UT-Affiliated Facility Leads the Fight Against One of Texas' Leading Causes of Death
Symposium on Population Health — February 2018
Tex Med. 2018;114(2):34-41.
By Lewis Foxhall, MD; Mark Moreno, and Ernest Hawk, MD, MPH
Lewis Foxhall, MD, is vice president for health policy and professor in the Department of Clinical Cancer Prevention at The University of Texas MD Anderson Cancer Center. Mark Moreno is vice president, governmental relations, at The University of Texas MD Anderson Cancer Center. Ernest Hawk, MD, MPH, is vice president for cancer prevention, head of the Division of Cancer Prevention and Population Sciences, professor in the Department of Clinical Cancer Prevention, and Boone Pickens Distinguished Chair for the Early Prevention of Cancer at The University of Texas MD Anderson Cancer Center.
Texas's size and unique population demographics present challenges to addressing the state's cancer burden. The University of Texas MD Anderson Cancer Center is one of 69 National Cancer Institute-designated cancer centers across the United States. While these centers traditionally have focused on research, education and training, and providing research-driven patient care, they are in a unique position to collaboratively advance population health through cancer control. Unlike the traditional academic model of a three-legged stool representing research, education, and patient care, MD Anderson's mission includes a fourth leg that incorporates population health approaches. MD Anderson has leveraged state- and national-level data and freely available resources to develop population-health priorities and a set of evidence-based actions across policy, public and professional education, and community-based clinical service domains to address these priorities. Population health approaches complement dissemination and implementation research and treatment, and will be increasingly needed to address the growing cancer burden in Texas and the nation.
Texas is unique among states, not only for its size, but for the diversity of its people. It is one of only four states that is "majority-minority," meaning that non-Hispanic whites constitute less than 50% of its 27.5 million residents. The United States as a whole is not expected to become "majority-minority" until 2044. While its size and diversity contribute to the state's strong socioeconomic standing ― Texas is the second largest U.S. economy and has the second highest Gross Domestic Product growth rate and the third fastest job growth rate over the past five years ― they also present unique challenges to the health of its population.
The University of Texas MD Anderson Cancer Center was established in 1941 as a hospital dedicated to cancer research and treatment for Texans. But its mission today goes far beyond this initial vision. MD Anderson now seeks to "eliminate cancer in Texas, the nation, and the world through outstanding research, patient care, education and training, and evidence-based cancer prevention and control actions." This last mission area ― evidence-based cancer prevention and control actions ― is well-aligned with the broader concept of "population health" and constitutes the focus of this article.
Below, we briefly review the state of cancer in Texas and then discuss the distinctive role that National Cancer Institute (NCI)-designated cancer centers like MD Anderson have in promoting population health. The remainder of the article will then be a presentation of MD Anderson's methods and selected actions to date in the area of population health. We close with a discussion of the challenges and opportunities we identified during this work.
Cancer in Texas
According to 2017 American Cancer Society (ACS) estimates, there will be 116,200 new cancer cases and 40,260 cancer deaths in Texas. Texas is the second most populous state, and it ranks third in the United States for both the number of new cancer cases diagnosed and the number of cancer deaths. Cancer is the second most common cause of death in Texas, with lung cancer remaining as the leading cause of cancer death. Cancer incidence and mortality relevant to Texas are found in Table 1.
Unfortunately, the state's cancer burden is not evenly distributed across the population. Some groups are affected by cancer more than others. Men in Texas have higher incidence and mortality rates than do women, and African-Americans have higher incidence and mortality rates than both Hispanics and non-Hispanic Whites. Texans with less education and income are also disproportionately affected by cancer. Notably, Texas has a large rural and frontier population. Nearly 70% of the 254 counties within Texas are rural and are designated as health professional shortage areas.1 In addition, Texas has one of the highest percentages in the country of people living in frontier areas (those with ≤7 people per square mile). Rural and frontier Texans are considered to be an underserved population as they have less access to medical care, tend to be older, have lower income, and are less likely to have health insurance.1 In 2015, Texas led the nation in the percent of both its adults (22%) and children (9%) who were uninsured.2 Those without insurance have been shown to experience worse cancer outcomes across the board.3
The Preventability of Cancer
It is estimated that 50% of cancer deaths are preventable by applying knowledge that we already have.4 The overarching goal of MD Anderson's population health/cancer control actions is to do exactly that ― to translate evidence-based knowledge and interventions to the population at large in order to measurably impact the cancer burden at local, state, national, and even global levels. Closing the gap between cancer research efforts and population program delivery has never been more urgent given recent estimates from the United Nations World Health Organization and the American Institute for Cancer Research of a doubling in cancer cases over the next 20 years. Through its foundational mission of a population health approach to cancer, MD Anderson has the ability to prevent such estimates from becoming a reality.
The Role of a NCI-Designated Cancer Center in Promoting Population Health
Currently, there are 69 NCI-designated cancer centers across the country. According to NCI, designated cancer centers "serve as major sources of discovery into the nature of cancer and of the development of more effective approaches to prevention, diagnosis, and therapy." While the criteria for Cancer Center Support Grant (P30) funding have evolved over the years, the emphasis has been and remains on linking cutting-edge research with patient care in order to perpetuate the translational research continuum (stages T0-T4). However, because much of population health is what happens beyond the T4 stage, it is often tacitly omitted from a cancer center's mission. Indeed, most cancer centers ― and other academic health centers ― employ a model of a three-legged stool for their mission, focusing on research, patient care, and education and training of researchers and clinicians.5 Although a focus on individualized clinical services is absolutely needed to treat current patients suffering from cancer, and while we certainly need more effective treatments for advanced-stage cancers, therapeutic services are necessarily limited in their reach and impact. Incorporation of a fourth leg representing a focus on cancer control or population health into the vision and mission of all cancer centers is required if, as a nation, we are to apply what we already know works to prevent far more cancers than we could ever hope to effectively treat. Incorporating a population health focus into cancer centers' missions will require investments in time and talent, but it also provides a unique, compelling, and broadly impactful opportunity for the nation's cancer centers to achieve a public benefit that is both significant and enduring.
MD Anderson's Approach to Population Health
According to the Centers for Disease Control and Prevention (CDC), cancer control "is a strategic approach to preventing or minimizing the impact of cancer in communities,"6 and it offers tremendous opportunity to impact population health in the future.7 Due to the breadth of potential actions in this area and to ensure a uniform understanding among all institutional stakeholders regarding these potential actions, MD Anderson's leaders defined its work in this space as "evidence-based actions in public policy (P), public and professional education (E) and community-based clinical services (S)." Definition of these three domains (P, E, and S) has allowed its faculty and staff to communicate around a complex topic in a simplified and consistent manner to maximize understanding of this important work and to distinguish it from NCI's other three mission-driven areas of responsibility (i.e., research, patient care, and education/training).
Data Sources and Prioritization Criteria for Population Health Actions
Cancer control priorities at MD Anderson are developed based on population health needs as determined using secondary data derived from community needs assessments or other sources, such as:
- The Health of Houston Survey (local);
- The Health Status of Northeast Texas (regional);
- Texas Behavioral Risk Factor Surveillance System and the Texas Youth Risk Behavior Surveillance (state);
- Texas Cancer Registry (state);
- The Health Status of Texas (state); and
- Cancer-related statistics from the American Cancer Society and the Surveillance, Epidemiology, and End Results Program (SEER; national).
In addition, MD Anderson uses information and data that it can access as part of its participation in Regional Healthcare Partnership 3 (RHP3), one of 20 regional health care partnerships established in Texas as a result of the 1115 Medicaid Transformation Waiver, and the Cancer Prevention and Research Institute of Texas (CPRIT)-funded Comparative Effectiveness Research on Cancer in Texas (CERCIT) project. MD Anderson annually assesses cancer-relevant data, trends, and concerns at both the national and state levels to ensure systematic monitoring of population health needs.
Needs are then prioritized based on the following considerations:
- Compelling data regarding an unmet, important need within our population;
- Availability of accurate, reliable, and serially measurable data on important cancer-related outcomes or risk factors;
- Availability of effective, evidence-based strategies for prevention and/or early detection;
- Potential for meaningful impact; and
- Alignment with the Texas Cancer Plan and/or other state and national health priorities.
Taking into account the cancer burden in Texas and given the above considerations, MD Anderson selected several priorities on which to focus its efforts (Table 2). To guide implementation of interventions and investments that address these priority areas, we have leveraged national- and state- level, peer-reviewed, freely available evidence compilations and guidelines. These include:
Representative MD Anderson Actions
MD Anderson's population-based approaches to cancer prevention are summarized in Table 3, according to priority area with relevant control domain and funding source indicated. A few selected examples are described below.
In the policy domain of cancer control, MD Anderson has provided support and education around policies related to restricting/prohibiting tobacco use and artificial ultraviolet radiation exposure. MD Anderson has served as a primary clinical and scientific resource in Texas for the legislature's consideration of:
- A Tobacco21 statewide policy;
- A law adopted in 2015 to prohibit sales of e-cigarettes to minors younger than 18;
- Legislation prohibiting the use of tanning beds by Texas teens younger than 18, which became law in 2013; and
- A state policy allowing children to possess and use sunscreen in public schools, which took effect in 2015.
Since then, we've disseminated our experience and lessons learned to several other states to assist them in considering similar policies and legislation. In addition, the UT System's Eliminate Tobacco Use Initiative, led by MD Anderson and the UT System, has resulted in all 14 UT campuses being tobacco-free as of May 1, 2017.
In the domain of public education, MD Anderson disseminates innovative, evidence-based educational programming designed to prevent tobacco initiation and to promote healthy lifestyles among school-age children. The ASPIRE (A Smoking Prevention Interactive Experience) tobacco prevention and cessation intervention was developed and tested by MD Anderson faculty in conjunction with others and is now codified as an evidence-based program in NCI's RTIPs database.8 It has been disseminated across 32 states, six international partners, and has reached at least 70,000 children in Texas since 2013. It was recently implemented in the Houston Independent School District, the fourth largest in the nation. MD Anderson also forged a partnership with the CATCH Global Foundation to support, expand (add content), digitize, and disseminate the CATCH (Coordinated Approach to Child Health)9 evidence-based childhood obesity prevention program across Texas and the nation, reaching nearly 2 million children across 10,000 sites.
Regarding professional education, MD Anderson has adopted the Project ECHO model10 as a platform to provide telementoring to local providers in the areas of cervical and breast cancer screening, tobacco cessation, palliative care, pathology, and survivorship. The institution's work with Project ECHO is most advanced in the area of cervical cancer screening involving physicians and advanced practice providers in the Lower Rio Grande Valley, where cervical cancer mortality is 31% higher than non-border counties and where there is a shortage of clinicians trained in management of cervical cancer. Another ECHO-based program is supporting primary care clinicians in the management of cancer survivors in Galveston, Austin, and Tyler. We have since been accredited as an ECHO Superhub, which allows us to train other institutions in the use of the ECHO model in oncology.
In the domain of community-based clinical services, Project VALET (Providing Valuable Area Life-saving Exams in Town) addresses barriers of cost and transportation by bringing free mobile mammography and follow-up diagnostic testing to high-need residential communities in Houston and the surrounding suburbs. Over the past five years, this project has provided screening and diagnostic services to 7,436 and 1,182 residents, respectively, and provided navigation-to-treatment services as needed. Screening for colorectal cancer is being addressed through partnerships with more than 60 federally qualified health centers in Houston and Southeast Texas with funding from CPRIT and the 1115 Medicaid waiver.
MD Anderson also is implementing comprehensive and collaborative community-based cancer control interventions that incorporate actions from all three of our defined domains of control. Our Be Well CommunitiesTM initiative, supported by major corporations, is an example of a public-private partnership seeking to improve health and wellness and to decrease the prevalence of cancer risk factors in selected communities. We are currently working with Pasadena and Baytown, the second and third largest cities in Harris County, respectively. In each of these communities, we have developed maps of key community assets, conducted key informant interviews, reviewed assessment reports and datasets to learn about community needs and demographics, recruited key community leaders and decisionmakers to serve as members of a community steering committee, and selected cancer-related areas of concern to address.
MD Anderson views research and control actions as vital, complementary activities that inform each other to initiate and perpetuate a virtuous cycle to address the needs of Texans. Many of our control actions have programmatic research associated with them. In one example of research informing control actions, MD Anderson's Ask-Advise-Connect (AAC) research project demonstrated a 13-fold increase in the proportion of smokers enrolling in cessation treatment over the traditional Ask-Advise-Refer model.11 Subsequently, the AAC model was disseminated to underserved smokers in Harris Health (safety net health care system) (CPRIT PP120191) and as part of the 1115 Medicaid waiver program, "Replicating Ask, Advise, Connect", which connected more than 71,000 smokers to treatment. Conversely, control actions may inform research, as MD Anderson's implementation of cervical cancer screening in the Lower Rio Grande Valley (CPRIT PP150012) informed research intending to pursue a more diverse array of "see and treat" options in low-resources settings to further improve technologies that support point-of-care cervical cancer screening and diagnosis in underserved populations (UH3CA189910).
Challenges and Opportunities
The work described herein has not been without its challenges. One of the earliest challenges identified in the prioritization process was the lack of reliable information systems that provide quantitative, serially measurable and locally actionable data on cancer risk factors and behaviors. A related challenge is the lack of validated intermediate markers or outcomes to guide the implementation of preventive interventions and their short- to intermediate-term evaluations. The time frame over which cancer occurs and the very nature of prevention itself, where, if done properly, nothing happens, challenges the assessment of preventive interventions.12 A third consistent challenge to our work has been the paucity of funding to support control actions. MD Anderson is fortunate to have established relationships with philanthropic donors, both individuals and corporations, that have enabled many of our cancer control actions, such as our Healthy Communities Initiative. The importance of philanthropic support to both develop and sustain control initiatives cannot be overstated.
Finally, as successful cancer control necessitates partnerships across sectors and/or various levels of a society or organization, there can be a lack of clarity around each stakeholder's role. Rarely do control efforts identify a singular leader or leader across time, so there is often no singularly empowered, or responsible, organizational lead for the implementation, evaluation, and follow-through of actions.
As so many efforts in cancer control identify the same "low-hanging fruit" in terms of priorities ― tobacco control, human papillomavirus vaccination, and colorectal/cervical cancer screening ― there is tremendous opportunity for a concerted effort across all types of stakeholders, including health systems and insurers, cancer centers and other academic health centers, non-profits and patient advocacy groups, private corporations, and governmental agencies, to come together and coordinate actions. Development of a national cancer control plan, building on the panoply of state-specific cancer control plans, and/or a national-level cancer control leader could substantially advance these "low-hanging fruit" initiatives and more rapidly reduce their related deaths.
Healthy Lifestyles Reduce Mortality and Improve Overall Health
Cancer prevention holds tremendous promise for a renewed focus on health and healthy lifestyles and for improving the quality of life, not only for cancer patients but for all. Growing evidence supports this notion, demonstrating significant reductions in cancer risk as well as cardiovascular-related, cancer-related, and all-cause mortality in those adhering to cancer prevention recommendations. A 2016 systematic review of 12 studies from 10 cohorts documents a 10% to 61% reduction in overall cancer incidence and mortality for those who strongly adhere to published cancer prevention recommendations from the American Cancer Society or the American Institute for Cancer Research.13 Individual studies also suggest that these same cohorts have a 36% to 58% reduced risk of dying from cardiovascular disease and a 26% to 42% reduced risk of all-cause mortality, objectively demonstrating the important connection between effective cancer control and the broader goals of population health.14-16
We believe that MD Anderson's foundational mission to a population-based approach to cancer prevention and control complements its robust cancer treatment and research programs, establishing a productive interface between the provision of research-driven clinical services to individuals and the implementation of evidence-based interventions in populations. Such population-based approaches to cancer prevention are often referred to as "the great unfunded mandate." But their potential to reduce the cancer burden is profound, as evidenced by the on-going reduction in lung cancer incidence and mortality that has followed tobacco control actions beginning in the 1960s. Nothing in all of cancer treatment has had as dramatic of an impact on cancer or overall mortality over the last 50 years, and so much more is possible. But it will take a commitment to effective, evidence-based population health by all 69 NCI-designated cancer centers to achieve it.
- Cancer Prevention Research Institute of Texas (CPRIT). Texas Cancer Plan 2012: A Statewide Call to Action for Cancer Research, Prevention, and Control. Austin, TX: CPRIT; 2012.
- Texas Medical Association. 2015 health insurance coverage, 2015. https://www.texmed.org/Template.aspx?id=42282. Accessed September 21, 2017.
- Walker GV, Grant SR, Guadagnolo BA, et al. Disparities in stage at diagnosis, treatment, and survival in nonelderly adult patients with cancer according to insurance status. J Clin Oncol. 2014;32(28):3118–3125.
- Colditz GA, Wolin KY, Gehlert S. Applying what we know to accelerate cancer prevention. Sci Transl Med. 2012;4(127):127–127.
- Wartman SA. The Academic Health Center: Evolving Organizational Models. Washington, DC: Association of Academic Health Centers; 2007.
- Centers for Disease Control and Prevention (CDC). National Comprehensive Cancer Control Program. www.cdc.gov/cancer/ncccp. Accessed October 13, 2017.
- Hiatt RA. New directions in cancer control and population sciences. Cancer Epidemiol Biomarkers Prev. 2017;26(8):1165–1169.
- Prokhorov AV, Kelder SH, Shegog R, et al. Project ASPIRE: an interactive, multimedia smoking prevention and cessation curriculum for culturally diverse high school students. Subst Use Misuse. 2010;45(6):983–1006.
- Coleman KJ, Tiller CL, Sanchez J, et al. Prevention of the epidemic increase in child risk of overweight in low-income schools: the El Paso coordinated approach to child health. Arch Pediatr Adolesc Med. 2005;159(3):217–224.
- Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011;364(23):2199–2207.
- Vidrine JI, Shete S, Cao Y, et al. Ask-Advise-Connect: a new approach to smoking treatment delivery in health care settings. JAMA Intern Med. 2013;173(6):458–464.
- Fineberg HV. The paradox of disease prevention: celebrated in principle, resisted in practice. JAMA. 2013;310(1):85–90.
- Kohler LN, Garcia DO, Harris RB, Oren E, Roe DJ, Jacobs ET. Adherence to diet and physical activity cancer prevention guidelines and cancer outcomes: a systematic review. Cancer Epidemiol Biomarkers Prev. 2016;25(7):1018–1028.
- McCullough ML, Patel AV, Kushi LH, et al. Following cancer prevention guidelines reduces risk of cancer, cardiovascular disease, and all-cause mortality. Cancer Epidemiol Biomarkers Prev. 2011;20(6):1089–1097.
- Vergnaud AC, Romaguera D, Peeters PH, et al. Adherence to the World Cancer Research Fund/American Institute for Cancer Research guidelines and risk of death in Europe: results from the European Prospective Investigation into Nutrition and Cancer cohort study1,4. Am J Clin Nutr. 2013;97(5):1107–1120.
- Kabat GC, Matthews CE, Kamensky V, Hollenbeck AR, Rohan TE. Adherence to cancer prevention guidelines and cancer incidence, cancer mortality, and total mortality: a prospective cohort study. Am J Clin Nutr. 2015;101(3):558–569.
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