal cancer should follow one of the following testing
schedules:
1. yearly fecal occult blood test (FOBT) or fecal immunochemical test (FIT);
2. flexible sigmoidoscopy every five years;
3. yearly FOBT or FIT plus flexible sigmoidoscopy every five years;
4. double-contrast barium enema every five years;
5. colonoscopy every ten years.
All positive tests should be followed up with colonoscopy. People should begin
colorectal cancer screening earlier and/or undergo screening more often if they
have any of the following colorectal cancer risk factors:
1. a personal history of colorectal cancer or adenomatous polyps;
2. a strong family history of colorectal cancer or polyps;
3. a personal history of chronic inflammatory bowel disease;
4. a family history of hereditary colorectal cancer syndrome.
The costs of treating early-stage colorectal cancer are approximately 1/4 the
cost of treating this cancer at a later stage, with cost savings of between
$24,000 and $34,000 per person. B
www.gastro.org/pubPolicy/issueBriefs/urges.html .
Cervical Cancer: All women should begin cervical cancer screening about three
years after they begin having vaginal intercourse, but no later than 21 years of
age. Screening should be done annually with the standard Pap test or every two
years with the liquid-based Pap test. Beginning at age 30, women who have had
three normal Pap test results in a row may get screened every two to three
years. Women who have risk factors including diethylstilbestrol (DES) exposure
before birth, Human Immunodeficiency Virus (HIV) infection, or a weakened immune
system should continue to be screened annually.
Endometrial (Uterine) Cancer: Women should be informed about the risks and
symptoms of endometrial cancer, and are strongly encouraged to report any
unexpected bleeding or spotting to their doctors. For women with, or at high
risk of, hereditary nonpolyposis colon cancer (HNPCC), annual screening for
endometrial cancer with endometrial biopsy should be offered beginning at age
35.
Prostate Cancer: Both the prostate-specific antigen (PSA) blood test and digital
rectal examination (DRE) should be offered annually, beginning at age 50, to men
who have at least a ten-year life expectancy. Men at high risk, including those
with a strong family history of prostate cancer diagnosed at an early age,
should begin testing at age 45. Men at even higher risk, due to multiple
first-degree relatives affected at an early age, could begin testing at age 40.
Depending on the results of this initial test, no further testing might be
needed until age 45.
For more information, visit the American Cancer Society at
www.cancer.org .
Objective III.2: Increase the cancer-screening services available to
under-insured and uninsured Montanans, as consistent with nationally accepted
screening guidelines.
Baseline:
1. Breast: Uninsured women over 40 who have had a mammogram within the past two
years: 47.2 percent.
2. Cervical: Uninsured women over 18 who have had a Pap test in the past three
years: 79.2 percent.
3. Colorectal: Uninsured adults over 50 who have received a sigmoidoscopy or
colonoscopy: 28 percent.
4. Prostate: Uninsured men over 40 who have had a PSA test in the past two
years: 33.3 percent.
5. No list of low-cost services available.
Outcomes: By 2011,
1. Breast: 70 percent of uninsured women over 40 will have had a mammogram
within the past two years (Healthy People 2010 goal: 70 percent).
2. Cervical: 90 percent of uninsured women over 18 will have had a PAP test
within the past three years (Healthy People 2010 goal: 90 percent).
3. Colorectal: 50 percent of uninsured adults over 50 who have ever received a
sigmoidoscopy or colonoscopy (Healthy People 2010 goal: 50 percent).
4. Prostate: 50 percent of uninsured men over 40 will have had a PSA test within
the past two years.
5. List of free or low-cost cancer-screening services will be made available to
the public and healthcare providers.
Data source: BRFSS 2004; uninsured respondents; process evaluation results.
Strategy 1: Identify additional data sources and analyze baseline data needs.
Strategy 2: Analyze Montana policies and laws on cancer-screening coverage;
implement strategies to improve identified gaps.
Strategy 3: Support legislative efforts and policies to broaden patients'
private and public health plan coverage for cancer screening; broaden coverage
for cancer screening among low-income, under- and uninsured Montanans.
Strategy 4: Work with the Montana State Planning Grant and similar organizations
to increase Montanans' insurance coverage for cancer screening and diagnosis.
Strategy 5: Collect data to determine cancer-screening coverage included in
insurance plans; implement strategies to address gaps and disparities. Encourage
insurance providers to provide for screening services based on evidence-based
screening guidelines.
Strategy 6: Identify, create and disseminate a list of agencies that provide
funds and/or services for breast, cervical, colorectal, and prostate cancer
screening. Add this resource list to the “Cancer Resource Roster” on the Cancer
Control web page.
Strategy 7: Support funding for:
A. Indian Health Services to cover cancer screening needs.
B. Ongoing implementation of the Montana Breast and Cervical Health Program.
C. Title X (Family Planning) activities in Montana that provide cervical cancer
screening and clinical diagnostic services.
Strategy 8: Support efforts to ensure healthcare providers and their staffs
receive ongoing education about low- or no-cost cancer screening resources.
Strategy 9: Support incentives for individuals and small businesses to purchase
health insurance that covers cancer screening.
Early Detection: What You Can Do:
Be proactive:
1. Follow the American Cancer Society's Cancer Detection Guidelines.
2. Discuss screening for breast, cervical, colorectal, and prostate cancer that
may be appropriate for you and your family with your healthcare provider.
3. Encourage your friends and family to get screened for cancer early detection.
Support policies: Encourage health plan coverage for cancer screening.
Be smart: If you're 50 or older, it's time to get tested for cancer. In Montana,
93 percent of all people diagnosed with colon cancer are 50+ and 81 percent of
women diagnosed with breast cancer are 50+ (Montana Central Tumor Registry
1999-2003).
Be informed: Know your cancer risk and know the cancer screening recommendations
appropriate for you.
Screening for Skin Cancer: Most melanomas of the skin can be seen by the naked
eye, and skin cancer can be cured if the tumor is found before it spreads
deeper. Skin cancer screening during regular clinical visits involves a two or
three minute visual inspection of the entire body. The American College of
Preventive Medicine recommends periodic total cutaneous examinations for
populations at high risk, which include those with personal or family histories
of melanoma, more than 50 moles, dysplastic nevi, a fair completion, a weakened
immune system, or a history of blistering sunburns, especially as a child or
teenager. Increased exposure to ultraviolet radiation from the sun or artificial
sources increases risk.
Check your skin once a month. The A-B-C-D-E Rule can distinguish a normal mole
from a melanoma. Notify your doctor if you notice of these signs.
A is for asymmetry: One half of a mole or birthmark does not match the other.
B is for border: Edges are irregular, ragged, notched, or blurred.
C is for color: The color is not the same all over and may include shades of
brown or black, or may have patches of red, white or blue.
D is for diameter: The spot is larger than 6 millimeters across (about the size
of a pencil eraser) or is growing larger.
E is for evolving: Lesions significantly change in size, shape, symptoms,
surface, or shades. (Adapted from www.cancer.org
and www.acpm.org/skincare.htm
)
Screening for Oral Cancer: Many oral cancers can be found early, during routine
screening examinations or by self-examination. Many doctors and dentists
recommend that you look at your mouth in a mirror every month to check for any
symptoms listed below. If these signs last more than two weeks, contact your
doctor or dentist:
1. lip or mouth sore that doesn't heal within two weeks.
2. lump in the mouth.
3. lump elsewhere, such as the face, jawbone or neck.
4. white/red patch on the gums, tongue or mouth lining.
5. unusual bleeding or pain; difficulty chewing or swallowing (Adapted from
www.cancer.org)
Description of table: Montana's Progress Toward Healthy People 2010 Goals. In
2004, 86.1% of Montana women aged 18 and older had had a Pap smear in the last
three years. The Healthy People 2010 objective is 90%. 71.9% of Montana women
aged 40 and older had had a mammogram in the last two years. The Healthy People
2010 objective is 70%. 52.6% of Montanans aged 50 and older had ever had a
sigmoidoscopy or colonoscopy. The Healthy People 2010 objective is 50%. End of
description.
Table of Contents
Treatment: We envision comprehensive cancer treatment
that meets national standards -- available to, and accessible by, all Montanans.
Cancer is a complex group of diseases. To further complicate matters, different
cancers behave differently and respond to different treatments. Treatment
choices depend upon the type and stage of cancer as well as a variety of
individual factors that include age, health, cultural and personal preferences.
Care is comprised of various services, resources and technology.
On average, 4,495 new cancer diagnoses are reported annually in Montana and
4,022 cases of cancer are treated annually. (Montana Central Tumor 5-year
averages, 1999-2003.) To effectively improve cancer treatment outcomes,
state-of-the-art care must be available, accessible, affordable, and utilized.
It is crucial to integrate, coordinate and maximize treatment, services and
resources.
While good cancer treatment can be available at the local level, Commission on
Cancer (CoC) approval ensures the quality of cancer care through adherence to
national standards, multidisciplinary consultation and quality assessments. All
sizes of facilities may be approved as the standards are categorized based on
the number of cancer patients treated. As of January 2005, four of Montana's
medical facilities were CoC approved. In 2003, the most recent year for which a
complete set of data are available, 36 percent of Montanans with cancer were
treated in CoC approved centers. Nationally, 80 percent of cancer patients are
treated in CoC approved facilities.
1. Clinical practice guidelines serve as a guide for doctors and outline
appropriate methods of cancer treatment, rehabilitation and follow-up care.
2. A system of community health advisors, patient navigation tools and Quality
of Life Resource Centers would improve use of the complex cancer healthcare
system, guide the patient and family, decrease stress, and improve
communication.
3. Efficient use of treatment services requires that evidence-based information
be available to healthcare providers and the public.
Availability: Montana is the fourth largest state in terms of land mass,
encompassing 147,046 square miles, and has just over 900,000 residents. This
equates to about six people per square mile, making Montana one of the last
remaining frontier states. Lengthy distances between population centers, coupled
with a small population, become obstacles to availability, capacity and
consistent state-of-the-art treatment.
Accessibility: Access to state-of-the art cancer treatment can be limited by a
variety of personal, geographical, and cultural barriers. This may include lack
of insurance, cost of care, location, lack of transportation, extraneous costs
including travel, child care, as well as other cultural and physical barriers.
Cancer patients should have access to all forms of therapy from which they can
benefit.
Affordability: Cost may be the biggest barrier to accessibility and optimum
cancer treatment. For the 19 percent of Montanans who lack health insurance,
cost is overwhelming. Even those who have health insurance may find that their
carrier doesn't provide complete coverage.
Utilization: In order to fully utilize state-of-the-art services, cancer
patients and their families must be aware of available services. Maximizing
utilization means empowering patients and their families by ensuring that they
know and understand their options.
First Steps:
1. Identify gaps in the availability and types of cancer treatment services;
and;
2. Identify barriers to accessibility and utilization of cancer care services,
which might include cost, geographic location, cultural factors, uneven
distribution of resources, or care choices that lack standardization.
The National Comprehensive Cancer Network (NCCN) is an alliance working to
develop treatment guidelines as tools to guide decision-making in cancer
management. The Commission on Cancer (CoC) is a consortium of professional
organizations dedicated to reducing the morbidity and mortality of cancer
through education, standard-setting, and monitoring the quality of care.
Membership is comprised of 100+ representatives of the American College of
Surgeons (ACoS) and the 39 national affiliated professional organizations.
The Commission sets standards for quality, multidisciplinary cancer care;
surveys hospitals; collects quality data with which to measure treatment
patterns and outcomes; evaluates hospital provider performance; and develops
educational interventions to improve cancer care outcomes at national and local
levels.
Goal I: Ensure prevailing standards of care for all cancer patients.
Objective I.1: Increase the percentage of cancer patients given care consistent
with national treatment standards.
Baseline: Thirty-six percent of cancer patients were treated by three CoC-approved
programs in 2003.
Outcomes: By 2007, determine the percentage of patients whose treatment was
consistent with national standards, but who were not treated in CoC-approved
programs. By 2011,
1. Define treatment barriers.
2. Define and promote treatment standards and resources.
3. Increase the number of CoC-approved programs in Montana to six.
4. Increase the number of patients treated at CoC-approved cancer treatment
centers by 25 percent.
Data sources: Montana Central Tumor Registry (MCTR) 2002; CoC 2005; provider
survey.
Strategy 1: Determine the percentage of patients whose treatment was consistent
with national standards, but who were not treated in CoC-approved programs.
Strategy 2: Promote visibility of CoC-approved programs by citing accredited
programs in cancer-treatment related materials and promotions.
Strategy 3: Encourage unaccredited centers treating cancers to move to CoC
approval status appropriate to their size.
Strategy 4: Support ongoing accreditation of CoC- approved programs.
Strategy 5:
A. Educate cancer patients about resources available, treatment options,
national treatment standards, rehabilitation and follow-up guidelines in a
cancer-specific format.
B. Educate health care providers about the resources available and promote
national cancer treatment standards and evidence-based practices as
user-friendly tools that are site and stage specific.
Strategy 6: Identify cancer patients' barriers to engaging in treatment,
rehabilitation and follow-up consistent with national standards. Analyze
disparities across population groups (e.g. racial, disability status,
geographic, economic). Design and implement strategies to assist patients in
overcoming these barriers.
Strategy 7: Promote accredited, professional, cancer-related education sessions
on evidence-based best practices, national standards, guidelines, cost-effective
treatment and follow-up care.
Strategy 8: Support enhanced telemedicine capacity.
Strategy 9: Promote resources and coordination for follow-up care in frontier
and American Indian reservation communities.
Objective I.2: Enhance childhood cancer oncology services in Montana.
Baseline: Data, analysis, and protocols are not available.
Outcomes: By 2008,
1. Define need for childhood oncology services.
2. Quantify and define service gaps and disparities.
3. Create, institute and promote communication protocols.
Data sources: Process evaluation results.
Strategy 1: Establish a committee to delineate and analyze data:
A. to determine the need for a pediatric oncologist to provide full- or
part-time consultation to childhood cancer patients and their families.
B. to determine disparities and gaps in childhood cancer services.
Strategy 2: If need is determined, strategize and implement enhancements to
childhood cancer services.
Strategy 3: Establish and promote protocols for communication:
A. among local, regional and tertiary childhood cancer treatment centers; and
B. among medical service providers and parents.
Profile: Rylie was just three when she started complaining of a headache. When
it didn't let up after a few days, Rylie's mother, Kim, took her to the
pediatrician, who attributed the toddler's symptoms to a virus. That was in
early June 2002. Four days later, Rylie wasn't better, and they went back in the
pediatrician's office. Though he prescribed antibiotics, Rylie remained
listless, and began running a low-grade temperature. After a few more days, Kim
took Rylie back for the third time. This time, the pediatrician ordered some
tests. Kim and Rylie hadn't been home for two hours when the doctor called. "I
need you and your husband to come back in, right now."
The doctor was pretty certain that Rylie had leukemia, but said that they'd have
to take her to the pediatric oncology center at the Denver Children's Hospital
for confirmation. The only option they could afford was to drive her there, so
Kim and her mother left the next day, with Rylie in the back seat. The diagnosis
came back June 25, and Rylie started intravenous chemotherapy immediately. She
stayed in the hospital for a week. After the initial round of chemotherapy, her
test results were good. Even so, 17 months of intense chemotherapy followed.
Every four months, Rylie and Kim would travel to Denver, then return to Montana
for follow-up care.
They thought they were out of the woods, but in November 2003, Rylie started
complaining of headaches again. The cancer was now in Rylie's central nervous
system, and her best chance lay in an unrelated umbilical cord blood transplant.
The Fairview University Medical Center was a pioneer in the field; by then they
had done over 6,000 cord blood transplants. March 1, Rylie, Kim, Rylie's dad,
Chris, and her brother Ty, arrived in Minneapolis. Rylie went through two months
of intensive chemotherapy, a time that Kim remembers as the worst of all. The
transplant itself was uneventful, and Rylie did remarkably well. She was up and
playing almost immediately.
The good news? Rylie's last day of medication was July 26, 2005, two days before
her sixth birthday. "At first I thought we didn't need other people, that we
could handle this ourselves. That just wasn't true. Throughout Rylie's illness,
we've received a lot of emotional and financial support from others. The
financial support, especially, was hard to accept, but ultimately it taught me
that it's okay to accept help. Everyone was so good to us. It seemed that
everyone who heard about Rylie wanted to help. If not for the generosity people
showed us, we would be telling a completely different story today." (Kim, mother
of Rylie, a 6-year-old cancer survivor.)
Montana children diagnosed with cancer are referred out-of-state to regional
cancer centers for initial treatment. Travel becomes a major obstacle for
families.
"Residents of poorer counties, irrespective of race, have higher death rates
from cancer. Disparities are caused by the complex interplay of low economic
class, culture, and social injustice, with poverty playing the dominant role."
(Harold Freeman, M.D.)
Goal II: Promote utilization of appropriate cancer services for childhood cancer
patients and their families.
Objective II.1: Make a list of short-notice travel resources for children
diagnosed with cancer and their families.
Baseline: No resource list is available for distribution.
Outcomes: By 2008, make a travel resource list available.
Data sources: Process evaluation.
Strategy 1: Compile a list of current resources available for transportation to
regional cancer centers, as well as resources providing for in. and out-of-state
travel expenses and destination housing options.
Strategy 2: Create and disseminate a travel resource list for newly diagnosed
pediatric cancer patients and add to the “Cancer Resource Roster” on the Cancer
Control web page.
Strategy 3: Identify and improve funding available for transportation and
housing for childhood cancer patients and their families.
Goal III: Assess and improve availability, accessibility, and timely utilization
of cancer treatment services for all populations.
Objective III.1: Analyze and improve cancer treatment services by geography,
ethnicity, socioeconomic level, age, disability, and insurance status.
Baseline: No clinically-based analyses have been identified.
Outcomes: By 2008,
1. Identify data resources for use in analysis.
2. Analyze and make recommendations for addressing identified barriers, gaps,
and disparities.
3. Identify public policies that present obstacles to equitable treatment.
4. Make recommendations for appropriate remediation.
Data sources: Process evaluation results.
Strategy 1: Identify existing cancer data and analyze for barriers and
disparities to availability, accessibility, and utilization by specific factors
(e.g., incidence, mortality, outcomes, cost, insurance coverage, readmission
rates, treatment choices, types of treatment, resources, and efficiency). If
data are unavailable, identify ways to meet data needs.
Strategy 2: Analyze public policy for barriers to treatment.
Strategy 3: Compare Montana's data with national trends to identify significant
variations.
Strategy 4. Develop strategies for implementation that will address identified
disparities and barriers, and fill service gaps.
Objective III.2: Reduce economic barriers to quality care for cancer patients.
Baseline: 4.5 percent of Montana cancer patients are coded "no insurance" in the
primary payer field of the MCTR (2001-2002).
Outcomes: By 2011,
A. reduce the number of Montana cancer patients coded as no insurance to 4
percent; and
B. ensure that a wide range of assistance is available for the under- and
uninsured.
Data sources: MCTR; process evaluation results.
Strategy 1: Support policies and legislation designed to broaden insurance
coverage for diagnostic and treatment services for low income, under- and
uninsured cancer patients.
Strategy 2: Support incentives that allow individuals and small businesses to
purchase health insurance.
Strategy 3: Support efforts to ensure healthcare providers and staff receive
ongoing education regarding low- or no-cost treatment resources.
Strategy 4: Collect the data necessary to:
A. analyze insurance coverage for cancer treatment.
B. determine the scope and reasons for lack/delay of treatment among diagnosed
cancer patients.
C. identify and implement strategies designed to reduce economic barriers and
inequities.
Strategy 5: Support continued funding for the Breast and Cervical Cancer
Treatment Program, the Montana Comprehensive Health Association, community
health centers, and cancer treatment through the Indian Health Service.
Strategy 6: Support Medicaid reimbursement to healthcare providers at
economically viable levels.
Strategy 7: Support expansion of Medicaid and Children's Health Insurance
Program (CHIP) eligibility and benefits to:
A. provide adequate coverage to uninsured cancer patients and their families.
B. reduce any identified health disparities among racial and ethnic groups,
poor, and medically underserved populations.
C. improve access to cancer care for medically underserved populations.
D. increase Medicaid and CHIP benefit utilization for adults and children with
cancer
Strategy 8: Work with the Montana State Planning Grant or similar organization
on under- and uninsured cancer treatment issues.
Note: Women screened through the Montana Breast and Cervical Health Program
may also be eligible for treatment benefits through the Montana Breast and
Cervical Cancer Treatment Program.
Objective III.3: Increase the number of healthcare providers offering their
patients help navigating the cancer care system.
Baseline: A comprehensive cancer treatment resource list is unavailable; there
are no American Cancer Society (ACS) Resource Centers in Montana.
Outcomes: By 2008, create a statewide cancer treatment resource list and
determine the number of cancer treatment centers and healthcare providers
offering patients access to community health advisor navigator programs,
self-navigation guides, or resource directories.
By 2011,
A. implement Cancer Resource Centers in five locations; and
B. increase by 20 percent the number of cancer treatment centers and providers
that facilitate access to community health advisor navigator programs,
self-navigation guides or resource directories.
Data sources: Process evaluation results; provider survey.
Strategy 1: By 2008, determine the baseline percentage of cancer treatment
centers, tribal health systems, and providers that facilitate access to
navigation guides or resource directories for cancer patients and families.
Strategy 2: Compile a list of cancer-related treatment resources in Montana,
organized by geography and update annually. Make the list available to cancer
treatment centers, providers, and the interested public.
Strategy 3: Add the treatment resource list to the ”Cancer Resource Roster” on
the Cancer Control webpage.
Strategy 4: Analyze resource gaps in availability and barriers to access and
utilization; design strategies to improve resource distribution and utilization.
Strategy 5: Promote establishment of evidenced-based community health advisors
or navigator programs; promote utilization of the programs starting at the time
of diagnosis. Encourage cancer treatment center navigator programs to practice
outreach to the frontier communities in their referral areas.
Strategy 6: Encourage navigator and resource staff training in clinical and
insurance systems, national standards and trends, cost-effective measures,
resources and services.
Strategy 7: Investigate funding to start an ACS Navigator Program in Montana.
Strategy 8: Promote establishment of ACS Cancer Resource Centers; start with
cancer treatment centers and expand outreach to referral communities.
Strategy 9: Sponsor distribution of patient self-navigation programs. Consider
promoting a cancer-specific checklist to improve cohesion of clinical services.
Montana by the Numbers (2000 Census):
1. Montana is a racially homogeneous state: 92.2 percent of the population is
White. The largest minority is American Indian, who comprise approximately 7.4
percent of the population.
2. 16.9 percent of the population between the ages of 21.64 and 39.6 percent of
the population aged 65+ have a disability.
3. 14.6 percent of the population overall is living in poverty.
4. The annual median household income is $33,024. The annual per capita income
is $17,151.
5. Of Montana's 56 counties, 45 qualify for "frontier" status because they have
six or fewer people per square mile.
Goal IV: Promote optimum patient/provider communication to improve cancer
survivors' experiences as healthcare consumers.
Objective IV.1: Increase healthcare providers' communication skills with cancer
survivors and their families regarding the illness, prognosis, treatment, and
follow-up options.
Baseline: The number of accredited education courses currently (2006) available
to physicians, nurses, pharmacists and other healthcare professionals that
address communication with cancer patients and their loved ones; the number of
courses on this topic currently available to and required of healthcare
students.
Outcomes:
1. By 2008, determine the baseline.
2. By 2010, increase by a percentage to be determined the number of accredited
education courses for health care professionals and the number of required
courses available to healthcare students on communicating with cancer patients
and their loved ones.
Data sources: To be determined.
Strategy 1: Determine the baseline number of accredited education courses and
required courses available to healthcare professionals and students on the topic
of culturally appropriate communication with cancer patients and families.
Strategy 2: Work with appropriate entities to increase the number of courses
available in Montana so that each healthcare provider who comes in contact with
cancer survivors has received training on the topic at least once every five
years.
Strategy 3: Explore incentives to encourage healthcare providers to increase
their knowledge and communication skills.
Patients who fully understand the treatment program experience greater
satisfaction with their care, and are more likely to complete treatment despite
the inevitable side effects.
Objective IV.2: Review, develop, and promote resources for improving
patient-provider communication.
Baseline: Resources currently available to patients on communication with
providers.
Outcomes: By 2008, delineate the resources available to patients on
communication with providers. By 2010, make a communications tool available to
all cancer patients
Data sources: Process evaluation results.
Strategy 1: By 2008, determine what resources are available to patients on
communication with providers.
Strategy 2: Add the patient/provider communication resource list to the “Cancer
Control Resource Roster” on the Cancer Control website and promote it to the
public.
Strategy 3: Define the common barriers to patient/provider communication.
Strategy 4: Identify programs or services to assist in overcoming barriers to
patient/provider communication. If no effective program exists, develop an
effective, comprehensive, culturally competent tool to help patients communicate
with their providers.
Treatment: What You Can Do:
Be proactive: If you or a family member is diagnosed with cancer, become
familiar with treatment options as well as national treatment, rehabilitation
and follow-up guidelines for that cancer. Ask about appropriate lower-cost
treatment choices.
Educate yourself: Use the community health advisor, navigator tools, resource
centers and rosters available for cancer patients.
Encourage:
1. your healthcare providers to participate in state-of-the-art educational
opportunities on cancer diagnosis, treatment and evidence-based cost-effective
care.
2. your local cancer treatment center to pursue size-appropriate Commission on
Cancer approval.
Support:
1. funding to assist the families of childhood cancer patients with travel;
2. participation in Comprehensive Cancer Control projects in your community; and
3. policies that improve access to quality care for low income and uninsured
Montanans.
Utilize: the resources available on effective communication to interact with
your healthcare provider.
Profile: Rita McDonald is a colon cancer survivor. "I could have been better
informed, ' she says. "I wasn't told that I should get a screening colonoscopy.
I was totally in the dark. That's why it's so important to me to get the word
out. I want to make a difference -- no one should have to go through what I have
and the cancer I had is almost 100 percent preventable."
Rita was experiencing diarrhea and other symptoms, but had written it off to
something she'd encountered on a recent vacation. When she went in to see her
doctor about it, though, she was immediately sent in for a colonoscopy. Within a
week, she was in surgery. Unfortunately, the cancer had already moved into
Rita's lymphatic system, making it much more difficult to treat. Rita says that
she is thankful that she had symptoms. Colon cancer is often called the "silent
killer" because there are often no symptoms until late in the disease.
After her surgery, Rita remembers lying in the hospital thinking that she would
make sure everyone she loved knew about this. She promised herself that she
would do whatever she could to see that this didn't happen to any of her family
or friends. With Rita's encouragement, her sister and sister-in-law both had
colonoscopies that July. As it turns out, her sister-in-law had colon cancer,
and her sister had polyps, which can develop into colon cancer if not removed.
Both were caught in time. Rita was lucky, too: January 2005 marked three years
of being cancer free. "This has been a really, really long ordeal. I just want
so much to make an impact on people so that they know they don't have to go
through what I'm going through. People need to understand that colon cancer is
preventable." (Rita McDonald.)
Table of Contents
Quality of Life and Survivorship:
Quality of Life: The individual's definition of what is acceptable physically,
psychologically, and spiritually.
Quality of Life is a standard throughout the cancer care continuum - from
diagnosis to remission, cure, or end of life. It includes active treatment,
survivorship, rehabilitation, palliative care, and hospice. Palliative care
identifies and addresses the physical, psychological, spiritual, and practical
burdens of illness. It is offered by an interdisciplinary team that includes
medical professionals, social services, spiritual advisors, and others. All are
focused on the relief of suffering and on supporting the best possible quality
of life for patients facing life-threatening illness and their families.
Though research indicates that cancer patients' pain and other symptoms often
are not well controlled, good symptom management can contribute to improved
quality and length of life. Medical literature suggests that patients and
families may have better outcomes if they are able to understand and direct
their care. In addition, many patients express the need to maintain control over
their care and feel that it improves their quality of life and survivorship.
Many cancer patients rely on spiritual or religious beliefs and practices to
help them cope with their diseases. Some patients may want their doctors and
caregivers to acknowledge their spiritual concerns, not only for end-of-life
issues but also during treatment. According to the Institute of Medicine,
quality end-of-life care should include pain management, psychosocial support,
and timely referral to hospice.
Increasingly, patients are using complementary and integrative medicine, which
support and are used in conjunction with traditional, evidence-based treatment.
Complementary therapies might include such activities as acupuncture, massage,
meditation, music therapy or biofeedback. Cancer patients should have access to
all forms of therapy from which they can benefit. Integrative medicine is a
total approach to medicine that involves mind, body, and spirit. For example,
relaxation might be used as a way to reduce stress during chemotherapy.
Childhood cancer brings with it a host of issues that affect the entire family.
Having cancer can bring physical, emotional, and cognitive changes that affect a
child’s ability to perform. Even so, returning to normal routines as quickly as
possible can provide a sense of purpose and hope to the family.
Nationally, the number of cancer survivors tripled between 1971 and 1999. There
were 9.8 million survivors in 2001.
Stages of Grief: Elizabeth Kubler-Ross originally defined the stages a person
goes through after learning of a serious illness, suffering a loss, or a major
life change.
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
Montana has palliative care programs in most major cities. Two meetings have
been held to initiate communication and facilitate cooperation among these
programs.
Goal I: Promote quality of life for cancer patients.
Objective I.1: Increase the percentage of hospitals that offer pain management
programs for cancer patients.
Baseline: Twenty-four percent of Montana hospitals reported pain management
programs (“Last Acts: Means to a Better End. A Report on Dying in America Today”
2002. Montana)
Outcomes: By 2011, increase the percentage of hospitals offering cancer pain
management programs to 50 percent
Data sources: Hospital survey
Strategy 1: Determine the percentage of hospitals offering pain management
programs.
Strategy 2: Support the cancer-related activities of the “Task Force on Pain and
Symptom Management” recognized by the Montana Legislature. Consider the task
force’s recommendations on pain and symptom management interventions, use of
complementary medicine, the needs of the medically underserved, drug
repositories, and end-of-life cancer pain treatment. Consider the Task Force's
analysis of state statutes.
Strategy 3: Promote pain management standards and develop an implementation plan
for increasing the number of cancer pain management programs.
Strategy 4: Educate the healthcare provider and patient communities about
standards related to cancer pain management.
Pain Management: There are disparities in access to effective pain management
for special populations, particularly racial minorities, children and the
elderly. For example, research indicates that nearly one-third of children's
cancer centers in North America did not use general anesthesia or deep sedation
for the majority of bone marrow procedures, and more than 25 percent used either
nothing or topical anesthesia (“Pain Information for Professionals”. American
Cancer Society: www.cancer.org ).
Palliative Care: Palliative care and symptom management is medical care that
lessens pain or the effects from treatment of a disease, such as cancer. It
helps to make patients more comfortable at every stage of illness. It is also
referred to as supportive care.
Palliative Care Guidelines: There are now practice guidelines for quality
palliative care established through the “National Consensus Project for Quality
Palliative Care”. These will set the standard for palliative care programs
across the nation. The guidelines describe core precepts for clinical palliative
care programs.
Aspects of Care are psychological and psychiatric, physical, social and
cultural, spiritual, religious and existential. Structure and Processes include
care of the imminently dying patient, and ethical and legal issues. Adapted
from:
www.nationalconsensusproject.org
Objective I.2: Increase the percentage of hospitals offering palliative care
programs that address cancer and treatment symptom management.
Baseline: Sixteen percent of Montana hospitals reported palliative care programs
(“Last Acts: Means to a Better End. A Report on Dying in America Today” 2002.
Montana)
Outcomes: By 2011, increase the percentage of hospitals reporting palliative
care and symptom management programs for cancer patients to 30 percent
Data sources: Hospital survey
Strategy 1: Determine the percentage offering palliative care and symptom
management programs.
Strategy 2: Ensure that cancer survivors across Montana have access to
palliative care, symptom management, and hospice programs.
Strategy 3: Promote national palliative care standards and develop an
implementation plan to increase palliative care programs that address symptoms
during cancer treatment for cancer survivors of all ages.
Strategy 4: Encourage palliative care programs to include routine recommended
order sets for symptoms associated with cancer treatment, as based on National
Hospice and Palliative Care Organization (NHPCO) and American Society of
Clinical Oncology (ASCO) guidelines.
Strategy 5: Develop and implement a plan for palliative care programs that
includes appropriate use of rehabilitation services designed to improve the
cancer survivors' quality of life.
Strategy 6: Educate healthcare providers and cancer patients, including
children, about symptom management, palliative care, and hospice programs.
Strategy 7: Identify availability of hospice care in rural areas, assess gaps in
availability and barriers to accessibility and utilization; design and implement
strategies to improve availability, accessibility, and utilization.
Hospice: A model of care that can be delivered in a variety of settings, and
which employs pain and symptom management within a defined end-of-life period of
less than six months.
Follow-Up Care: It is natural for anyone who has completed cancer treatment to
be concerned about what the future holds. Many people are concerned about the
way they look and feel, and about whether the cancer will recur. They wonder
what they can do to keep the cancer from coming back. They also want to know how
often to see the doctor for appointments, and what tests they should have.
Understanding what to expect after cancer treatment can help patients and their
loved ones plan for follow-up care, make lifestyle changes, and reach decisions
about quality of life and finances.
Follow-up care involves regular medical checkups that include a review of a
patient's medical history and a physical exam. It is important because it helps
to identify changes in health. The main purpose is to check for the return of
cancer in the primary site (recurrence), or the spread of cancer to another part
of the body (metastasis). Many times, recurrences are suspected or found by
patients themselves between scheduled checkups. It is important for patients to
be aware of changes in their health, and report any problems to their doctor.
The doctor can determine whether the problems are related to the cancer, the
treatment the patient received, or an unrelated health problem. For more
information, visit:
http://cis.nci.nih.gov/fact .
Goal II: Empower cancer survivors and their families to maximize control over
their lives and the disease through the appropriate use of resources and
deliberate end-of-life decisions.
Objective II.1: Identify and add to the cancer quality of life resources
available to survivors, families and employers. Help ensure their ability to
identify their roles, responsibilities and rights.
Baseline: A comprehensive cancer quality of life resource list is unavailable.
Outcomes: By 2008, a quality of life resource list will be available to cancer
survivors, their families and employers. By 2011, the level of resources will
increase by a percentage to be determined once a baseline has been established.
Data sources: Process evaluation results; quantitative evaluation results
comparing baseline resources available with those available in 2011.
Strategy 1: Identify resources that describe roles, responsibilities and rights
attendant to cancer care and quality of life. Create a database designed to
educate cancer survivors, family members, and employers. Add the quality of life
resource list to the “Cancer Resource Roster” on the Cancer Control webpage.
Strategy 2: Add the resources available to facilitate access to psychological,
physical, social, emotional, vocational, economic, and spiritual support
services to the cancer quality of life resource list.
Strategy 3: Analyze gaps and barriers to quality of life cancer services, and
implement strategies to overcome them.
Strategy 4: Develop and distribute new and existing resources including patient
educational materials, roles and responsibilities, treatment options, common
symptoms management, patients' rights, legal, and ethical end-of-life options.
Strategy 5: Increase awareness and encourage expansion of support groups as a
tool to help survivors and their families meet their psychological, physical,
social, emotional, vocational, economic, and spiritual needs.
Strategy 6: Promote outreach to improve access to these support groups for
survivors, families, and employers in smaller communities.
Strategy 7: Make information on return-to-work and other aftercare issues
available to survivors.
While it may be reasonable to hope for a long life, it is also possible to hope
for different things -- being comfortable...being supported by loving
care...having the time to review the past and to take pleasure from it...taking
the opportunity to resolve problems and to continue to love and be loved.
Adapted from the National Coalition for Cancer Survivorship.
The Americans with Disabilities Act (ADA) calls for employers to provide
"reasonable accommodation" for workers with disabilities, which may include
anything from special equipment or lighting to flexible schedules. The Family
and Medical Leave Act (FMLA) requires many employers to allow unpaid,
job-protected leave. The Health Insurance Portability and Accountability Act of
1996 (HIPAA) has helped ensure that pre-existing conditions may not be excluded
in certain new health policies if gaps in coverage are relatively short.
Objective II.2: Increase the number of cancer patients who have access to
advanced healthcare directives through their healthcare providers.
Baseline: To be determined.
Outcomes: By 2008, determine the number of healthcare providers who make
advanced healthcare directive planning available to their cancer patients By
2011, improve the number of healthcare providers making advanced healthcare
directive planning available by a percent to be determined.
Data sources: Healthcare provider survey.
Strategy 1: Determine the baseline number of healthcare providers assisting with
advance healthcare directive planning.
Strategy 2: Review and assess the status of Montana State Law pertinent to
advance healthcare directive planning.
Strategy 3: Work with the Palliative Care Summit Workgroup to develop strategies
that will encourage healthcare providers to make advanced healthcare directives
planning available to their cancer patients.
Strategy 4: Educate healthcare providers about the availability and use of
advanced healthcare directives, including living wills, Durable Medical Power of
Attorney forms, “Five Wishes”, and the Montana Choices Bank Repository Act, a
voluntary registry for consumers who wish to ensure that their healthcare
providers have access to their advanced healthcare directives.
Strategy 5: Identify and review problems with “Comfort One” and consider
implementing a Physician Orders for Life Sustaining Treatment (POLST) form
similar to those used in Washington, Oregon, and West Virginia.
Objective II.3: Develop and communicate a Patient's Bill of Rights for cancer
care.
Baseline: A standardized Patient's Bill of Rights for cancer care has not been
developed.
Outcomes: By 2008, determine baseline data on the status of a Patient's Bill of
Rights in Montana. By 2011, begin promoting a standardized Montana Patient’s
Bill of Rights for cancer care.
Data sources: Process evaluation results
Strategy 1: Gather and review Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) standards for Patient's Bill of Rights; review status of
Montana state laws as well as clinical standards recommended by the National
Consensus Project for Quality Palliative Care.
Strategy 2: Draft a prototype Patient's Bill of Rights for cancer care in
Montana.
Strategy 3: Determine whether the implementation of a standardized Patient's
Bill of Rights for cancer care should be initiated at the legislative or
voluntary level, and promote implementation in the appropriate venue.
5 Wishes: The Five Wishes articulate your desires to your family and doctors.
1. Who you want to make healthcare decisions for you if you can't make them for
yourself.
2. What kind of medical treatment you want...or don't want.
3. How comfortable you want to be.
4. How you want people to treat you.
5. What you want your loved ones to know.
Profile: Cindy Peterson had a cough she couldn't shake, and she was short of
breath. She tried antibiotics, but they didn't help. When she was still coughing
the next week, she asked for another prescription. Instead the doctor listened
very carefully to her chest. "I don't like the way that sounds," he said. "I
want you to get an x-ray right now." Cindy had the x-ray. And then another.
Shortly after that, they drained two liters of fluid from her lungs. Cindy is a
nurse, and the color of the fluid terrified her. The only time she' d seen fluid
that color, it had been in a patient with metastatic cancer. The doctor really
didn't need to give her the news. She already knew. When he came into her office
the next day, she started to cry as soon as he shut the door. Her doctor
referred her to a gynecological oncologist in Spokane. They scheduled surgery
immediately. Cindy was in the hospital for a week, then came back to Montana for
chemotherapy. In the meantime, she started educating herself. She didn't have
any illusions: the literature was grim. She had stage IV ovarian cancer, and the
five-year survival rate was five percent. Cindy joined a clinical trial right
away, and received excellent treatment from her doctor in Great Falls. It's now
been two and a half years since she first learned that she had cancer. Cindy has
always had a positive outlook on life. Even though the cancer diagnosis was hard
to accept, she knew she had to face the challenges ahead. Her choices were to
accept the fate the statistics dictated, or take control of her own fate and
defy the statistics. She chose to take control. She started small, by setting
attainable life goals. She wanted to see her kids graduate from college. Now she
wants to see her kids get married and to spoil grandkids. After that, she says
she'll set new goals.
"Be informed, not afraid. A positive attitude helps. Educating yourself helps,
too. The internet is a wonderful tool -- use it to inform yourself, but don' t
just accept everything you read. No matter how bad the odds are, there are
exceptions. People do survive. And if it isn't about survival, it's about
quality of life. Don't look for death, look for life. I really started looking
at the three Fs differently, Faith, Friends, Family. I need my family to get
through this, and my family needs me. I intend to be there for them." (Cindy
Peterson).
What is a Durable Medical Power of Attorney? A legal document that allows an
individual the opportunity to legally authorize a trusted family member or
friend to make healthcare decisions at such time as s/he can no longer do so.
The Durable Medical Power of Attorney goes into effect immediately after
execution and delivery to the agent, and remains in effect until terminated or
revoked.
The Patient's Bill of Rights
1. Information disclosure: You have the right to accurate and easy-to-understand
information about your health plan, healthcare professionals and facilities.
2. Choice of providers and plans: You have the right to a choice of healthcare
providers who can provide access to appropriate high-quality health care.
3. Access to emergency services: If you have severe pain, an injury or sudden
illness that convinces you that your health is in serious jeopardy, you have the
right to receive screening and stabilization emergency services whenever and
wherever needed, without prior authorization or financial penalty.
4. Participation in treatment decisions: You have the right to know your
treatment options and to participate in decisions about your care. Family
members or your designees may represent you if necessary.
5. Respect and nondiscrimination: You have the right to considerate, respectful
and nondiscriminatory care.
6. Confidentiality of health information: You have the right to talk in
confidence with healthcare providers and to have your healthcare information
protected. You also have the right to review, copy, and request corrections to
your own medical record.
7. Complaints and appeals: You have the right to a fair, fast, and objective
review of any complaint you have against your health plan, doctors, hospitals,
or other healthcare personnel. This includes complaints about waiting times,
operating hours, the conduct of healthcare personnel, and the adequacy of
healthcare facilities.
Adapted from the Patient's Bill of Rights used by the U.S. Advisory
Commission on Consumer Protection and Quality in the Health Care Industry. (www.cancer.org
)
An individual is considered a cancer survivor from the time of diagnosis,
through the balance of his or her life.
Goal III: Ensure childhood cancer survivors are provided age-appropriate
services.
Objective III.1: Establish and implement methods to assist school
administrators, teachers and students with the unique challenges presented by
children with cancer and their siblings.
Baseline: There is no consistent approach by schools for addressing the needs of
children affected by cancer.
Outcomes: By 2010, define and implement methods for addressing the educational
needs of children affected by cancer.
Data sources: Process evaluation results.
Strategy 1: Identify the challenges and emotional needs of children with cancer,
their siblings, and families correlated with school reintegration activities.
Strategy 2: Research best practice models and develop age-appropriate methods to
address identified educational needs.
Strategy 3: Develop creative alternative education plans for children cancer
survivors.
Strategy 4: Develop and provide in-service training and continuing education
opportunities for educators who work with childhood cancer survivors and their
siblings.
Objective III.2: Identify the non-educational needs unique to children with
cancer and their siblings.
Baseline: A children's special needs resource list has not been identified.
Outcomes: By 2010, develop, distribute, and maintain a special needs resource
list.
Data sources: Process evaluation results.
Strategy 1: Establish a committee to identify the non-educational needs unique
to children with cancer and their siblings.
Strategy 2: Develop and routinely update a comprehensive list of the resources
available to pediatric cancer patients in Montana, such as specialty services,
wig programs, camps, scholarships, wish-granting organizations and home health
agencies. Add the resource list to the “Cancer Resource Roster” on the Cancer
Control webpage.
Strategy 3: Determine existing resource and service gaps and develop strategies
to address the disparities, overcome the barriers, and fill the gaps.
Strategy 4: Develop an information distribution plan to reach all newly
diagnosed pediatric cancer patients and their families.
How to Help Children with Cancer in Your Community
1. Support local fundraisers.
2. Volunteer your time to local nonprofits that work with children who have
cancer.
3. Advocate for the state and federal policies that will assist children with
cancer and their families with their travel and treatment needs.
Goal IV: Ensure that there are opportunities for safe and effective use of
complementary medicine in cancer care in Montana.
Objective IV.1: Increase patient, healthcare provider, and institutional
awareness of the available complementary therapies from which cancer patients
have been shown to benefit.
Baseline: No baseline data describing the level of awareness of complementary
cancer therapies is available.
Outcomes: By 2008, determine how many accredited educational presentations on
complementary cancer therapies are available.
By 2011, increase the number of accredited educational presentations on
complementary cancer therapies by a percent to be determined.
Data sources: To be established.
Strategy 1: Conduct a study to determine how many accredited educational courses
that address complementary cancer therapies are available to Montana survivors,
healthcare providers, and institutions.
Strategy 2: Educate allopathic/osteopathic healthcare providers on the potential
contribution of complementary therapies and American Indian therapies in cancer
care.
Strategy 3: Educate patients on the potential harm associated with
self-prescribed care.
Strategy 4: Educate allopathic/osteopathic healthcare providers and patients
about the difference between licensed and unlicensed complementary care
providers.
Strategy 5: Establish a method whereby allopathic/osteopathic providers and
patients can easily identify and access licensed naturopathic providers as well
as other licensed or certified complementary care providers.
Strategy 6: Develop tools to improve communication between complementary
healthcare providers and allopathic healthcare providers, and educate cancer
patients to communicate information about medications, care plans and
supplements to all their healthcare providers.
Naturopathic physicians are licensed in Montana as primary healthcare providers.
They have broad training and can contribute and participate in many aspects of
cancer care, such as data collection, early detection, integrative treatment,
quality of life, research, and advocacy. By utilizing the naturopathic
physician’s expertise in nutrition, lifestyle modification, environmental health
issues, and health maintenance, cancer prevention can be maximized.
The American Cancer Society recognizes the need to balance access to
complementary therapies, while protecting patients from methods that might be
harmful. The ACS supports patient access, but strongly encourages oversight and
accountability.
Quality of Life & Survivorship: What You Can Do
1. Talk to your healthcare provider about your goals and values for end-of-life
decisions, your treatment, and concerns about symptoms and pain management.
2. Complete and communicate an advanced healthcare directive.
3. Educate yourself about your disease and know what to expect.
4. Understand the Patient's Bill of Rights.
5. Support expansion of hospice care availability in frontier and American
Indian communities and support programs that enhance quality of life for cancer
patients.
Table of Contents
Research: The process of scientific discovery is, in
effect, a continual flight from wonder. (Albert Einstein)
Clinical trials: Research studies involving people that test new, promising
prevention and treatment methods to determine whether they are safe, effective,
and better than current standards of care.
The best management for any cancer patient is in a clinical trial. Participation
in clinical trials is especially encouraged. (National Comprehensive Cancer
Network).
Effective methods for Diagnosis, Treatment and Prevention (DTP) of cancer rely
on evidence generated from closely-interrelated clinical and basic research.
Basic research adds to the understanding of the biology of cancer and is
invaluable in designing applications to human disease. Observations of disease
development drive basic research studies. Translational research, an
intermediate step, links bench science and bedside clinical medicine. Overall,
carefully collected and interpreted evidence has the ability to improve outcomes
for patients with cancer.
Clinical trials are research studies involving people. They represent the final
stages of this long and careful cancer research process. When an approach
demonstrates promise, clinical trials or investigations are designed on a
scientific data-driven basis to find out if it is safe, effective, and better
than the current standard of care. This allows research to advance without
compromising current standards of care.
Clinical trials are performed in accredited cancer treatment centers with formal
mechanisms that protect the patient, the facility, and the healthcare provider.
Patients participating in clinical trials have access to newer, potentially more
effective and less costly approaches. The outcomes for the same type and stage
of cancer are often better for those participating in clinical trials. They also
offer patients and researchers opportunities to contribute to the body of
knowledge. Trials have the potential to improve personal care and make lasting
contributions to the field of medicine.
Participation in clinical trials is voluntary. Nationally, only two to three
percent of cancer patients are treated in clinical trials. Identifying and
overcoming barriers to participation can provide better care and data for the
emerging advances in cancer management and prevention. Financial and other
barriers to participation exist for patients and providers. Health insurance
providers may not cover the routine patient care costs for patients in clinical
trials.
This Comprehensive Cancer Control Plan proposes a centralized person as a
resource for scientifically sound cancer information. The liaison will provide
an effective, coordinated mechanism to increase awareness of cancer-related
issues in Montana. The cancer medical liaison will perform multiple tasks.
1. Develop and implement tools, including a web-based resource, that provide
up-to-date information for patients, healthcare providers, insurance providers,
policy makers, and basic researchers. The tools will facilitate participation in
basic cancer research, appropriate utilization of translational technology, and
increased utilization of clinical trials in Montana.
2. Respond to health care professionals by providing access to evidence-based
information that improves the effective, efficient use of new technologies as
they progress to state-of-the-art and become standards of care.
3. Organize educational opportunities through a speakers bureau, seminars,
teleconferences, web links, funding opportunities, and translational technology
directed toward cancer management.
Basic, translational, and clinical research all offer advances to cancer
management. Overcoming barriers to participation in cancer research for both
patients and professionals needs to be addressed through educational efforts
that are accurate, easy to access, comprehensive, up-to-date, and responsive to
need. Through awareness and education, there is an opportunity to reach all
populations in Montana that may benefit from cancer research activity in all of
its forms.
“The genius, then, is in the bridge or the translation.” (Dr. Grant Harrer).
Goal I: Provide professionals and the public with access to cancer research
information.
Objective I.1: Create a list of web links relating to science and
evidenced-based cancer information.
Baseline: There is no identified comprehensive list of web resources available.
Outcomes: By 2008, a list will be available on-line and routinely maintained.
Data sources: Process evaluation results.
Strategy 1: Identify and review possible websites and generate a list of links
to science and evidence-based cancer information.
Strategy 2: Maintain the resource list on the Cancer Control webpage, and market
this resource to the public and providers.
Objective I.2: Create a position for a liaison to serve as a cancer information
resource for healthcare providers and the public.
Baseline: There is no central liaison resource available.
Outcomes: Establish a liaison and make her/him available statewide through a
toll-free help line.
Data sources: Process evaluation results.
Strategy 1: Create a job description and identify a physical location and
funding for the central liaison. Position duties will include such tasks as:
coordination of professional education programs; information management;
resource dissemination; and organization of a speakers' bureau, teleconferences,
and other activities.
Strategy 2: Establish a toll-free help line for access to the liaison and market
this resource to providers and the public.
Objective I.3: Establish an educational program on state-of-the-art,
cancer-related practices.
Baseline: No comprehensive educational program is available.
Outcomes: By 2011, create and institute a professional educational program on
state-of-the-art, cancer-related practices.
Data sources: Process evaluation results.
Strategy 1: Coordinate this program through the central liaison described in
Objective 1.2.
Strategy 2: Market this resource to providers and the public. Include
information on the program in professional cancer education statewide.
Goal II: Assure high-quality cancer research in Montana.
Objective II.1: Increase the percentage of Montana cancer patients who
participate in clinical trials.
Baseline: 2.2 percent of all eligible patients were in clinical National Cancer
Institute (NCI) trials in Montana. A percent of patients in other clinical
trials will be determined from private companies and other in-house clinical
trials.
Outcomes: By 2008, determine the percentage of Montana cancer patients who are
participating in clinical trials. By 2011, increase the baseline level of
participation by a percentage to be determined.
Data sources: Montana Cancer Consortium (MCCC) 2003 for NCI trials;
pharmaceutical, private and in-house clinical trials -- method to be established
Strategy 1: Implement a tool to determine the percentage of Montana cancer
patients who are participating in clinical trials.
Strategy 2: Educate healthcare providers and the public on clinical trials
available to Montanans of all ages. Provide on-going public education on the
benefits and limitations of clinical trials.
Strategy 3: Encourage care coordinators to inform cancer patients of clinical
trials germane to their conditions; increase the number of healthcare providers
recommending clinical trials to their patients.
Strategy 4: Support policies encouraging insurers to make appropriate
reimbursements for routine patient care costs for those in Phase II and III
clinical trials.
Strategy 5: Design and implement strategies to increase participation in
clinical trials; increase the number and type of clinical trials available in
Montana.
Objective II.2: Increase the number of researchers, research dollars, and
studies devoted to community-based, clinical, basic science, translational,
epidemiologic, genetic, and other cancer-related research.
Baseline: To be determined.
Outcomes: By 2008, determine the baseline for research dollars, studies and
researchers in Montana. By 2011, increase funds, active researchers and the
number of studies on cancer-related topics by numbers or percentages to be
determined.
Data sources: To be established.
Strategy 1: Determine the level of research dollars, number of studies and the
number of active researchers working on cancer-related topics in Montana.
Strategy 2: Conduct an assessment to define the supportive infrastructure for
research.
Strategy 3: Design strategies to enhance the level of research funding; increase
the number of researchers, and improve the infrastructure for cancer research in
Montana.
Strategy 4: Encourage and facilitate Montana researchers in their applications
for cancer-related funding.
Strategy 5: Support increasing culturally competent research in communities and
populations with a disparate burden of cancer.
The mission of translational research is to translate basic science into
clinical applications, and to use clinical observations to generate scientific
research. Translational research focuses on the integration of activities from
bench to bedside.
Profile: Patricia Lieberg's life changed completely in less than a month.
Looking back, she realized there'd been signs that something wasn't quite right.
She felt as if she'd pulled some muscles, but couldn't explain why. She'd
developed some facial hair, experienced flushing and shortness of breath. She
finally went to see her doctor. He ordered an ultrasound, which revealed what
appeared to be a large tumor on her kidney. He referred her to a specialist in
Great Falls, who immediately ordered an MRI. The results revealed that the tumor
wasn't on her kidney after all: the adrenal tumor had grown up into the vena
cava, the large vein that returns blood to the heart. Patricia had
adrenocortical carcinoma, which affects about one in two million people. After
looking at the MRI results, the doctor said, "I don't even want to touch you
here. You need to be in Bethesda, Maryland. They're the specialists." Once
there, they removed the adrenal tumor; by then, the tumor had invaded her heart
and lungs. The operation went well, and Patricia flew home two weeks later.
They'd told her to come back in six months for a follow-up CAT scan. The more
she thought about it, the more uncomfortable she became with the idea of
waiting. She asked her physician to order a CAT scan locally. It's a good thing
she did: it revealed that the cancer nodules were growing. Neither radiation nor
surgery would help. Her best hope was a clinical trial. Patricia agreed to
participate in the trial that included new chemotherapy drugs. She has now been
through seven treatments in Bethesda, with three or four weeks between
treatments. Because she's participating in a clinical trial, they help with
airfare and some of her other expenses. Last time they checked, her doctors were
delighted to find that some of the smaller nodules had disappeared, and others
had shrunk. It's great cause for celebration: this cancer is so invasive that
the treatment is considered a success if the cancer doesn't continue to grow.
"The clinical trial was a great choice for me. Otherwise I'd be dead or close to
it by now, the cancer was that bad and had gone that far. My family has been so
supportive, but this has changed all of us a lot. You definitely realize what's
important. If I could help others, I'd want to them to know how important it is
to keep a positive attitude, and to refuse to give up. There will be down days
and days you don' t feel good, but you have to remember there will be good ones,
too. Just don' t give up." (Patricia Lieberg).
New technology, if used wisely, can yield great benefits. If used
indiscriminately, it can add unnecessary costs. Researchers must determine
best-use scenarios before promoting wide use. Clinical trials help determine the
most efficient, safe, appropriate, and effective use of new technologies.
Research: What You Can Do.
1. Become knowledgeable about cancer research in the state.
2. Support public policy and legislation promoting increased cancer research and
funded cancer research in Montana.
3. Become an ambassador for participation in cancer clinical trials and support
the application of the information gained from these trials.
4. Ask your doctor about clinical trials that you or a family member may agree
to participate in.
5. Support local fund raisers that provide funding for cancer research in
Montana.
The Montana Cancer Consortium is a nonprofit organization whose mission it is to
bring state-of-the-art cancer treatment to Montana and Northern Wyoming through
clinical trials sponsored by the National Cancer Institute. (http://www.mtcancer.org).
Table of Contents
Data, Registry & Surveillance
“A national system of cancer registries can help us understand the disease
better and use our resources to the best effect in prevention and treatment.”
(Dr. Donna Shalala).
Incidence: The number of new cases of a disease diagnosed each year.
Morbidity: Disease or the incidence of disease within a population. Morbidity
also refers to adverse effects caused by a treatment.
Cancer is actually a catch-phrase for many diseases with a wide variety of
causes. It can result from genetic predisposition, lifestyle choices,
environmental factors, or a combination thereof. Many causes are as yet unknown.
Cancer in its many forms represents a major public health issue, as well as a
significant challenge to measure and record. Public health agencies rely on
several types of information to understand cancer: reports, vital statistics,
surveys, assessments of potential exposures, and administrative sources.
Cancer surveillance activities in Montana can be grouped into two main
categories: morbidity and mortality information, and risk behavior information.
The Montana Vital Statistics Bureau and the Montana Central Tumor Registry (MCTR)
conduct surveillance of cancer and mortality. Cancer mortality data is gathered
from death certificates.
Cancer is a reportable disease in Montana. The MCTR maintains the data management system on the incidence of various cancers, stage at diagnoses, treatments, and outcomes of cancer and other reportable tumors. This system, which has been in existence since 1979, establishes cancer incidence and relative survival rates.
Incident cases -- or the count of each tumor occurrence -- include
information such as diagnosis, stage, and treatment. These are submitted to the
MCTR by 60 hospitals, two radiation centers, one Veteran’s Administration
hospital, three pathology laboratories, and many out-of-state cancer registries.
Currently, there is no mechanism to report physician-based cancer cases to the
MCTR. These cases are estimated to be an additional two to three percent of all
cancer tumor incidence.
Surveys on health status, risk behaviors, and life experiences of populations
are used to capture prevalence data, which can tell us how widespread a given
condition is at a specific point in time.
Modifiable health-risk behaviors are monitored by the Montana Behavioral Risk
Factor Surveillance System (BRFSS). This survey of adult Montanans collects
information about a number of health behaviors and preventive practices on a
continuous basis. These include tobacco use, nutrition, exercise, healthcare,
access, and cancer-screening behaviors.
The Environmental Public Health Tracking Project (EPHT) coordinates the
collection, integration, analyses, and interpretation of data about exposure to
environmental hazards, and its effect on human health. The Department of Public
Health and Human Services (DPHHS) and the Department of Environmental Quality (DEQ)
were awarded federal funding in October 2002 to participate in building a
national EPHT network, the ultimate goal of which is to integrate data systems
nationwide, so that all sectors of the public can take action to prevent and
control environmentally related health effects. Existing surveillance systems
yield the baseline rates of disease, mortality, or morbidity necessary to detect
disease clusters.
Sources of administrative data, including providers, insurers, hospitals, and
local health departments also produce health data that could help highlight
cancer risks and trends and enhance cancer control efforts, but these data are
not readily accessible. Integrating and sharing this data would improve efforts
to plan, evaluate, and craft cancer control policy.
Data can help identify areas where greater efforts are needed, potential causes
and progress toward reducing cancer mortality. Access to complete, timely, and
accurate cancer data is critical to our ability to evaluate progress toward
comprehensive cancer prevention and control.
Goal I: Data collected by the Montana Central Tumor Registry will meet the North
American Association of Central Cancer Registries (NAACCR) Gold Standard for
complete, high quality and timely data.
Objective I.1: Improve reporting of reportable cancer cases to the MCTR within
24 months of the close of the diagnosis year.
Baseline: Currently, there is 92.1 percent case ascertainment within 24 months
of year end (MCTR 2002)
Outcomes: By 2010, increase ascertainment within 24 months of year end to 95
percent
Data sources: MCTR
Strategy 1: Analyze barriers to reporting and utilize physician input and other
states' procedures to design a process that will educate healthcare providers
and facilitate the reporting of tumors.
Strategy 2: Review other data sources including hospital cancer registrars,
physicians' offices, the Office of Vital Statistics, Indian Health Services
(IHS) and the Montana Breast & Cervical Health Program (MBCHP).
Strategy 3: Evaluate case ascertainment on American Indian Reservations and
develop a mechanism for collecting missing data.
Strategy 4: Review "pathology only" cases and contact primary physicians to
obtain reportable data on missing cases.
Strategy 5: Evaluate existing, and develop new, data exchange agreements that
encourage other states to collect and provide data to MCTR on Montana cancer
patients treated in those states.
Objective I.2: Decrease the percentage of "race unknown" and "death certificate
only" cases reported.
Baseline: Among reported cancer cases, 4.2 percent are categorized as “race
unknown” and 5 percent as “death certificate only” (MCTR 2002)
Outcomes: By 2010, reduce those categorized as “race unknown” to 3 percent;
reduce those listed as “death certificate only” to 3 percent.
Data sources: MCTR
Strategy 1: Analyze source of "race unknown" and "death certificate only"
designations and design strategies for implementation to improve reporting.
Strategy 2: MCTR will request tumor case information from certifying physicians
and hospitals where death occurred.
What is Reportable?
1. All malignant cancers (including in-situ) except basal cell carcinoma or
squamous cell carcinoma of the skin.
2. All benign tumors of the brain.
3. All carcinoid tumors.
What is "death certificate only”? A cancer case that has been reported to the
MCTR based on a cancer diagnosis on the death certificate.
Why is this important? A high percentage of “death certificate only” cases in
the MCTR could indicate under-reporting of cancer cases by hospitals and
physicians.
Goal II: Analyze and disseminate cancer-related data.
Objective II.1: Increase the dissemination and use of Montana Central Tumor
Registry data.
The Montana Central Tumor Registry (MCTR) is the primary cancer-surveillance
tool in Montana. The MCTR maintains a data management system that tracks the
occurrence and characteristics of cancer and other reportable tumors. It
collects information on such things as demographics, staging, treatment,
follow-up, and outcomes. The data are gathered for all Montanans regardless of
whether or not they are treated here.
Baseline: The MCTR currently publishes a biennial report.
Outcomes: Publish the MCTR report annually and post on the Cancer Control
Section webpage.
Data sources: Process outcome results.
Strategy 1: Publish and disseminate an annual MCTR report, to include education
on MCTR, risk factor data, incidence by tumor type, mortality, and benchmark
comparisons. Add to the Cancer Control webpage.
Strategy 2: Regularly assess and disseminate information on the cancer burden in
Montana utilizing existing data sources. Identify the need for additional data
sources and work toward establishing data links.
Strategy 3: Promote use of the MCTR data in cancer research publications.
Develop creative avenues to present cancer-related data, such as utilizing
Geographic Information Systems (GIS) data maps.
Cancer cluster: A statistically significant, greater-than-expected number of
cancer cases that occurs within a group of people in a geographic area over a
period of time.
Objective II.2: Increase the amount of cancer cluster information available on
the Cancer Control webpage.
Baseline: The cluster investigation protocol is not widely implemented within
DPHHS; cancer cluster information is not available on-line.
Outcomes: By 2008, publish cancer cluster educational information on the Cancer
Control webpage.
Data sources: Process evaluation results.
Strategy 1: Implement and institutionalize the use of the cancer cluster
investigation protocol within DPHHS.
Strategy 2:
a. Produce a Cancer Control webpage that includes cancer cluster investigation
reports
and educational information.
b. Link the Cancer Control webpage to the DPHHS health data website.
c. Incorporate data from the Montana Central Tumor Registry, Montana Breast and
Cervical Health Program and Vital Statistics.
Cancer, in general, is common. According to the American Cancer Society, about
1,399,790 Americans will be diagnosed with cancer in 2006.
"Somewhere, something incredible is waiting to be known." Carl Sagan
Objective II.3: Improve the availability, accessibility, and utilization of
cancer-related data.
Baseline: There is no cancer-related data resource list; there is no broad-based
analysis of cancer using multiple data sources.
Outcomes: By 2008, create a cancer-related data resource list; create a
broad-based cancer analyses; post on the Cancer Control webpage.
Data sources: Process evaluation.
Strategy 1: Compile a list of cancer-related publications and data resources,
and add to the “Cancer Resource Roster” on the Cancer Control webpage .
Strategy 2: Post a link on the Cancer Control webpage to the Center for Disease
Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS)
and other cancer-related data sources.
Strategy 3: Collect and analyze data on cancer from multiple sources including
the MCTR, Vital Statistics, BRFSS, claims, insurance, and admissions data.
Identify barriers, gaps, and disparities in the cancer control continuum.
Implement interventions to rectify the deficiencies.
Strategy 4: Periodically publish and promote a comprehensive Montana cancer
control report. Include updates on the progress of Comprehensive Cancer Control
Plan projects.
Strategy 5: Support standardization and integration of databases among Indian
Health Service, Montana Breast and Cervical Health Program, the MCTR, the EPHT
and the Rocky Mountain Biomonitoring Consortium (RMBC).
Strategy 6: Utilize and support analyses of BRFSS and American Indian survey
data to learn more about risk factors. Add appropriate questions to on-going
surveys as needed for comprehensive cancer control.
Strategy 7: Develop a taskforce to:
a. support the Comprehensive Cancer Control Program's internal and external data
needs.
b. work with the cancer epidemiologist.
c. identify gaps, needs, disparities, and barriers in cancer data and determine
interventions to rectify the deficiencies.
Strategy 8: Establish new data sources for use in assessing, strategizing, and
prioritizing future comprehensive cancer control activities.
Some racial and ethnic groups have higher incidences of, and deaths due to,
cancer. Such disparities may be due to multiple factors, such as the late stage
of disease at diagnosis, barriers to healthcare access, biologic and genetic
differences, health behaviors, cultural differences, exposures to carcinogens in
the environment and the workplace, and other risk factors.
Objective II.4: Collaborate with Montana's Environmental Public Health Tracking
project to establish integrated databases that allow epidemiological
investigations of health hazards from environmental exposures and other sources.
Baseline: Databases are not currently integrated.
Outcomes: By 2011, integrate data sets from the MCTR and the MBCHP; integrate
data sets from the remaining agencies listed in Strategy 1.
Data Sources: Process evaluation results.
Strategy 1: Collaborate with the DPHHS Environmental Public Health Tracking
project to integrate cancer-related databases, including MCTR, and MBCHP data as
well as other existing or emerging sources of environmental or health-related
data (e.g., Department of Environmental Quality, data from other DPHHS
divisions, the Environmental Protection Agency, Agency for Toxic Substance and
Disease Registry (ATSDR), the Occupational Safety and Health Administration (OSHA),
and the United States Department of Agriculture (USDA).
Strategy 2: Support creation of the information technology needed to enhance
cancer data collection, as through the Informatics Section of the Public Health
Improvement and Preparedness Bureau.
Strategy 3: Increase access to cancer-related data for epidemiological analyses
by working with the Health Planning Section of DPHHS to establish a Montana
Interactive Health Database website for data analyses.
Strategy 4: Disseminate results derived from a newly established Montana
Interactive Health Database to allow comparative analyses over time and
establish trends in cancer related health conditions in Montana for use in
assessing progress and making comparative analyses.
Strategy 5: Promote the use of datasets by epidemiologists and public health
agencies to improve knowledge, enhance investigations, and create risk-reduction
strategies and guidelines for cancer care in Montana.
Timeline for Available Data: Hospitals report abstracted information on cancer
patients that are diagnosed and treated, usually after the patient has completed
treatment. Treatment can take six months or more. After the cancer case is
submitted to the MCTR, the case is entered into the MCTR database and checked
for quality. Over 100 data variables are checked for consistency and validity.
Sometimes, hospitals need to be contacted for more information. Yearly data are
not available for about 12 to 18 months after the year-end, so hospitals have
time to report all their cases and the MCTR staff has time to enter and review
every case. On average, a hospital needs one hour to abstract one cancer case.
After the MCTR receives the abstracts, they need one-half to one hour for each
cancer case.
CDC’s one-stop shop for environmental public health data:
http://www.cdc.gov/nceh/tracking/resources_data.htm
Profile: Lou Olcott is the Biomonitoring Program Manager and Laboratory Training
Coordinator for the Laboratory Services Bureau of the Department of Public
Health and Human Services. She and Dr. Kammy Johnson work with the Rocky
Mountain Biomonitoring Consortium (RMBC), formed through a grant award from the
Centers for Disease Control and Prevention in 2002. The proposal was to
integrate the biomonitoring program among six states: Montana, Wyoming, Utah,
Colorado, Arizona and New Mexico. Each state has a member with an
epidemiological background and laboratory background. All of the states in the
consortium have geophysical commonalities and similar contamination issues. The
RMBC includes large border states with sparse populations, few population
centers and a history of mining and smelting.
Biomonitoring assesses human exposure to toxic substances by the laboratory
measurement of these substances or their metabolites. The biomonitoring project
will include establishment of baseline data for environmental toxins. The
Consortiumn s primary objective is to increase existing laboratory capabilities
and capacity within the region, and conduct biomonitoring as funds permit. The
goal of the RMBC is to implement and expand the regional laboratory based
biomonitoring program to:
1. develop laboratory capacity to monitor human exposure to environmental
chemicals.
2. determine the number of people in the RMBC region exposed to environmental
chemicals, as well as the degree of their exposure.
3. increase the capacity of the RMBC states and local health departments to
deliver the environmental health services that help prevent disease resulting
from exposure to toxic substances.
4. work closely with local partners and other governmental entities to protect
the health and well being of our citizens.
Table of Contents
Resource List:
1. Cancer Control Planet: cancercontrolplanet.cancer.gov
2. Cancer in Montana Annual Report:
www.cancer.mt.gov
3. Behavior Risk Factor Surveillance System:
www.dphhs.mt.gov/hpsd/BRFSS
4. Environmental Public Health Tracking:
www.dphhs.mt.gov/epht
5. North American Association of Central Cancer Registries:
www.naaccr.org
6. American Cancer Society: www.cancer.org
7. CDC's Cancer Prevention and Control Program:
www.cdc.org/cancer
8. The National Institutes of Health's National Cancer Institute (NCI):
www.cancer.gov/cancer_information
9. NCI Cancer Progress Reports:
http://progressreport.cancer.gov
10. National Toxicology Program:
http://ntp-server.niehs.nih.gov
Data, Registry & Surveillance: What You Can Do.
1. Support data collection strategies. Participate in the BRFSS survey if called
upon to do so.
2. Ask your legislators to support:
a. the MCTR and EPHT
b. acquisition of hospital discharge data for information about cancer in
Montana
3. Utilize the information in Montana's cancer reports to understand and
increase your knowledge about cancer and to reduce your risks.
Table of Contents
Advocacy
"Advocacy is the pursuit of influencing outcomes -- including public policy and
resource allocation decisions within political, economic, and social systems and
institutions -- that directly affect lives." (David Cohen, Co-Director, Advocacy
Institute).
Advocacy can mean many things for many different people and situations. For the
purposes of this plan, advocacy refers to developing the public health
infrastructure needed to implement the Montana Comprehensive Cancer Control (CCC)
Plan. It also refers to advancing the legislative policy that can improve the
ability to prevent and treat cancer, and improve survivors' quality of life from
diagnosis through the course of the disease.
Montana's public health system is made up of a complex network of people,
systems, and organizations in public and the private sectors. By improving the
infrastructure we are strengthening all parts of the public health system that
work to execute the Montana CCC Plan. Public policy can result in better
healthcare, support for research, and the creation of an effective
infrastructure. Collectively, these can lead to reductions in cancer incidence
and mortality.
Besides being a medical, social, psychological, and economic issue, cancer is a
political issue. Lawmakers at all levels make decisions that impact our ability
to reach our cancer control goals. For example, decision makers determine how
much money goes into cancer research, the policies that affect the public health
infrastructure, and state funding levels for public health.
Public health policy impacts thousands and is a critical tool for realizing the
goals of this plan. Educating the public, the media, and decision makers about
the importance of sound policy could ultimately reduce cancer incidence and
mortality rates and improve cancer survivors' quality of life.
Profile: John Bohlinger
John Bohlinger is the Lieutenant Governor of Montana and a cancer survivor. He
is quick to say how important it is to be open about his experience, and
believes that by talking about cancer, we can begin to effect change.
John got a physical exam every year, so he was well aware of the fact that his
PSA levels had started creeping up. The prostate-specific antigen (PSA) is a
protein produced by the cells of the prostate gland. The PSA test, which
measures the levels of the antigen in the blood, went from one the first year,
to two the next, then four, then eight. Year-by-year, it was doubling. He was 58
years old when he learned that he had prostate cancer.
He started educating himself. He researched the disease on the internet,
discussed it with his doctor, his wife, family, and friends. After a lot of
thought, John decided that surgery was his best and safest option, particularly
since he had a very strong family history of the disease. John’s father was 49
when he died, and John lost his mother a few years afterward. Both died of
cancer. It came down to the fact that he wanted to eliminate the presence of
cancer altogether. The surgery went well, and John has been a survivor for more
than six years.
"I believe it’s important to tell our stories. My wife, Bette, offered a shining
example of courage and grace in the face of adversity. It isn’t just about
surviving – it’s how we live that defines us.” (Lt. Governor John Bohlinger).
Profile: Bette Bohlinger was always been moderate in her habits. She ate right,
exercised every day, watched her weight, and she'd gotten a clean bill of health
from a physical in October. Because her mother had been diagnosed with breast
cancer when Bette was a little girl, she had always worked hard to avoid the
risk factors that can lead to cancer. It seemed to pay off. She was healthy,
active, and had lots of energy. She'd needed that energy for the past year while
she and husband, John, worked on a vigorous gubernatorial campaign for Brian
Schweitzer. When Brian Schweitzer won the race for governor, she and John were
jubilant. Life was good. They were ready to celebrate by meeting their family in
Big Sky for a four-day Thanksgiving holiday. As soon as they arrived, though,
Bette developed a severe headache she couldn't shake.
As soon as she got home to Billings, she went to see her doctor. The doctor
asked if there'd been other symptoms. "Nothing except some bruising I can't
explain", Bette paused, and then, remembering something she'd read, "Maybe you
should test me for leukemia." She was half joking, and was surprised when her
doctor took the suggestion seriously.
Bette was stunned when she learned that she had acute myeloid leukemia. Her
platelet level was so low that her headache had actually been caused by bleeding
on the surface of her brain. She started treatment the same day, and she was
given a 10-20 percent chance of survival for one year.
"I was stunned when I learned that I had leukemia," Bette said. "I'd practically
been the poster child for moderation. Suddenly I found myself thinking that it
hadn't mattered after all. But I've since changed my mind. I've recovered much
more quickly than anyone expected, and I know it's because I've lived such a
healthy life."
It was touch and go for months. For several days running, she had a temperature
of 106 degrees. Her treatment team had no option but to put her on a sheet of
ice water to try to bring down the fever. Her kidneys and liver started to fail,
and her heart was racing at 140 beats per minute. Bette says she doesn't
remember those days. John does. With tears in his eyes, he remembers the doctor
coming by early one morning to say, "I'm not sure that she's going to live
through this day. Call your kids and tell them to come say goodbye to their
mother." All six of the Bohlinger's children came, from all points of the
country.
Day by day, Bette survived. She attributed much of it to the wonderful care she
received. Chemotherapy lasted from the end of November until the first of May.
Her hair had grown back and food had begun to taste good again when she went in
for her three-month check-up. They found no evidence of cancer, and her doctors
said her chances of survival had grown to 60-70 percent for one year. She was
thankful they continued to grow with every passing day.
Update: Montana suffered a grievous loss when Bette Bohlinger succumbed to
cancer in January 2006.
"One thing that really helped me was the big stack of cards and letters I
received every day, many from people I didn't even know. It helped to know that
people were praying for me and thinking of me, to know that people cared. If I
could pass on two things I've learned from all this, I would encourage people to
take care of themselves, and to be open about their cancer experiences. Share
your story. Speak out. We can use our stories to give others hope." (Bette
Bohlinger).
Goal I: Implement Montana's Comprehensive Cancer Control Plan.
Objective I.1: Increase political support for public health and implementation
of the Montana CCC Plan.
Baseline: During the 2005 Montana Legislative Session, two bills and one Senate
Joint Resolution were introduced that had a direct connection to cancer, and
none mentioned the Montana CCC Plan.
Outcomes: Cancer will be raised as a campaign issue during the next several
political cycles, and an increased number of resolutions and/or bills addressing
cancer-related issues will be presented during the legislative sessions and in
the U.S. Congress. By 2006, establish baseline number of U.S. congressional
bills with a direct connection to cancer.
Data sources: Montana legislative website; American Cancer Society (ACS)
Legislative Survey; the ACS National Government Relations Department.
Strategy 1: Determine the number of U.S. congressional bills with a direct
connection to cancer.
Strategy 2: Determine baseline levels of knowledge and legislative support for
the Montana CCC Plan and public health infrastructure by adding CCC related
questions to the American Cancer Society Legislative Survey in 2006.
Strategy 3: Develop state and federal political support for the Montana CCC Plan
and the public health infrastructure needed for its implementation.
Strategy 4: Establish a legislative taskforce for the Montana Cancer Control
Coalition (MTCCC) in 2005. Link cancer-related legislation to the Montana CCC
Plan.
Strategy 5: Educate and update state and federal legislators on the Montana CCC
Plan and progress toward implementation and outcomes:
a. Generate an annual progress report
b. Provide progress reports to legislative leadership and committees working on
health-related issues.
c. Provide state, tribal and federal legislators with MTCCC position papers on
key issues.
Strategy 6: Involve state, tribal and federal legislators in implementing the
Montana CCC Plan.
Strategy 7: Build a base of advocacy for the Montana CCC Plan and affiliated
stakeholder groups. Identify policies that can support the plan.
Strategy 8: Educate cancer survivors and their loved ones on the importance of
being involved in the political process in a variety of ways including voting,
serving on committees and taskforces, serving as lawmakers, lobbying, and
educating.
Strategy 9: Develop guidelines for MTCCC members to use when working with
legislators and decision makers. Communicate priority legislative issues to
stakeholders and healthcare providers with position papers.
American Cancer Society contact information, call toll free, 1-800-227-2345.
Advocate, Participate, Update, Motivate, Educate, Legislate:
Advocacy Websites
1. www.acscan.org
2. www.canceradvocacynow.org
3. www.plwc.org
4. www.cancercare.org
5.
www.cancersurvivaltoolbox.org/
6.
www.cdc.gov/cancer/survivorship
7. www.cansearch.org/policy
Objective I.2: Increase public support for Montana' s CCC Plan.
Montana has the 31st highest overall cancer incidence rate and the 33rd highest
overall mortality rate among the 50 states and the District of Columbia.
Baseline: There is limited awareness of the CCC Plan, as reflected by the fact
that there were no news items mentioning the Montana Comprehensive Cancer
Control Plan in 2004.
Outcomes: Beginning in 2005, public interest in, and awareness of, the Montana
CCC Plan and the issues surrounding cancer will increase annually.
Data sources: Results of media coverage tracking; annual number of hits on the
Cancer Control webpage; number attending periodic Montana Cancer Control
conferences.
Strategy 1: Track coverage of comprehensive cancer control activities in the
media, hits on the webpage, and attendance at Montana Cancer Control
conferences.
Strategy 2: Refer to the CCC Plan when implementing each strategy and tactic.
Strategy 3: Develop and execute a communication plan for the implementation
process that includes press releases, the webpage, presentations, and other
materials.
Strategy 4: Hold statewide public forums during fall 2005 to introduce the draft
CCC Plan.
Strategy 5: Sponsor periodic Cancer Control conferences; use as venues to
promote the Montana CCC Plan.
Strategy 6: Distribute an annual progress report.
Strategy 7: Engage the media:
1. Develop relationships with Montana's media outlets.
2. Provide the plan to the media.
3. Periodically provide the media with updates.
4. Provide media with story ideas on the face of cancer.
Strategy 8: Provide multiple opportunities for the public to participate in the
implementation process.
"Survivors face numerous issues throughout their diagnosis and treatment, and
for the remaining years of their lives. Many of these issues could be addressed
through coordinated public health initiatives." (A National Action Plan for
Cancer Survivorship: Advancing Public Health Strategies).
Objective I.3: Build the capacity
needed in the Department of Public Health and Human Services (DPHHS) staff and
Montana Cancer Control Coalition infrastructures to execute the CCC Plan.
Baseline: Existing communication systems and staffing time dedicated to
implementing the Montana CCC Plan.
Outcomes: By 2007, fill the positions (private and public) necessary to execute
the CCC Plan; implement the plan within the established timelines; establish a
functioning listserv; ensure that all legislators and key decision makers know
of the CCC Plan as they move into the 2007 and 2009 legislative sessions.
Data sources: DPHHS and stakeholder reports; legislative poll.
Strategy 1: Develop the internal and external communication structure to carry
out the implementation process and build the relationships needed to foster an
environment conducive to change.
a.. Develop communication systems within DPHHS, the Chronic Disease Department,
the steering committee, and other key stakeholders.
b. Develop an external communication system to educate and involve medical
associations, medical service providers, private sectors, state administration,
state legislature, congressional delegates, survivors, tribal governments,
media, other chronic disease groups, and local communities.
c. Create a listserv for stakeholders to communicate with one another.
Strategy 2: Develop and/or revisit a clear understanding of stakeholder roles
and responsibilities within the context of implementation.
Strategy 3: Develop a plan to expand public health infrastructure and the
infrastructure to support the Montana Cancer Control Coalition.
a. Assess existing infrastructure; identify and resolve gaps.
b. Identify and provide the training and technical assistance necessary to
execute the CCC Plan.
c. Clearly define a timeline with checkpoints and accountability.
Objective I.4: Secure the resources needed to execute the CCC Plan.
Baseline: The Centers for Disease Control and Prevention (CDC) implementation
grant.
Outcomes: By 2007, raise the in-kind and cash resources needed to execute the
key strategies of the CCC Plan.
Data sources: Montana CCC program financial reports; periodic stakeholder
reports to be established.
Strategy 1: Establish an expertise workgroup to work with public, private and
nonprofit stakeholders to identify existing in-kind and cash resources that can
be utilized for implementation; periodically poll stakeholders about the
resources used for plan implementation.
Strategy 2: Assess existing infrastructure for resource needs.
Strategy 3: Develop and execute a resource acquisition plan that includes making
requests to private and nonprofit stakeholders and identifying the funding roles
of local, state, and federal governments.
"Never doubt that a small group of thoughtful committed citizens can change the
world. Indeed, it's the only thing that ever has." (Margaret Mead).
Profile: Lois Fitzpatrick is a medical librarian and a ten-year survivor of
breast cancer. She was the one who found her cancer -- she spotted a dimple in
the mirror, checked, and found a lump. Within two days, she'd gotten in to see
her doctor. He didn't waste any time, either. She found herself at a surgeon's
office almost immediately. Because she is a medical librarian, she'd already
done a lot of research. While she was in the operating room for a surgical
biopsy, she heard the doctors say something about a frozen section and she knew
it was cancer. Lois had the biopsy on Monday; on Thursday she had a lumpectomy.
The cancer was Stage One, and hadn't spread to the lymph nodes.
Lois had just turned 43 and had two young daughters at home. She was terrified
that she wouldn't see her daughters finish growing up. She got several opinions
on next steps, and thoroughly researched them. Ultimately she decided to fight
back aggressively, with everything she could. Lois chose to undergo
chemotherapy, radiation, and hormone therapy.
"I wanted to beat the life out of the cancer, so I went through the whole
series. I would do it again. In retrospect, I made all the right decisions.
First I advocated for myself by doing my research. I decided I had to be a 100
percent full participant. I wanted to be very clear that this was not going to
be something done to me. This was going to be something I was doing for myself."
The ten years of survivorship have been busy ones. Lois talks with many women
who have breast cancer, and she's worked with the American Cancer Society, Susan
B. Komen, and has become certified as a breast self-exam instructor. When she's
working with women, she encourages them to ask the hard questions. Lois believes
that information is power, and she's working hard to empower other women.
"I try to help others. I lobby to get bills through. I get the word out. I want
to be a voice for those women who can't speak for themselves. That's why I
lobby; why I testify. We've got to keep finding new and better ways to beat this
thing." (Lois Fitzpatrick).
Suggestions for effective communication with a healthcare team:
1. Become a partner and actively participate in the cancer care plan.
2. Develop and expect an attitude of respect and cooperation.
3. Provide accurate information about family history.
4. Keep a list of questions for doctors or other team members.
5. Take notes when having important conversations with doctors.
6. Ask for explanations of anything you don’t understand.
7. Inform team members of concerns.
8. Have reasonable expectations about the time the team members can spend.
9. Let team members know the patient’s care preferences.
10. Develop positive relationships with team members.
11. Expect confidentiality.
12. Recognize and accept that communication and other problems will occur.
13. Address confusion, frustrations, or disagreements directly.
(Adapted from American Cancer Society “Understanding the Healthcare System”).
Advocacy: What You Can Do.
1. Get involved with the Montana Cancer Control Coalition and comprehensive
cancer control activities in your community. Complete and mail the member
information form included in this document.
2. Talk to your lawmakers about cancer issues, early and often.
4. Support funding the Montana Comprehensive Cancer Control Plan implementation
projects.
5. Attend an annual Montana Cancer Control Conference.
6. Remain informed on cancer control issues.
Table of Contents
Implementation, Evaluation and Evolution:
Implementation: The Montana Cancer Control Coalition (MTCCC) is committed to
implementing the Montana Comprehensive Cancer Control (CCC) Plan. This will
require organizations and members to work together on cancer control activities.
The MTCCC has restructured for implementation as indicated in the organizational
chart.
Description of organizational chart depicting the Montana Cancer Control
Coalition. The Steering Committee (represented by a hexagon at top center),
interacts with the Communication, Evaluation and Evolution Standing Committees
(depicted by a rectangle at top left). It also interacts with the Ad Hoc
Committees on Transition, the Cancer Conference, By-laws, and any other ad hoc
committees formed as needed (depicted by a rectangle at top right). The Steering
Committee also interacts with the Implementation Teams on Prevention, Early
Detection, Treatment and Research, and Quality of Life and Survivorship
(depicted as an oval at lower left). The Implementation Teams also interact with
any Ad Hoc Taskforces (depicted by a hexagon at the bottom center). The Support
Expertise Workgroups on Data, Funding and Resources, Education, and Legislation
(represented by an oval at lower right) interact with the Steering Committee,
provide input to the Implementation Teams and interact with any Ad Hoc
Taskforces. End of description.
The responsibilities and roles of the Steering Committee and members have been
redefined. The Steering Committee is the governance and decision-making body.
Communication, Evaluation, and Evolution will continue as standing committees.
Ad hoc committees will form and dissolve as needed.
The Steering Committee will direct implementation activities and establish
timelines. It will continue to recruit, maintain memberships, and build
partnerships, as well as plan distribution. The Steering Committee will also
continue to develop leadership skills among volunteers, guide data and
communication priorities, identify resources, and coordinated cancer control
activities.
The Communication Committee will develop short- and long-range internal,
external and media communication plans.
The Evaluation Committee ensured that CCC Plan objectives are measurable, and
include identified data sources, baseline data, and target outcomes whenever
possible. This committee will develop the evaluation framework, the evaluation
plan, and guide, monitor, and assess the evaluation of the Comprehensive Cancer
Control Program, the MTCCC, CCC Plan implementation activities, and outcomes.
The Evolution Committee will prioritize auxiliary and newly strategies using
documented criteria, and consider such factors as evaluation results, new
opportunities, science, and trends, and use them to make recommendations for
change to the Steering Committee.
MTCCC members have confirmed their commitment to CCC Plan implementation by
registering for implementation teams, support expertise workgroups, and standing
committees. Implementation teams are organized around the CCC Plan sections of
Prevention, Early Detection, Treatment and Research, and Quality of Life and
Survivorship. Resources are limited. Prioritization using established criteria
will set the order in which objectives and strategies are addressed.
The implementation teams will work together to finalize and implement
prioritized strategies. The coalition identified cross-cutting issues and
defined workgroups to provide expertise in the areas of data, education,
legislation, and funding and resources. The workgroups are utilized for their
expertise by the Steering Committee and the teams to research and identify
tools, projects, best practices, and resources in their areas of expertise. As
implementation progresses, evaluation and evolution will be key to ensuring
sustainability.
Montana Cancer Care Coalition Working Together…
Evaluation: Evaluation will consist of four parts:
1. Comprehensive Cancer Control Program;
2. Montana Cancer Control Coalition;
3. CCC Plan implementation process and environment; and
4. CCC Plan short, intermediate and long-term outcomes.
The Evaluation Committee will establish an overall evaluation protocol, as well
as develop and oversee implantation of an evaluation plan. It will determine the
needs, questions, methods, and framework for evaluating the CCC Program, the
MTCCC, CCC Plan cancer control activities, and outcomes. The Evaluation
Committee will also identify stakeholders who are already implementing CCC Plan
activities.
The Evaluation Committee will also assess progress toward stated objectives and
outcomes, and toward achieving short- and long-range goals. They will undertake
such activities as:
1. periodically assessing progress in meeting program goals;
2. evaluating the coalition for networking, member satisfaction, technical
assistance and educational needs;
3. evaluating prioritization and implementation processes and the environment
within which implementation occurs; and
4. creating and overseeing evaluation plans for cancer control activities, and
the process and progress toward outcomes.
The committee will analyze utilization and availability of resources, and
internal and external infrastructures. An annual progress report will be
presented at a cancer control conference. Evaluation results will be used to
improve the CCC Program, the MTCCC structure and function, the implementation
process, change or develop cancer control activities, and improve progress
toward desired outcomes.
Program evaluation is a systematic way to learn from past experience, and
improve performance and outcomes.
Evolution: The Montana Comprehensive Cancer Control Plan is a living document
and an essential starting point for addressing cancer in Montana. The plan will
change and evolve with time, information, new opportunities and changing needs.
The Evolution Committee will oversee recommendation for change made to the
Steering Committee. The critical steps of evolution include:
1. continuing to recruit and maintain a broad-based membership;
2. creating recommendations based on assessments and using them to implement
changes to the program, the coalition and the plan;
3. prioritizing ideas, suggestions, new and ongoing strategies based on
established criteria, protocols, and evaluation results. Unprioritized issues
and ideas from the planning process are available at
www.cancer.mt.gov under the
“Auxiliary Strategy List”. This will be periodically updated and prioritized by
the Evolution Committee.
4. Adding, changing, or disbanding ad hoc committees and taskforces as projects
are completed and priorities emerge;
5. sustaining an implementation process that continues to evolve in response to
evaluation results, the environment, data, resources, new evidence and science,
healthcare trends, opportunities, national programs, and the need for cancer
control in Montana;
6. continuing a comprehensive, multifaceted approach to decreasing the burden of
cancer on Montana.
7. ensuring accountability throughout the comprehensive cancer control process
through evaluation, response and modification;
8. maintaining fidelity to the vision: A comprehensive, statewide,
evidence-based approach to reduce the burden of cancer in Montana, motivated by
compassion…an investment in the future.
Organizations and individuals interested in joining the MTCCC to implement this
plan should complete and return the member information form of this document or
online at www.cancer.mt.gov .
Resources:
1. Agency for Healthcare Research and Quality (AHRQ):
http://www.ahrq.gov/
2. American Cancer Society (including American Cancer Society Facts and
Figures):
www.cancer.org
3. American College of Surgeons, Commission on Cancer:
http://www.facs.org/cancer/coc/coc.html
4. American Society of Clinical Oncology (ASCO) People Living With Cancer:
www.plwc.org
5. Behavioral Risk Factor Surveillance System:
http://www.cdc.gov/brfss/
6. Cancer Care: www.cancercare.org
7. Cancer Control Planet : http://cancercontrolplanet.cancer.gov (See other
statesn CCC
plans)
8. Cancer Plan: http://www.cancerplan.org/
9. C-Change: http://www.ndoc.org/default.asp
10. Centers for Disease Control and Prevention (CDC):
www.cdc.org and
http://www.cdc.gov/od/ads/opspoll1.htm
11. CDC Evaluation Working Group:
http://www.cdc.gov/eval/framework.htm
12. Colorectal Cancer Costs in Montana:
http://gastro.org/pubPolicy/issueBriefs/urges.html
13. Council of State Governments: http://www.healthystates.csg.org/
14. Entrez PubMed: www.ncbi.nlm.nih.gov/entrez
15. Healthy People 2010: http://www.healthypeople.gov/default.htm
16. Lance Armstrong Foundation: http://www.laf.org/
17. Montana Central Tumor Registry Annual Report:
www.cancer.mt.gov
18. Means to a Better End: A Report on Dying in America Today:
www.endoflifecommission.org/end_pages/national_report.htm
19. Messengers for Health Project: Suzanne Christopher, Ph.D., Principle
Investigator. suzanne@montana.edu or 406-994-6321
20. National Comprehensive Cancer Control Program:
http://www.cdc.gov/cancer/ncccp/index.htm
21. National Cancer Institute (NCI): www.cancer.gov and National Cancer
Institute's
Cancer Information Service: http://cis.nci.nih.gov/
22. NCI Cancer Progress Report: http://progressreport.cancer.gov/
23. National Coalition for Cancer Survivorship
www.canceradvocacynow.org
24. National Comprehensive Cancer Network
http://www.nccn.org/default.asp
25. National Consensus Project on Quality Palliative Care
http://www.nationalconsensusproject.org/index.html
26. Partnership For Prevention http://www.prevent.org/index.cfm
27. Youth Risk Behavior Surveillance System
http://www.cdc.gov/HealthyYouth/yrbs/index.htm;
http://www.opi.state.mt.us/
Table of Contents
Glossary:
Alternative medicine: Therapeutic approaches used in place of traditional
medicine to treat or ameliorate disease, that do not follow generally accepted
medical methods and
may not have a scientific explanation for their effectiveness.
Cancer: The umbrella term to describe many different diseases in which cells grow and reproduce out of control.
Cancer Burden: Overall impact of cancer in a community.
Carcinogen: Any substance known to cause cancer.
Clinical trials: Research studies that involve patients. Studies are designed to find better ways to prevent, detect, diagnose, or treat cancer and answer scientific questions.
Complementary medicine: Practices used to enhance or complement standard treatments, but which are not recognized as standard or conventional medical approaches.
Culturally competent: Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that enable effective work in cross-cultural situations.
Distant stage: Cancer has extension beyond adjacent organs or tissues or metastases to distant site(s) or distant lymph node(s).
Epidemiology: The study of disease incidence and distribution in populations, and the relationship between environment and disease. Cancer epidemiology is the study of cancer incidence and distribution as well as the ways surroundings, occupational hazards, and personal habits may contribute to the development of cancer.
Evidence-based: The process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions.
Five-year survival: Five-year survival is a term commonly used as the statistical basis for successful treatment. A patient with cancer is generally considered cured after five or more years without recurrence of disease.
Follow-up: Monitoring a person’s health over time after treatment. This includes keeping track of the health of people who participate in a clinical study or clinical trail for a period of time, both during the study and after the study ends.
Genetic susceptibility: An inherited increase in the risk of developing a disease.
Healthcare professional: Practitioners in disease prevention, detection, treatment, and rehabilitation are known as health care professionals. They include physicians, nurses, dentists, dietitians, health educators, social workers, and therapists, among others.
Health disparities: Differences in the incidence, prevalence, mortality and burden of cancer and related adverse health conditions that exist among specific population groups in the United States.
High risk: The chance of developing cancer is greater for an individual or a group of people than for the general population. People may be considered to be at high risk from many factors or combination of factors, including family history, personal habits, or exposure to carcinogens.
Hospice: Special care for people in the final phase of illness, their families and caregivers, usually provided in the patient's home or a homelike facility.
Incidence: Incidence is the number of times a disease occurs in a given population. Cancer incidence is the number of new cases of cancer diagnosed each year. The Montana Central Tumor Registry maintains cancer incidence data in Montana.
Incidence rate: A measure of the rate at which new events occur in the population. The number of new cases of a specified disease diagnosed or reported during a defined period of time is the numerator, and the number of persons in the stated population in which the cases occurred is the denominator.
Informed decision-making: Choices and preferences stated after the individual understands the nature and risks of their cancer diagnosis and treatment options.
Integrative medicine: Combining the best ideas and practices of conventional and alternative medicine into cost-effective treatments in the best interests of patients, to stimulate the potential for natural healing. It neither rejects conventional medicine nor embraces alternative practices uncritically.
Localized stage: Cancer that is limited to the site of origin. There is no evidence of metastasis elsewhere in the body.
Malignancy (or malignant): Cancerous; can invade nearby tissue and spread to other parts of the body.
Metastatic cancer stage: Cancer that has spread from the place in which it started to other parts of the body.
Moderate physical activity: Physical activity that does not cause sweating or hard breathing.
Morbidity: Any departure, subjective or objective, from a state of physiological or psychological well being. In this sense, sickness, illness, and morbid condition are similarly defined and synonymous.
Mortality rate: A rate expressing the proportion of a population who die of a disease, or of all causes. The numerator is the number of persons dying; the denominator is the total population (usually the midyear population) in which the deaths occurred. The unit of time is usually a calendar year. To produce a rate that is a manageable whole number, the fraction is usually multiplied by 1,000 to produce a rate per 1,000. This rate is also called the "crude death rate."
Obesity: A condition in which a person has abnormally high amounts of unhealthy body fat; medically defined as a BMI of 30 or greater.
Overweight: Being too heavy for one’s height. Excess body weight can come from fat, muscle, bone and/or water retention. Being overweight does not always mean being obese (25.0 to 29.9 BMI).
Palliative care: Care that does not alter the course of a disease, but improves the quality of life.
Prevalence: In medical terminology, prevalence typically has been defined as the number of cases of a disease that are present in a population at a point in time. In the case of smoking prevalence in population, the term in used to define the number of people in that population who are regular smokers.
Practice guidelines: Provide physicians and other healthcare providers with a medically proven set of directions or principles to assist with patient care decisions, appropriate diagnostic, therapeutic or clinical procedures; incorporating the best scientific evidence with expert opinion. Recommendations are based on rigorous clinical research and professional consensus.
Primary prevention: The reduction or control of factors believed to be causative for a health problem and includes reducing risk, education to reduce sexually transmitted diseases, and environmental exposures such as reducing ambient lead to prevent intellectual impairment. This category also includes health-service interventions, such as vaccinations or such preventive "therapy" tools as fluoridated water supplies or dental sealants.
Prostate-specific antigen: A protein whose level in the blood goes up in some men who have prostate cancer or benign prostatic hyperplasia. Also called PSA.
Quality of life: In cancer treatment, the concept of ensuring that cancer patients are able to lead the most comfortable and productive lives possible during and after treatment. New treatment techniques and social and emotional support groups are adding to the quality of life for cancer patients as well as to their survival.
Radon: A radioactive gas released by uranium, a substance found in soil and rock. Exposure can damage lung cells and lead to lung cancer.
Regional: Cancer that extends beyond the limits of the site of origin into surrounding organs or tissues or regional lymph nodes.
Risk factor: Anything that has been identified as increasing the chance of getting a disease, e.g., tobacco use, obesity, age, or family history of some cancers.
Secondary prevention: Involves early detection and treatment, such as mammography for detecting breast cancer or Pap tests for detecting cervical cancer.
Secondhand smoke: Smoke that comes from the burning end of a cigarette and smoke exhaled by smokers. Also called ETS or environmental tobacco smoke. Inhaling ETS is called involuntary or passive smoking.
Stage: A distinct phase in the course of a disease, in cancer, typically defined by containment or spread of the tumor: in situ, localized, regional or distant spread.
Tertiary prevention: Involves providing appropriate supportive and rehabilitative services to minimize morbidity and maximize quality of life, such as rehabilitation from injuries. It includes preventing secondary complications.
Translational research: Provides a link between bench science and bedside clinical medicine.
Vigorous physical activity: Physical activity that causes sweating and hard breathing.
Table of Contents
Member Information Form: To join the MTCCC in preventing and controlling cancer
in Montana, please complete and return this form.
Name:
((Credentials):
(Work) Title (put N/A if not applicable):
(Work) Organization (put N/A if not applicable):
Mailing Address (street, city, state):
Zip:
Delivery Address (street, city, state -- if different from mailing address):
Zip:
Contact Phone:
First Telephone Number (please indicate whether this is your home, work or cell
number and provide area code, number and your extension, if applicable):
Fax (area code and number):
Second Telephone Number (please indicate whether this is your home, work or cell
number and provide area code, number and your extension, if applicable): :
E-Mail Address:
Organization or group that you officially represent (if applicable):
What is your area of interest? Please indicate which implementation groups you
want to work on: Prevention Team; Early Detection Team; Treatment and Research
Team; Quality of Life and Survivorship Team; Data Workgroup; Education
Workgroup; Funding and Resource Development Workgroup; Legislative Workgroup;
Communication Standing Committee; Evaluation Standing Committee; Evolution
Standing Committee.
Are you 17 years of age or younger?
If you are, please provide the name of an adult sponsor:
Area code, telephone number and extension of adult sponsor:
Return this form to:
Sue Miller, DPHHS
1400 Broadway Room C-317 or P.O. Box 202951
Helena, MT 59620-2951 or e-mail sumiller@mt.gov or call 406-444-3624.
The Cancer Control Section of the Public Health and Safety Division of the
Department of Public Health and Human Services attempts to provide reasonable
accommodations for any known disability that may interfere with a person
participating in this service. Alternative accessible formats of this document
will be provided upon request. For more information, call the Cancer Control
Section at 406-444-3624.
You may make copies of sections of the Comprehensive Cancer Control Plan for
noncommercial, educational use. No reprint of this document or parts thereof
should be used in a way that could be understood as an expressed or implied
endorsement of a commercial product, service, or company. To use this document
in electronic format, permission must be sought from the Cancer Control Section
of the Montana Department of Public Health and Human Services. Please be sure to
include acknowledgement of the Montana Comprehensive Cancer Control Plan in any
reproductions. All other rights remain the property of the Cancer Control
Section of the Montana Department of Public Health and Human Services.
This publication was supported by Cooperative Agreement #U55/CCU821883 from the
Centers for Disease Control and Prevention. Its contents are solely the
responsibility of the authors and do not necessarily represent the official
views of the Centers for Disease Control and Prevention.
5,000 copies of this public document were published at an estimated cost of
$2.86 per copy, for a total of $14,300, which includes $14,300 for printing and
$0 for distribution.
For more information or to request a copy of the Montana CCC Plan, contact:
The Cancer Control Section
Department of Public Health and Human Services
1400 Broadway Room C-317 or P.O. Box 202951
Helena, MT 59620-2951
406-444-3624
Access the plan online at www.cancer.mt.gov
Credits:
Medical consultant, managing editor: Barbara G. Lloyd, M.D.
BLloydMD@mt.gov
Editing, layout, and design services: Sherrie Downing Consulting,
www.SherrieDowning.com
Alternative formats: Montana Disability and Health Program
http://mtdh.ruralinstitute.umt.edu
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