Issues and Insights

Lynn Silver, M.D., M.P.H.
Assistant Commissioner
Bureau of Chronic Disease
NYC Department of Health and Mental Hygiene
New York City

Marian S. Krauskopf, M.S.
Director
Cancer Prevention Program
Bureau of Chronic Disease
NYC Department of Health and Mental Hygiene
New York City

How do you change disease patterns in a society? Caries are being vanquished with fluoridation. Automobile accident deaths diminished with seat belts, car seats and speed limits. Lead poisoning is fading away since lead has been removed from gasoline and paint.

In contrast, our traditional approach to the war on cancer has been research for cures and promotion of early detection through screening. But this approach has yielded only modest gains: since 1978 the all-site cancer mortality rate declined by 10%. (1,2) While tremendous progress has been made in some areas, to make further headway we need to reconceptualize cancer as, at least in part, a preventable disease. (3,4)

As public health authorities we must use the full range of interventions we know to be successful. We should ask: how can we change the environment to create sustainable reductions in the risk of cancer and other chronic diseases? Most of the great victories of public health came from changes in our environment. These changes often reduced population risk through regulatory, legislative and tax policies. Then, to address those cases which we still fail to prevent, we must continue to increase early detection, improve treatment and work to eliminate the striking disparities in outcomes.

In contrast, car accidents, diabetes and obesity – to which cancer is increasingly linked (5) – have more than doubled in our city since the 1990s. And, of course, up to one in four cancer cases are thought to be smoking-related. (6-8)

Smoking is the nation's leading cause of preventable death – and cancer. The most successful policies have been those which change the environment for smoking. These have included New York City's Smoke-free Air Act of 2002, raising the cigarette tax to the highest in the nation, aggressive media campaigns, and individualized support and medications for cessation. With this combination of hard-hitting strategies, New York City now has 300,000 fewer adult smokers, which we estimate will prevent 100,000 early deaths in subsequent years. (9) Smoking rates fell even more dramatically among young adult women where a 41.8% drop (23.2 to 13.5) was achieved between 2002 and 2005. (10) The proportion of teens who smoke was cut in half, from 17.6% in 2001 to 8.5% in 2007, compared to a 20% national teen smoking rate in 2007. (11) Cancer mortality rates in NYC are edging down from 187 per 100,000 in 2000 to 174 per 100,000 in 2006. (12) The full health benefits of these tobacco control efforts on cancer incidence and death will not be realized for many years.

After smoking, obesity is the second underlying cause of preventable death and illness. Obesity increases the risk of cancers of the endometrium, kidney, gallbladder (in women), breast, colon and esophagus. (13) If obesity and overweight could be reduced in the United States, it has been estimated that 90,000 cancer deaths could be prevented each year. (14) The American Cancer Society and the President's Cancer Panel have all recognized the key role of combating obesity in addressing cancer. (15) Yet our epidemic of obesity has clearly not been caused by changes in people’s genes or in basic biology over twenty years. Rather, population caloric intake has increased by 200 or more calories per day. (16) The ubiquity of poor quality energy-dense food in our society poses a tremendous challenge to individuals and to public policy. Governments and industry have been slow to act to correct the problem. (17) For example, limiting unhealthy food in school cafeterias and vending machines or restricting fast food restaurants in low income neighborhoods where obesity is highly prevalent are measures that have only begun recently. (18,19) It is primarily through changing the environment, and not solely exhorting people to exercise and eat right, that we may begin to reverse the extraordinary growth of obesity and its health consequences.

Policy measures that can improve our food environment promise to have the strongest impact on what people eat. In New York City, we have recently required prominent posting of calories in chain restaurants and are already beginning to see these chains change their offerings. New guidelines for all city food procurement were issued in September 2008, building on earlier progress in school food and day care, and will affect over 225 million meals and snacks a year. Where food is sold and how much it costs has a profound influence on what people buy. The City is working to increase access to fruits and vegetables in poor communities by expanding farmers' markets, licensing 1,000 new "Green Carts" that will sell produce in underserved communities, and promoting placement of supermarkets in those communities.

Making New York City an even easier place to walk, bicycle, use public transportation or take the stairs will be other key steps to reduce obesity and create sustainable environmental change. These changes have already begun as part of PlaNYC, the City's long-term sustainability plan.

A number of studies have found a link between alcohol consumption and the increased risk of developing certain types of cancers including: mouth, esophagus, pharynx, larynx, colorectal and liver cancers in men and women, as well as breast cancer in women. (20) The effects are further compounded when cigarette smoking is paired with alcohol consumption. As in the case of smoking, taxation has proved effective to reduce alcohol consumption. Regulations regarding hours of access to sales, and provision of treatment for problem drinkers, are also effective. (21-23)

Lastly, government supported immunization programs have proven effective in preventing communicable disease, and are significant in those cancers caused by viruses. The HPV vaccine recently approved by the FDA, protects against 70% of cervical cancers if administered to girls and women before they are exposed to the types of virus included in the vaccine. (24) Hepatocellular cancer has a variety of causes, including the hepatitis B virus, for which a preventive vaccine exists. (25) Effective vaccine programs require government policies to support them to ensure high levels of uptake, including subsidies to ensure that all those eligible can access the vaccine.

Through addressing smoking, obesity and immunizations, we can prevent a significant part of cancers and other chronic illnesses that affect our citizens. Simultaneously, we must continue to promote improved screening, early detection and access to treatment. Since 2003, the City has focused its efforts on colon cancer, because of its unique characteristic as one of the most preventable, yet least prevented cancers. With widespread promotion of colonoscopy for New Yorkers over 50, screening rates have increased from 42% in 2003 to 62% (26) in 2007 and most encouragingly, previous striking disparities between African Americans, Hispanics and Whites in screening rates have disappeared. But we still have a long way to go to vanquish colon cancer. Partnerships such as the NYC Colon Cancer Control Coalition (C5) have been critically important, garnering the social support needed for the changes that can really reduce disease in our city. The Department's Primary Care Information Project is expanding the use of high quality electronic health records to thousands of NYC primary care providers that automatically prompt clinicians to provide key recommended preventive care such as cancer screenings. This strategy will also help improve screening rates.

Through this combination of policy approaches for environmental change, community programs, and improving the delivery of health care, we believe that a far more significant portion of cancer deaths can be prevented.

References

1. National Cancer Institute. Cancer control:objectives for the nation, 1985-200. NCI Mongraphs. Mo 2. Washington, DC:Government Printing Office. 1986 (NIH publication no. 86-2880)
2. Ries LAG, Melbert D. Kraphcho M, Stinchcomb DG, Howlander N. Horner MJ, Mariotto A, Miller BA, Feuer EJ, Altekruse SF, Lewis DR, Clegg I, Eisner MP, Reichman M, Edwards BK (eds). SEER Cancer Statistics Review, 1975 – 2005. National Cancer Institute. Bethesda MD. http//seer.cancer.gov/csr/1975_2005/. Accessed June 20, 2008.
3. Bailer JC, Gornik HL. Cancer Undefeated. New Engl J Med. 1997:336:1569-1574
4. Anand Om Jybbynajara AB, Sundaram C, Hari kumar KB, Tharakan ST, Lai OS, Sung M, Aggarwal BB. Pharm Res. 2008 Wep;25(9): 2097-116. Epub 2008 Jul 15.
5. Calle, E. et.al, overweight, obesity, and Mortality from Cancer in a Prospectively Studied Cohort of U.S. Adults. NEJM; 2003; 348:1625-1638.
6. Boffetta P, Tubiana M, Hill C, Bonial M, Aurengo A, Masse R, Valleron AJ, Monier R, de The G, Boyle P, Autier P. The causes of cancer in France. Ann Oncol. 2008 Sep 2.
7. President's Commission on Improving Economic Opportunity in Communities Dependent on Tobacco Production While Protecting Public Health. Tobacco communities at a crossroad: The prelim inary of the President's Commission on Improving Economic Opportunity in Communities Dependent on Tobacco Production While Protecting Public Health. Washington, DC. January 26, 2001.
8. Centers for Disease Control and Prevention (CDC).Ellis JA*, Perl SB*, Frieden TR*, Huynh M*, Ramaswamy C*, Gupta LS*, Kerker BD*. Decline in smoking prevalence--New York City, 2002-2006. MMWR Morb Mortal Wkly Rep.2007 Jun 22;56(24):604-8.
9. Ellis JA, Perl SB, Davis K, Vichinsky L. Am J Public Health. 2008 Feb;98(2):310-6. Epub 2008 Jan 2.
Centers for Disease Control and Prevention. Response, U.S. Department of Health and Human Services. Cigarette use among high school students _ United Sstates, 1992-2007.20MMWR 2008;57(25):689-691.
10. Ellis JA, Perl SB, Davis K, Vichinsky L. Am J Public Health. 2008 Feb;98(2):310-6. Epub 2008 Jan 2.
11. Centers for Disease Control and Prevention. Response, U.S. Department of Health and Human Services. Cigarette use among high school students. United States, 1992-2007. MMWR 2008;57(25):689-691
12. NYC Vital Statistics, DOHMH.
13. Calle EE,20Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. 2003:24;348(17):1625-38.
14. Calle EE, Rodriguez C. Wakler-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. 2003;348(17):1625-38
15. Silver LD , Bassett MT. Food Safety for the 21st Century. JAMA. 2008;300(8):957-959.
16. Nielsen SJ, Siega-Riz AM, Popkin BM. Trends in energy intake in the United States between 1977-1996: Similar shifts seen across all age groups. Obesity Research 2002; 10:370-378.
17. Silver LD , Bassett MT. Food Safety for the 21st Century. JAMA. 2008;300(8):957-959.
18. Fernandez M. Pros and cons of a zoning diet: fighti ng obesity by limiting fast-food restaurants. New York Times, September 24, 2006
19. Abdoolah T. Limits proposed on fast food restaurants. Los Angeles Times. Sept. 10, 2007
20. Boffetta P, Hashibe M. Alcohol and cancer. Lancet Oncol. 2006;7:149-56.
21. Norstrom T, Skog OJ. Saturday opening of alcohol retail shops in Sweden: an=2 0impact analysis. J Stud Alcohol. 2003;64(3):393-401.
22. Gruenewald PJ, Remer L. Changes in outlet densities affect violence rates. Alcohol Clin Exp Res. 2006;30:1184-1193
23. Moyer A, Finney JW, Swearingen CE, Vergun P. Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction. 2002;97(3):279-92.
24. Steinbrook R. The potential of human papillomavirus vaccines. New Engl J Med. 2006;354:1109-1112.
Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J Hepatol. 2006;45(4):529-38
25. Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J Hepatol. 2006;45(4):529-38
26. New York City Community Health Survey, 2007.