ARLINGTON, Va.—Science, policy, and legislation are combining to foster progress in cancer prevention. That was the word from speakers here at the American Society of Preventive Oncology (ASPO) Annual Meeting.
Funding of research on prevention and payment for preventive services traditionally has lagged, but that is changing. For example, the National Institutes of Health Office of Disease Prevention recently released a sweeping strategic plan for prevention research through 2018. The plan, approved by NIH Director Francis Collins, MD, earlier this year, is focused on six priorities (see box).
In addition, the National Cancer Institute's Division of Cancer Control and Population Sciences revealed in its fiscal year 2013 progress report that the grant portfolio included about 800 grants valued at nearly $450 million. The research—which encompasses work in the United States and in more than 40 countries—is geared toward reducing the risk, incidence, and mortality from cancer and enhancing the quality of life for cancer survivors.
Expanded Coverage under ACA
Expanded coverage under the Affordable Care Act has given prevention a needed boost, noted Thomas A. Sellers, PhD, MPH, Director of Moffitt Cancer Center. Scientific advances he cited were the following:
* Integrative molecular epidemiology to inform better early detection and intervention strategies;
* Screening of biomarker panels to detect cancers at the very earliest stages;
* Early mutational profiling of cancerous tumors to identify driver mutations and target these mutations with individually tailored therapies;
* Focused investigations into how environmental factors may exert an effect by altering transcriptional controls; and
* Assessing how lifestyle factors may affect health.
“We know a lot about what causes cancer, but what's frustrating to me is that although we do have evidence from animal models and toxicology reports about things in the environment that are harmful, we need to apply what we know,” he added.
Also speaking, William G. Nelson, MD, PhD, Director of the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, said, “There is nothing like public health that is going to pay going forward. In the future, we're going to intervene before symptoms appear and preserve normal function.”
Among the scientific advances he noted, he cited gene-expression profiling: “It's becoming increasingly inexpensive to sequence DNA… We're talking about sequencing for under $1,000. Human cancers have many somatic genetic defects… We're going to target the mutant protein from a gene.” In this kind of individually tailored treatment, only cancer patients with that mutant protein would receive a drug targeted specifically against that protein.
Nelson also hailed the promise of immunotherapy in arresting the progression of cancer, stating that immune checkpoint inhibitors are poised to transform cancer care—for example, the approved drug ipilumumab and the investigational drug nivolumab.
He also predicted that specialized cancer clinics specific to a type of cancer, such as pancreatic cancer, will be established as new pathologic techniques yield earlier and more precise diagnoses.
In addition to cutting-edge new science, the meeting also featured presentations on lifestyle behaviors such as smoking and physical activity. The following are some of the highlights of the research presented.
Retinol-Binding Protein 4 & Risk of Colon Adenoma
A study believed to be the first of its kind showed that higher circulating levels of serum retinol-binding protein 4 (RBP4), a recently discovered biomarker of insulin resistance, are associated with a risk of colon adenoma—especially and surprisingly among those with a lower body mass index (BMI). Insulin resistance is believed to be a key linking obesity to colon cancer, said study co-author Li Li, MD, PhD, Associate Director for Prevention Research at Case Comprehensive Cancer Center and Professor of Family Medicine at Case Western Reserve University.
But in this study of 626 patients, the risk association of RBP4 was largely limited to non-obese patients with a BMI of less than 28. “It's kind of intriguing,” Li told OT, since the risk association in these thinner patients was unexpected. “The relationship of RBP4 with cancer, including colon neoplasia, is largely unexplored.”
Asked by OT how this new finding might eventually be used in clinical practice, he said, “In terms of the big picture, this biomarker has been proposed as an early serum marker to screen for pre-diabetes.” As for colon cancer, he said, “It's too early to say how it can be used in cancer clinical practice. Further study is warranted.”
Smoking History & Breast Cancer Survival
While smoking has been associated with a higher risk of developing many cancers, including breast cancer, less is known about how a patient's smoking history influences breast cancer survival. In a study of 22,870 female residents of Wisconsin, Massachusetts, and New Hampshire who were diagnosed with invasive breast cancer between 1988 and 2008, current and long-term smokers at the time of diagnosis were 20 percent more likely to die from breast cancer than those who had never smoked (adjusted for breast cancer stage).
In this large population-based sample of patients with breast cancer, current smoking was also associated with increased mortality from lung cancer, cardiovascular disease, and respiratory disease, reported Polly Newcomb, PhD, MPH, Head of the Cancer Prevention Program and Research Professor in Epidemiology at Fred Hutchinson Cancer Research Center and President-Elect of ASPO.
“The elevated mortality risk observed here for known smoking-related diseases adds confidence to the breast cancer findings,” she said, noting that this, of course, is one important reason for breast cancer survivors who still smoke to quit.
Incentive-Based Interventions to Help Smokers Quit
Giving smokers an incentive-based intervention can increase the number of smokers who quit, but in unexpected ways, according to a Minnesota study presented at the meeting. The Minnesota Department of Health sent persuasive direct-mail materials termed “emotionally evocative” coupled with a $20 incentive geared toward increasing the use of Minnesota's QUITPLAN Helpline.
A total of 1,183 people were surveyed after being connected to the helpline. Social networks played a strong role in increasing use of the helpline: Specifically, the study showed that telling others about the $20 incentive was robustly related to use of the helpline. Put another way, the $20 incentive played a key role in the process of smokers telling others about the incentive-based intervention, and this combined effect boosted the use of helpline services.
In fact, the odds of using the helpline were 217 percent higher for people who told others about the monetary incentive compared with those who did not.
Physical Activity in Iowa Women's Health Study
Physical activity does matter for cancer survivors when it comes to quality of life, according to another smoking-related study presented at the meeting.
In a sampling from the Iowa Women's Health Study of more than 12,000 older women without a smoking history and 1,707 older women diagnosed with cancer between 1986 and 2002, the inactive cancer survivors had a poorer quality of life than survivors who were physically active.
In fact, among women who were physically active, cancer survivors had a quality of life that was similar to women who had not had cancer.
In this study, physical inactivity was more strongly associated with poor general health and poor physical function in elderly, long-term cancer survivors, compared with women without cancer. The researchers said these findings support the need for interventions to help older women maintain or regain a physically active lifestyle after a cancer diagnosis.
Improving Access to Prevention Services Among Hispanic Women
Increased insurance coverage for cancer prevention services is good news, but it will not help all Americans if everyone does not have access to them. One way to improve access to cancer preventive services among Hispanic women is to provide patient navigators—“promotoras”—lay Hispanic/Latina community members who receive special training to help women receive health services in the community.
“In disadvantaged neighborhoods, this program reduces the time to diagnosis and treatment in women with breast abnormalities,” said Amelie G. Ramirez, Dr PH, Director of the Institute for Health Promotion Research, the Dielmann Chair in Health Disparities Research & Community Outreach, and the Max and Minnie Tomerlin Voelcker Endowed Chair in Cancer Health Care Disparities at the University of Texas Health Science Center in San Antonio.
Ramirez, who has spent 25 years doing studies on health disparities, said her ongoing studies have shown that the patient navigation offered by promotoras leads to fewer missed medical appointments, faster treatment, and more timely follow-up care. Promotoras are now being used to help Hispanic women enroll in the Affordable Care Act.
Ramirez said her next research project will be to see whether the patient navigation provided by promotoras can improve the quality of life of cancer survivors. She noted that program has worked so well that some patients become too dependent on their promotoras, and the promotoras have to be trained to help their patients detach and learn to do things for their health independently.
Speakers at the ASPO meeting emphasized that proven cancer preventive services are still not available to all Americans. Elizabeth A. Platz, PhD, Professor in the Bloomberg School of Public Health and the Martin D. Abeloff Scholar in Cancer Prevention at Johns Hopkins University, said: “In countries like the United States, we have had success in reducing the burden of infection-associated cancers overall. But national and local health disparities in access to and the uptake of preventive strategies, screening, and treatment still exist, since some of these cancers—for example, those that are HPV- and HBV-associated—are often still viewed as only an international problem.”
According to the NCI's 2013 Annual Report to the Nation on the Status of Cancer, in the year 2010 fewer than half (48.7 percent) of girls age 13 through 17 had received at least one dose of the HPV vaccine to protect them against cervical cancer, and only 32 percent had received all three recommended doses.
The 6 Priorities of the NIH Office ofDisease Prevention, 2014-2018
1. Systematically monitor NIH investments in prevention research and assess the progress and results.
2. Identify prevention research areas for investment or expanded effort by NIH.
3. Promote use of the best available methods in prevention research and support the development of better methods.
4. Promote collaborative prevention research projects and facilitate coordination across the NIH and with other public and private entities.
5. Identify and promote use of evidence-based interventions as well as the conduct of implementation and dissemination research in prevention.
6. Increase the visibility of prevention research at the NIH and across the country.