Public Health Feature - January 2008
By Crystal Conde
Thanks in part to a Texas Medical Association campaign, voters took a giant step forward in fighting cancer in November when they approved Proposition 15 to pay for major improvements in cancer prevention and research in the state. The state constitutional amendment authorizes $3 billion in general obligation bonds to create the Cancer Prevention and Research Institute of Texas.
Over the next 10 years, cancer research institutions can apply for a portion of $300 million annually in grants and loans. Additionally, up to 10 percent of funding, or $30 million a year, will pay for cancer prevention and control programs.
The amendment passed with 61-percent approval. TMA and the Texas Public Health Coalition, along with advocacy groups and lawmakers, championed its passage.
Proposition 15 did have its opponents, however. They objected on a fiscal basis, specifically $1.6 billion in interest they say will be a burden on taxpayers. They also questioned why state money should be used to fight cancer when other diseases are worthy of research funding.
In the end, Proposition 15 proponents won, appealing to the tens of thousands of Texans whose lives have been touched by cancer. Last year, about 95,000 Texans were diagnosed with cancer, and about 37,000 died from the disease. Cancer costs Texans $30 billion a year in direct and indirect costs. Funding prevention and control initiatives across the state will alleviate the financial toll of the disease.
Frontline physicians, research institutions, and medical schools, as well as patients and Texas residents, are in a prime position to benefit immediately from increased access to screening services, according to Jeffrey Levin, MD, MSPH, an occupational medicine specialist at The University of Texas Health Center at Tyler and member of the TMA Council on Public Health. Eduardo Sanchez, MD, MPH, director of the Institute for Health Policy at The University of Texas School of Public Health, says the entities will gain in the long term from the establishment of enhanced, effective prevention programs.
TMA lobbied lawmakers in last year's legislative session to put the proposition on the ballot, then worked for its passage in the election. TMA assisted the legislators who authored the bill, educated lawmakers about the importance of Proposition 15, collaborated with other advocacy groups such as the Lance Armstrong Foundation, Susan G. Komen for the Cure, and the American Cancer Society, and advocated for implementation of the Texas Cancer Plan, which outlines recommendations on cancer needs in the state. The plan proposes professional education on prevention, screening, and early detection, all part of the mission of TMA's Physician Oncology Education Program (POEP).
The association also rallied support among its members and their patients by including a pro-Proposition 15 poster in Texas Medicine that doctors could hang in their offices, purchasing radio ads, creating slate cards for placement in physician offices, and drafting editorials and news releases county medical societies could submit to their local media.
Marilyn Leitch, MD, chair of the steering committee for POEP and a surgical oncologist at The University of Texas Southwestern University Medical Center, says the funding invested in cancer prevention, detection, and screening in Texas is crucial to make sure patients receive the best care.
"This is a great opportunity for all of Texas and for POEP to expand efforts and focus on issues that are particularly important to Texas physicians with respect to what they'd like to be able to do for their patients," Dr. Leitch said.
At the 2007 TMA Fall Conference, the TMA Council on Public Health developed guiding principles for program funding through the institute. The council also outlined specific provisions to put prevention dollars in the hands of frontline practicing physicians to improve patient care. (See " Council on Public Health Funding Recommendations .")
Dr. Sanchez spoke to the council about possible recommendations it could generate to improve cancer prevention. He encouraged TMA to see that funding is used to research effective prevention strategies, while simultaneously supporting the use of clinical preventive services and vaccines to reduce the incidence of cancer.
"With services delivery, an opportunity exists to ensure an individual diagnosed with cancer gets evidence-based, quality care in a timely manner, irrespective of what system that person is in. We would benefit to know how we can optimize that researchable issue," he said.
TMA Past President Ladon Homer, MD, says there is an immediate opportunity for all physicians, not just researchers, to benefit from the funding.
"A portion of the funding will enhance care for patients by giving their physicians educational opportunities to learn about the latest cancer treatments and techniques. This is a bill for cancer research, but there are also provisions for patient care and prevention that will benefit the public and reduce the incidence of cancer in the state," he said.
Mark Clanton, MD, MPH, chief medical staff officer for the American Cancer Society, has identified a potential way the funding can directly impact women in Texas. More women who qualify for the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program would have the opportunity for screenings.
Dr. Clanton says that nationally only about 15 percent of eligible women receive screening services through the program. Using part of the 10 percent of funding designated for prevention each year for screening would have an instant positive effect.
The institute must have the proper infrastructure before funding is allocated. The new cancer institute is authorized to sell bonds as early as Jan. 1, 2008, but its Scientific Research and Prevention Programs Committee doesn't have the authority to act until a majority of the members are appointed and rules for awarding grants have been established.
On Dec. 1, the Texas Cancer Council was reorganized as part of the prevention and research institute. Gov. Rick Perry, Lt. Gov. David Dewhurst, and House Speaker Tom Craddick will appoint members to the committee early this year.
Once the scientific committee has reviewed grant and loan applications, an Oversight Committee will hear recommendations on awarding research, therapy development, and clinical trial grants and loans. The committee will be composed of Attorney General Greg Abbott, Comptroller Susan Combs, and nine members selected by the governor, lieutenant governor, and House speaker.
Once it begins operation, the institute's main goals will be:
- To create and expedite innovation in cancer research and enhance the potential for medical or scientific breakthroughs in preventing and curing cancer;
- To attract, create, or expand public or private research capabilities to increase cancer research and create high-quality new jobs; and
- To implement the Texas Cancer Plan, a statewide guide for cancer prevention and control created by the Texas Cancer Council. The plan is online at www.tcc.state.tx.us .
The institute will have a Cancer Research Fund that will include matching funds from federal or private sources of 50 cents on every dollar spent in state funding. The fund will have money from the sale of bonds; patents, royalties, and license fees and other income; legislative appropriations; gifts, grants, and other donations; and interest earned on investments. In addition to paying for grants and loans, the money will be used to operate the institute, as well as purchase needed laboratory facilities by or on behalf of a state agency or grant recipient.
For the state to realize the full impact of the $300 million a year, the institute must devise programs and products that practicing physicians can offer at the community level.
To persuade legislators of the need to fund research that will yield efforts focused on preventive medicine, health promotion, and health services, the Texas Comprehensive Cancer Control Coalition gave them a broad definition of research. By outlining the academic areas of cancer research, as well as applications research, the group aimed to:
- Show that physicians could use the funding to develop effective educational interventions for patients,
- Translate research findings into practical applications,
- Improve quality of life, and
- Address health disparities.
The institute's Oversight Committee will determine what types of research it will fund.
Active physician participation to ensure appropriate investment of the $3 billion is pivotal, according to Dr. Levin. He says the academic community and physicians need to be involved in TMA and their local medical societies to contribute to developing the institute's infrastructure.
Sen. Jane Nelson (R-Lewisville) was the Senate sponsor of House Bill 14, legislation signed by Governor Perry in June that allowed for the creation of the institute. Senator Nelson agrees that the institute's success depends on stakeholders' ability to make good decisions in distributing funds.
"The passage of Proposition 15 will have a major impact in the fight against cancer. Because it is going to take some time to put in place the system for approving research grants, my hope is that we can move quickly on the resources available for prevention," she said.
Crystal Conde can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
Council on Public Health Funding Recommendations
The TMA Council on Public Health identified four key areas for focusing prevention and research funds available through the Cancer Prevention and Research Institute of Texas.
Council member Jeffrey Levin, MD, MSPH, says the council and other physicians need to be involved in developing the institute's infrastructure to make sure Texans see the best return on this investment.
The council's recommendations will help physicians gain access to some of the $300 million per year in funding. They include:
- Focus group meetings for researchers and prevention experts and the public should be held to determine the institute's focus, goals, and values and the strategic plan of the institute.
- Physician participation on the Oversight Committee and the Scientific Research and Prevention Programs Committee is essential to ensure that high-quality, cost-effective projects receive adequate funding.
Health Service Delivery Systems
- These systems should align incentives and promote system changes to improve effective prevention counseling. Additionally, adequate reimbursement for preventive counseling by physicians in the medical home is essential.
- Social marketing techniques that affect behavior, such as statewide public education campaigns on the prevention and cessation of tobacco use, are a proven effective strategy. Funding to implement a statewide tobacco campaign - one targeting adults and one targeting adolescents - would save lives and dollars spent treating cancer and other diseases. Additionally, laws prohibiting smoking in public places are another effective deterrent to tobacco use.
- Approximately one-third of annual national cancer deaths are due to nutrition and physical activity factors, including obesity. For the majority of Americans who do not use tobacco, dietary choices and physical activity are the most important modifiable cancer risk factors. Because of the link between nutrition, physical activity, obesity, and cancer, TMA supports statewide implementation of coordinated school health education (CATCH) to address obesity, instill healthy nutrition and physical activity behaviors, and improve overall health.
- TMA supports funding for and implementation of strategies for medical education of physicians at multiple levels (undergraduate, graduate, and continuing medical education) to use prevention strategies in public health systems and practice settings.
- Cancer vaccines to treat existing cancers (therapeutic vaccines) or to prevent the development of cancer (prophylactic vaccines) should be funded through the institute. Currently, the only prophylactic vaccines available are for the prevention of viruses that will lead to liver cancer (hepatitis B) and cervical cancer (HPV). Several vaccines under development block the effects of nicotine.
Clinical Preventive Services
- Any effort to reform the health system in the state or the nation should include greater use of evidence-based preventive services.
- Resources should be committed in ways that reduce tobacco use and obesity and increase use of appropriate clinical preventive services. A portion of the research funding should focus on studying effective prevention counseling models and strategies that promote healthy behavior.
- Programs funded by the institute should target those clinical preventive services with the highest impact on health and the most cost-effective, evidence-based prevention services. These include the following cancer sites and policies: smoking cessation, colorectal screening, cervical cancer, and breast cancer.
- Research and prevention grants funded by the institute should focus on performance-improvement strategies to assist physicians in providing preventive care and screening.
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