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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 nu