Fulfilling the Potential of Cancer Prevention and Early Detection

Cancer ranks second only to heart disease as a leading cause of death in the United States, making it a tremendous burden in years of life lost, patient suffering, and economic costs. Fulfilling the Potential for Cancer Prevention and Early Detection reviews the proof that we can dramatically reduce cancer rates. The National Cancer Policy Board, part of the Institute of Medicine, outlines a national strategy to realize the promise of cancer prevention and early detection, including specific and wide-ranging recommendations. Offering a wealth of information and directly addressing major controversies, the book includes:

• A detailed look at how significantly cancer could be reduced through lifestyle changes, evaluating approaches used to alter eating, smoking, and exercise habits.
• An analysis of the intuitive notion that screening for cancer leads to improved health outcomes, including a discussion of screening methods, potential risks, and current recommendations.
• An examination of cancer prevention and control opportunities in primary health care delivery settings, including a review of interventions aimed at improving provider performance.
• Reviews of professional education and training programs, research trends and opportunities, and federal programs that support cancer prevention and early detection.

This in-depth volume will be of interest to policy analysts, cancer and public health specialists, health care administrators and providers, researchers, insurers, medical journalists, and patient advocates.

This book was issued as a report by the National Cancer Policy Board, which was established in 1997 by the Institute of Medicine and the National Research Council. The book is ambitious, and I approached it hoping to learn how to use our current knowledge to realize the potential of the prevention and early detection of cancer for reducing mortality due to cancer by 50 to 80 percent. Unfortunately, I was often disappointed. Much of the book is based on background papers, which in many instances seem to be given more prominence than I would have expected from a committee report. As chapter 2 shows, much has already been achieved by prevention. Decreases in smoking have led to reductions in mortality due to lung cancer; dietary changes may have reduced the incidence of colon cancer; and screening has contributed to a reduction in the rate of cervical cancer. Yet the recent reduction in mortality due to breast cancer is almost certainly a result of neither of these kinds of prevention but of improvements in adjuvant therapy for stage II disease. And none of these achievements have resulted from an organized approach to cancer control. Rather, they are attributable to increased public awareness about causes and effects, for which the American Cancer Society and, more recently, various government agencies that have used fiscal initiatives can take credit. The greatest disconnect between what is achievable and what has been achieved probably lies in the area of changes in lifestyle. Chapter 4 starts with a description of various models of the process involved in making such changes and continues with extensive sections covering such topics as smoking-cessation interventions, weight-loss interventions, and dietary interventions, but none of the models considered in these sections are related to those discussed at the beginning of the chapter. In practice, people need incentives in order to be persuaded to make behavioral changes. These incentives often fall within the purview of government in its widest role and involve long-term political action. I found the chapters on early detection disappointing. Although the discussion of spiral computed tomography for lung-cancer screening was excellent, it emphasized that screening outside of the public health context will lead to disaster, because often the wrong people will be screened and those found to have an abnormality on screening will be overtreated. The U.S. health care system is ill equipped to deal with the organizational requirements of screening. The financial consequences are serious (we overspend on screening for cervical cancer, for instance, by billions of dollars annually), and expectations can be unrealistic. For example, the potential reduction in mortality from colorectal cancer of 30 to 80 percent that is cited in chapter 11 seems optimistic. Although the expectation if colonoscopic screening were implemented universally might be an 80 percent reduction, failures of compliance would, in practice, lead to a much smaller reduction. The final chapter tries to tie things together and make appropriate recommendations, many of them to Congress. I was especially pleased that the National Cancer Policy Board recommends research on how to encourage behavioral change. However, to realize the full potential of prevention and early detection, many political initiatives will be required, and I fear that it will take a great deal of activity to produce a congressional response. Furthermore, the cancer establishment will have to stop placing so much emphasis on the "genetic revolution" and start focusing more on public health. These changes will be extremely hard to bring about, but this book may serve to accelerate the process. Cancer is destined to become the number-one killer of North Americans within the next decade, and time is running out for preventing our current facilities from being overwhelmed. Prevention is the only sensible solution. Anthony B. Miller, M.B., F.R.C.P.
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