Download A New Strategy for Cancer Control Research

Vol. 8, 957–964, November 1999
Cancer Epidemiology, Biomarkers & Prevention
Review
A New Strategy for Cancer Control Research
Robert A. Hiatt1 and Barbara K. Rimer
Division of Cancer Control and Population Sciences, National Cancer Institute,
NIH, Public Health Service, United States Department of Health and Human
Services, Bethesda, Maryland 20852
Introduction
The 20th century saw the emergence of cancer as a leading
cause of disease and death in the industrialized world. Cancer
was the eighth most common cause of mortality at the beginning of the century, with a death rate in 1900 of 64 per 100,000
persons (1). At the close of the 20th century, it ranked second
and reached a peak of 205.6 deaths per 100,000 in 1993 (2).
Given current trends, cancer will replace cardiovascular disease
as the leading cause of death early in the 21st century (3).
Slowly at first, and then more rapidly since 1975, efforts to
discover the causes and cures for cancer have intensified and
received a substantial infusion of public and private support.
Ammunition for the War on Cancer, a war initiated in 1971 by
the National Cancer Act (4), has been developed primarily by
the basic and clinical sciences. Earlier dreams of a “magic
bullet” that would cure cancer have now given way to the
realization that cancer is many diseases; thus, many bullets will
be required for its control. Now, at the end of the century, we
are benefiting from rapid advances in molecular biology and
genetics that may hold promise for understanding the causes of
cancer and for providing strategies for its prevention, early
detection, and cure. Yet, despite the excitement engendered by
recent discoveries at the molecular and cellular levels that may
help to clarify the process of carcinogenesis, the reality is that
cancer remains, to a large degree, a disease in which human
behavior and societal factors play important causative roles. It
has been estimated that as much as 50 –75% of cancer mortality
in the United States can be attributed to external, nongenetic
factors, most of which are related to human behaviors such as
tobacco use, overuse of alcohol, improper diet, lack of physical
activity, overexposure to sunlight, and sexual activity leading to
exposure to certain viruses (5–7). Modification of these behaviors and the societal forces that influence them is critical to
reducing risk and is the focus of cancer control.
As the 21st century dawns, it is time to examine new
strategies for cancer control research. We now use a new
definition developed by the NCI’s2 Cancer Control Program
Review Group with an added emphasis on outcomes that improve the quality of life (8):
“Cancer control research is the conduct of basic and applied research in the behavioral, social, and population sciences
Received 8/10/99; accepted 9/8/99.
1
To whom requests for reprints should be addressed, at National Cancer Institute,
Executive Plaza North, Suite 243, 6130 Executive Boulevard, Rockville, MD
20852. Phone: (301) 435-7206; Fax: (301) 496-8675; E-mail: hiattr@dcpcepn.
nci.nih.gov.
2
The abbreviations used are: NCI, National Cancer Institute; ACS, American
Cancer Society; DCCPS, Division of Cancer Control and Population Sciences;
SEER, Surveillance, Epidemiology, and End Results; CDC, Centers for Disease
Control and Prevention.
that, independently, or in combination with biomedical approaches, reduces cancer risk, incidence, morbidity, and mortality and improves quality-of-life.”
Cancer control strategies must be based on a recognition of
the critical role of human behavior in the control of cancer and
must effectively apply the wide-ranging discoveries in the basic
cancer sciences, including basic behavioral research, to improve public health. Interventions must be firmly grounded on
scientific evidence, especially the findings that result from
epidemiological and surveillance research. Epidemiological research is essential to assess the weight of evidence for particular
cancer risk-reducing behavioral recommendations. Surveillance research and its application tells us where we are in our
progress against cancer, generates hypotheses for more basic
research and interventions, and provides important data for
understanding the role of health services and policies on cancer
outcomes. Research in epidemiology, cancer-related behaviors,
and surveillance should be woven together inextricably to optimize progress in the control of cancer.
This report sets forth our views of the expanding scope of
cancer control research, with examples of NCI programs and
initiatives that are designed to advance cancer control well into
the next century. For perspective, we provide a backdrop of
some salient historical features of cancer control research and
the accomplishments of this field to date.
A History of Cancer Control
The term cancer control has long been a source of confusion
and debate. In fact, the scope of cancer control has changed
with the emergence of new knowledge and will continue to
evolve over time. The earliest reference to “cancer control,” of
which we are aware, appeared in 1913 with the formation of the
American Society for the Control of Cancer, which became the
ACS in 1945 (9). The driving force behind the formation of this
organization was concern about the need for the early surgical
treatment of cervical cancer, a cancer that was often fatal in the
early 1900s. Even in 1913, the first cancer control recommendations included a call for cancer registration and the analysis
of vital statistics, the study of the geographic distribution of
disease and the influence of diet, and education to provide “a
concise outline of accepted cancer facts (10).” In the first
decades of this century, however, the medical profession generally did not readily accept the idea of cancer control, because
cancer was much less common than it is now, and its outcome
was usually dismal (11). Furthermore, the medical profession
was resistant to governmental interference in the practice of
medicine, and organized state and federal cancer control efforts
were not likely to have its support (11).
Legislative language first identified cancer control in 1937
when, with the formation of the NCI (PL 75-224), the Surgeon
General was authorized to act through the Institute and the
National Cancer Advisory Council to “cooperate with state
health agencies in the prevention, control, and eradication of
cancer.” Congress intended that the NCI would carry out intramural research and support extramural research and cancer
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control, which it referred to as the “useful application of their
results (12).” By the mid-1900s, the major focus of cancer
control was the dissemination of research discoveries through
communications and education. Research in cancer control per
se was not yet part of the paradigm.
With the enactment of The National Cancer Act of 1971
(PL 92-218), Congress reaffirmed its support for cancer control
and authorized specific dollar amounts for the Director of the
NCI to carry out relevant programs with state and other health
agencies (4). Prior to this time, as Breslow et al. (11) argued,
the NCI had failed to carry out its mandate in cancer control,
largely because of the lack of clarity in its conception. This
derived primarily from the “lack of sharp differentiation between research and control. . . on the one hand and between
control and health care on the other” (11). A working group
formed after the 1971 act stated:
“Cancer research seeks to find the means for combating
cancer, whereas cancer control is concerned with identifying,
community testing, evaluating, and promoting the application
of means that are found (13).”
The Division of Cancer Control and Rehabilitation, reestablished in the NCI in 1973, was the first structural unit within
the NCI devoted to cancer control (11). Although, by this time,
efforts in cancer research had brought about notable advances
such as Pap smear screening for cervical cancer, mammography
use for the early detection of breast cancer, identification and
regulation of some carcinogens in the workplace, and publication of the Surgeon General’s landmark Report on Smoking and
Lung Cancer in 1964 (14), this organizational entity made it
possible to begin a more systematic program in cancer control.
In the last quarter of the century, the science of cancer
control was accelerated by the formation of the NCI’s Division
of Cancer Prevention and Control in 1983, led by Peter Greenwald. The development and promulgation of a definition and
framework for cancer control placed the field on a sound
scientific basis and recognized the importance of research in
this field. Greenwald and Cullen (15) defined cancer control
research as “the reduction of cancer incidence, morbidity, and
mortality through an orderly sequence from research on interventions and their impact in defined populations to the broad,
systematic application of the research results.”
This definition was accompanied by a framework that
described a linear series of phases from hypothesis generation
(Phase I) to methods development (Phase II) to controlled
intervention trials (Phase III). Studies in defined populations
(Phase IV) and demonstration projects (Phase V) led to nationwide prevention and health services programs (15). The concept proposed a logical progression–from basic research
through tests of intervention efficacy to community applications–that attempted to focus investigators on the need to build
appropriate foundations before moving on to larger scale tests.
This paradigm, which paralleled the model of drug development, effectively stimulated a generation of investigators to
think more rigorously about cancer control science as a
hypothesis-driven and evidence-based endeavor. The logical
progression of inquiry gave cancer control researchers a
focus and fostered a large body of new cancer control knowledge (16 –21).
Cancer Control Accomplishments of the 20th Century
Until the very end of the 20th century, deaths from cancer have
risen inexorably. Absolute numbers of deaths from cancer continue to increase in an aging population–539,508 cancer deaths
in 1996 (2). Adjusting for the effect of age (direct age adjust-
ment to 1940 U.S. standard population), however, we have seen
cancer deaths go from 79.6 per 100,000 in 1900 to a peak of
135.0 per 100,000 in 1990 and, since then, an annual decrease
of 0.6% to 127.9 in 1996.3 This is the first sustained downward
trend in the cancer death rate since the beginning of the century.
During this period, decreases in mortality rates have been noted
for cancers of the lung, pancreas, brain, and prostate in men, for
breast and cervical cancers in women, and for cancers of the
colon/rectum and stomach in both men and women (22). Decreases in incidence have also been noted for cancers of the
lung (men), colon/rectum, prostate, urinary bladder, oral cavity
and pharynx, and leukemia (22). Although evidence directly
linking the decline in cancer to a reduction in smoking behavior, dietary modifications, changes in food preparation and
storage, and screening is not often available at the national
level, the relentless upward trend in cancer mortality has been
reversed, and there are clear signs that cancer control research
and its applications have played a major role (22–24).
There is good evidence, in particular, that the trends in
cancer mortality can be linked to changes in behavioral risk
factors. Since the 1964 Surgeon General’s report on the health
consequences of smoking, the prevalence of smoking among
adults has decreased significantly, from 45% in 1964 to ,25%
in 1995 (25). Today, there are as many former as current
smokers in the population. Recognition of tobacco use as a
health hazard and subsequent public health antismoking campaigns have resulted in changes in social norms to prevent the
initiation of tobacco use, promote cessation of use, and reduce
exposure to environmental tobacco smoke (26 –28). Changes in
smoking behavior prior to 1986 have been estimated to have
resulted in the prevention of nearly 2.1 million smoking-related
deaths between 1986 and the year 2000 (29).
An increased understanding, through behavioral research,
of the barriers to cancer screening has made it possible to
develop effective strategies to promote adherence to both breast
and cervical cancer screening (16). The use of screening Pap
smears for cervical cancer in this country has increased markedly, to the point where ;91% of women of ages 18 years and
older report having been screened at least once (30). This test
is a well-established part of routine preventive care, and death
from cervical cancer is becoming an increasingly rare event in
the United States, decreasing from 5.2/100,000 in 1973 to
2.7/100,000 in 1996 (2). Screening mammography has been
shown to reduce mortality by ;30% in women .50 years (31,
32), and its use has been widely adopted. In the period 1987–
1990, there was a 2-fold increase in self-reported mammography use in every age and race/ethnic group (33), associated with
the implementation of large-scale behavioral screening interventions. In 1992, a national survey reported 51% of women
age 50 and over having had at least one mammogram in the
previous year or two (30). As mammography rates have risen
dramatically, overall breast cancer mortality has decreased
(34).
Evidence supports the beneficial effects of fruit and vegetable consumption in protecting against cancer, but in the
period 1989 –1991, only 32% of U.S. adults reported eating five
or more servings a day, and the mean intake was only about 4.3
servings (35). Major national efforts to help improve this foodrelated behavior, such as the “5 A Day for Better Health
Program” that was initiated in October 1991 (36), have been
associated with increases in daily fruit and vegetable consump-
3
L. A. Ries, personal communication.
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tion to about 4.9 servings by 1994 –1996 (37). Also, consumer
awareness of the need to eat a minimum of five vegetables and
fruits every day improved substantially between 1991 and
1997–from 8% of those surveyed to 39% (38).
Behavioral research into effective psychosocial and behavioral interventions for cancer survivors has led to practices
that contribute to the reduction of cancer pain, enhancements in
the quality of life, and in some cases, prolonged survival (20,
39 – 41). All of these salutary changes in the nation’s cancer
burden can be attributed, at least partially, to the efforts of
cancer control research and its successful application at multiple levels of the health care system and community (42, 43).
The decreases in mortality for lung cancer and cervical cancer,
in particular, provide compelling evidence that aggressive and
sustained public health action in the control of cancer at the
behavioral and societal levels can, over the long term, have
dramatic results.
Challenges for Cancer Control Research
Despite our successes, we also have recognized limitations,
challenges, and failures in cancer control. Although tobacco
use has been decreasing overall, the rate of decline has
slowed in recent years, especially among women and minorities (44, 45). Tobacco use by teenagers is on the rise (46).
Data from the 1997 Youth Risk Behavior Survey indicate
that the prevalence of current cigarette smoking among
United States high school students increased from 27.5% in
1991 to 36.4% in 1997 and that, in 1997, 42.7% of students
used cigarettes, smokeless tobacco, or cigars during the 30
days preceding the survey (47). The commercial interests of
the tobacco industry remain a powerful countervailing force
against the widely understood dangers of tobacco use addiction and the public health programs mounted to combat
them. Likewise, although the use of mammography has risen
dramatically overall, there still remain sizeable underserved
segments of the population who are not getting appropriate
screening (48). Pap smears can prevent deaths from cervical
cancer, but we still have an estimated 4800 deaths/year (49).
Most deaths are among older women, and screening is less
common after menopause (50). Despite the body of evidence
that a sedentary life style, weight gain, and obesity appear to
increase the risk of developing cancer as well as other
chronic diseases, such as noninsulin-dependent diabetes and
cardiovascular diseases (51), these problems represent a
growing health problem in the United States. Data from the
third National Health and Nutrition Examination Survey
(NHANES III, 1988 –1994) indicated that 55% of United
States adults were overweight or obese, with 22% classified
as obese (52). Comparison of data from NHANES III with
similar data from NHANES II (1976 –1980) indicated that
prevalence of obesity increased by 8%, and average weight
increased by 3.6 kg. Also, recent findings show ;47% of the
United States white population are not “very likely” to
protect themselves against the harmful effects of sun exposure through appropriate behaviors, e.g., using sunscreen,
wearing protective clothing, and seeking shade on a sunny
day (53). Surveillance research continues to reveal troublesome disparities in cancer incidence and mortality by race/
ethnicity and socioeconomic status that need to be better
understood if interventions are to be effective in eliminating
these differences (54). Finally, although organized systems
of health care delivery are becoming the norm in the United
States, there is no national population-based system to monitor the quality of care experienced by cancer survivors (55).
Thus, although there have been successes in cancer control
and evidence that the burden of cancer may be decreasing in the
United States, this is not a time to be complacent. Rather, it is
time to look in new directions to achieve an even greater
population impact. We must ask ourselves if we are appropriately prepared for this challenge. Is the logical next step for
research in tobacco control and dietary modification further
investment in large community and state-based trials and demonstration projects, in the conduct of more basic research, or
some combination of these alternatives (56)? What are the roles
of obesity and physical activity in cancer causation? The excitement generated by discoveries in molecular biology and
genetics is driving much of the activity in cancer research, but
how can the resulting opportunities be optimized for cancer
control? One of the first areas where the biomedical, behavioral, and social sciences may intersect is in understanding the
nature of tobacco addiction, the vulnerability of some people to
its harmful effects, and the social practices and policies that
influence tobacco use behaviors. As we learn more about the
susceptibility to tobacco addiction of persons with certain genotypes, we may be able to tailor both pharmacological and
behavioral interventions. But advances in genetics bring challenges as well. For example, too little is known about how best
to communicate information on genetic susceptibility to patients and the public. Trade-offs exist for the individual between the benefits and the potential adverse psychosocial and
economic effects of knowing one’s genetic status. Research on
cancer risk communication and informed consent is needed in
many areas, including communicating about the application of
proven methods of chemoprevention, such as the use of tamoxifen to prevent breast cancer, and about screening tests where
there is uncertainty about benefit (e.g., prostate-specific antigen, mammography for women ages 40 – 49, and hormone
replacement therapy). A stronger evidence base is needed to
define effective behavioral interventions that can lead to sun
avoidance and a reduction in skin cancer (melanoma) incidence
and mortality (57). The increasingly clear role of the human
papillomavirus, hepatitis C, hepatitis B, EBV, and other viruses, as well as the role of Helicobacter pylori, in cancer
etiology calls for effective prevention strategies and research on
the role of behavior in their transmission. There is increasing
appreciation of the association of low socioeconomic status and
relative deprivation with adverse cancer outcomes, but how
does understanding this relationship inform intervention research and public health action? The growing population of
cancer survivors, now .8.1 million (49), requires answers for
a number of questions related to decision making, treatment
preferences, quality of life, reproductive health, the risks for
second primary tumors, and social and economic threats to the
quality of their long-term survival. Finally, fundamental
changes in the way health care is delivered in the United States
offer new opportunities for behavioral research to discover how
cancer prevention and control interventions can be applied in
large, organized, and integrated health care systems.
This brief survey of the challenges still facing us has
included only a portion of the critical questions requiring answers from cancer control research. As we accept this considerable challenge, we must examine, once again, the basic tenets
of the field, including the adequacy of the current definitions
and frameworks that underpin cancer control research. It is now
time to build on the achievements of the pioneers in the field of
cancer control and look to the future.
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A New Strategy
Review and Reorganization. From 1996 through 1998, the
Cancer Control Program Review Group and the Cancer Prevention Program Review Group, which were established at the
request of the Director of the NCI, convened to examine the
cancer prevention and control program and to recommend new
directions for a research agenda and the organizational infrastructure needed to support these recommended changes (8,
58). Important societal trends were identified that will have a
major impact on cancer prevention and control at the beginning
of the next century–an aging and more diverse population, the
revolution in communications and informatics, the explosion in
the rate of discovery in molecular biology and genetics, and the
fundamental changes in our system of health care delivery. In
addition, a public health agenda for the control of tobacco use
is evolving, as well as new opportunities for health care systems, community organizations, families, and individuals to
benefit from smoking prevention and cessation interventions.
These trends collectively open up numerous new areas for
cancer control research and emphasize the need for a refined
strategy to guide us forward in efforts to further reduce the
cancer burden in this country. In part, as a consequence of the
Review Groups’ recommendations, two new extramural divisions, the Division of Cancer Prevention and the DCCPS, were
created from the previous Division of Cancer Prevention and
Control. This was the first major reorganization in the NCI’s
cancer control program since 1984, and it has important implications for the cancer control research agenda.
The formation of two new NCI Divisions and their current
rapid growth are indications of the new emphasis being placed
on cancer control. Organizationally, the Division of Cancer
Prevention is also concerned with the broad challenges of
cancer control research. However, it will focus primarily on the
biomedical aspects of prevention and, in particular, the increasing research opportunities in chemoprevention, nutrition and
cancer, cancer biomarkers, and early detection research based
on discoveries in cancer biology, drug development, and other
basic sciences.
The establishment of the new DCCPS, based on the broad
and far-reaching recommendations of the Cancer Control Review Group, has five major programmatic components in: Epidemiology and Genetics Research, Behavioral Research, Cancer Surveillance Research, and Applied Research. The Office of
Cancer Survivorship also is located in this Division because of
the importance of epidemiology, behavioral sciences, and surveillance to the needs of survivors and their providers. Central
to the mission of this Division is the emphasis on behavioral
research, although it is recognized that effective behavioral
interventions depend frequently on the application of discoveries in fundamental behavioral and biomedical sciences as well
as epidemiology; surveillance is required to identify the populations for etiological and intervention research.
The New Strategy for Cancer Control. Our new strategy
recognizes that human behavior is a major determinant of
successful cancer control. It highlights the fact that behavioral
intervention research has an underpinning in the basic sciences
that requires ongoing support and integration into the cancer
control process. Beyond that, behavioral research must be
grounded firmly in epidemiological and surveillance research
and informed by biomedical discoveries. Also, our strategy
explicitly recognizes the importance of broader social and cultural influences on cancer control. The ultimate goals of cancer
control are to reduce cancer risk, incidence, morbidity, and
mortality and to improve the quality of life through application
of research findings.
Cancer control research must address several realities that
define the nation’s current health status, and it must evolve with
the changing needs of the population. A dramatic reduction in
tobacco use is needed among both adolescents and adults in the
United States and beyond, if further advances are to be made in
reducing the burden of tobacco-related cancers. A comprehensive cancer control strategy also should increase the proportion
of Americans who follow the dietary guidelines formulated by
the NCI and other organizations to maintain their recommended
body weight, incorporate appropriate physical activity into their
daily lives, and reduce their exposure to the sun and various
infectious agents. The successful promotion of proven screening methods in breast, cervical, and colorectal cancers and their
integration across diverse healthcare systems and communities
could have a major impact in reducing mortality from these
diseases. Interdisciplinary research is needed so that individual
and family decisions about genetic testing are based on an
understanding of gene and environmental interactions and their
associated risks. The quality of life among cancer survivors can
be improved, and the probability of second cancers can be
reduced. The disproportionate burden of cancer experienced by
some minority and medically underserved segments of the
population and the influence of social inequalities on cancer
outcomes must be understood so that attempts can be made to
eliminate them.
The objective of our strategy is to foster a program that
integrates epidemiological, genetic, behavioral, and cancer surveillance research to accelerate a reduction in the cancer burden. This means describing what we know about the etiology of
cancer and the biological, behavioral, and social determinants
of cancer risk, incidence, and mortality; developing effective
behavioral interventions for reducing cancer incidence, morbidity, and mortality across all populations; improving the
quality of life of cancer survivors; and developing innovations
in methodology that will improve the way we assess cancer
control needs and the impact of interventions. The program
must be based on a sound, comprehensive surveillance strategy
that includes both cancer registration of geographically welldefined populations as well as applied research based on these
surveillance data. We view the new DCCPS as an integrated,
interdisciplinary endeavor. The interaction of the cancer control
disciplines within the divisional structure serves as a microcosm for how cancer control research can function in institutions and communities throughout the United States.
A Framework for Cancer Control. Cancer-related behaviors
are multifactorial in nature and influenced by psychosocial,
physiological, and biological factors as embodied in the biobehavioral model developed by Norman Anderson and his colleagues (59). The model was adapted to the problem of tobacco
control in a way that illustrates these relationships (Fig. 1). The
three overarching categories of factors–social, psychological,
and biological–are mediated by behavioral, neurochemical, and
physiological factors to influence behavioral end points in the
individual, including tobacco use, dependence, cessation, and
relapse. By recognizing the complexity of the determinants of
tobacco use and addressing these behavioral mediators, the
NCI’s research agenda has the potential to reduce tobaccorelated cancers dramatically (60).
In addition to our adaptation of this causal framework for
tobacco use and other behaviors, the framework adopted by the
Advisory Committee on Cancer Control of the National Cancer
Institute of Canada (61) is useful for understanding the struc-
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Fig. 1. Biobehavioral model of
nicotine addiction and tobacco-related cancers. This framework was
adapted from a more general biobehavioral model of health outcomes
developed by Norman Anderson
(59). This adaptation illustrates the
complex interplay of social, psychological, and biologic factors that interact with genetic vulnerabilities to
result in tobacco use, nicotine addiction, and cancer.
tural elements in cancer control research (Fig. 2). In this framework, cancer control research is based largely on discoveries in
basic or fundamental research that, along with epidemiological
inquiry, answer the question “What do we know?” and encompasses discovery from many health-related disciplines, including biomedical sciences, psychology, sociology, anthropology,
and economics. Intervention research builds on the evidence
base from epidemiological studies and fundamental research
and then attempts to discover effective means to apply what has
been learned at all levels of the health system and community.
It answers the question of “What works?” Although interventions are primarily behavioral in cancer control, they also can be
combined with pharmacological interventions, where appropriate, and can be sociological, legislative, or policy driven in
nature. When successful, these interventions are promoted at
the health system, community, state, and national levels, as well
as in the clinic and at the bedside. The process is iterative; the
application of these interventions generates new needs and
hypotheses for further fundamental research, including basic
biobehavioral research. Also, for applications to be effective,
research on the process of dissemination and diffusion itself,
including research on communication and informatics, is an
essential part of the cancer control research framework.
The role of surveillance of cancer control measures and
cancer outcomes is critical to cancer control and serves both to
generate hypotheses for cancer control research and to assess the
outcomes of cancer control interventions. Surveillance research
answers the question “Where are we?”, but it also helps to form the
question “Where do we need to go?”. Historically, populationbased surveillance has served more of a descriptive and hypothesis-generating function. It now must be enhanced so that it also can
clarify the connections between changes in risk factors and early
detection behaviors and cancer outcomes, as well as the influences
of the quality of health services and clinical treatment on cancer
survival, quality of life, and mortality. Surveillance research must
not only describe the cancer burden and track changes in cancer
rates; it also must explain the reasons for observed disparities and
trends in this cancer burden.
Finally, information synthesis is critical to cancer control.
Synthesis answers the question “What’s next?” and is rightfully
at the interface of all other cancer control research activities.
Much more effort is needed to synthesize what we have learned
from basic and fundamental research and epidemiology to
determine when to move forward into intervention research.
Likewise, a synthesis of intervention research results is needed
before we decide whether it is time to move to applied public
health and health services applications or whether more basic or
other pre-intervention science research is needed. As an example, numerous community-level intervention studies in breast
and cervical cancer screening have been carried out in underserved groups, but there presently is only limited understanding
of the implications of this body of research. Although there
have been selected meta-analyses (62– 64), a more comprehensive approach to synthesis is needed. Much of cancer control
practice in the behavioral area is still rooted in anecdote rather
than evidence. Future cancer control practice must be based on
a synthesis of available research findings in an effort to optimize the chances of developing successful cancer control strategies in this challenging area. Finally, synthesis is needed of the
knowledge generated by surveillance research to further form
the development of interventions and to generate new hypotheses for epidemiological and other more basic research.
New Cancer Control Research Programs. DCCPS has been
organized to meet the challenges of cancer control for the next
century. We now turn our attention to describing some selected
new directions to provide specific examples of how the NCI can
and will be supporting the research agenda in cancer control
over the next decade.4
Our understanding of the etiology of cancer in populations
is at the foundation of cancer control research and must be
integrated into the process that leads to the development of
successful interventions. Epidemiology is more than just a set
of methods for measuring associations of exposure and disease
in individuals (65). Rather, it is a multidisciplinary approach to
understanding the causes of disease in populations. Epidemiology provides a substantial component of the scientific evidence for the development of preventive, including behavioral
interventions, by explaining the contributions of biological,
psychological, and social factors to cancer etiology. For example, epidemiological studies of the interaction of genetic susceptibility markers and environmental factors will permit more
targeted screening, diagnosis, and treatment. Epidemiological
research into the type, duration, and intensity of physical activity at various stages of life, and a synthesis of the results, will
4
More current information is available at http://DCCPS.nci.nih.gov/DCCPS.
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Fig. 2. Cancer control research activities. Adapted from the 1994 Advisory
Committee on Cancer Control, National Cancer Institute of Canada (61). This
framework illustrates five categories into which all cancer control activities can
be assigned and the central role of knowledge synthesis and decision making. All
areas act through application and program delivery to reduce the cancer burden.
be needed to develop appropriate interventions to decrease the
risk of colorectal and, possibly, breast cancer (66). Epidemiological evidence linking social inequalities to adverse cancer
outcomes can be used to develop health policies to improve
prevention, early detection, and treatment services to those in
need. The new cancer control strategy will support a broadbased epidemiological program in all these areas and seek to
link results to intervention development.
We are also fostering research in cancer epidemiology with
substantial investments in resource infrastructure. Genetic epidemiology, for example, includes a network of cooperative family
registries in breast and colon cancer and another network of
centers studying individuals at high risk of cancer from inherited
susceptibility. These new mechanisms bring epidemiology closer
to the latest discoveries in the laboratory and clinic and allow us to
understand the most effective interventions for genetically susceptible individuals. We must not forget, however, that epidemiology
is fundamentally a population-based science, and it is the eventual
applications of new discoveries to populations that will have the
greatest impact in cancer control (65). Other initiatives are needed
to bring epidemiology together with behavioral and surveillance
sciences more effectively.
In the area of intervention research, we are funding basic
biobehavioral research to improve our understanding of the
mechanisms that govern cancer-related health behaviors.
Among these behaviors, recognition of the overwhelming importance of tobacco use in the etiology of major cancers must
be central to an effective cancer control strategy. A national
strategy to reduce tobacco use requires further research and
training across a spectrum of topics, from the understanding of
addiction and treatment of heavy smokers to community- and
state-level media and policy interventions. The NIH’s biobehavioral framework that was adapted to the tobacco control
problem illustrates the interrelationship of contributing factors
(60). The NCI is making major new investments in tobacco
research in each of the areas represented by this framework to
accelerate advances in our knowledge about cancer and the
development of interventions to prevent tobacco use and to help
people quit. This includes the formation of transdisciplinary
centers for tobacco control research, investments in basic
biobehavioral research to form interventions, and research on
societal factors mediated through state- and community-level
policy and media messages.
In other areas of primary prevention, we need to synthesize what has been learned from past research in diet, weight
control, and physical activity as they relate to the control of
cancer to determine “What’s next?”. The research generated by
the “5 A Day for Better Health” program has advanced our
understanding of broadscale interventions that include the simple “use five fruits and vegetables a day” message, but now new
research is needed on the determinants of dietary behavior, the
interaction of dietary behavior, weight control and physical
activity, more targeted diet-related interventions, and new
methods of dietary assessment for tracking the impact of interventions. Continued efforts are needed to reach population
subgroups at higher risk, evaluate dietary intake patterns, and
develop effective behavioral interventions.
Effective interventions are needed to encourage people to get
regular screening for cervical, breast, and colorectal cancers. New
approaches are needed to identify individuals who do not adhere to
screening recommendations and to develop interventions appropriate for them. Furthermore, research is needed to aid both individuals and providers in informed decision making for screening in
the face of uncertain evidence of efficacy. New discoveries of
biomarkers and genetic susceptibility will soon make screening
tests available that must be evaluated in clinical trials and population-based settings. Concerns about the acceptability of these
tests and adherence to them, as well as recruitment and retention
to the trials themselves, are increasingly important areas for behavioral cancer control research.
Attention to the associations of race and ethnicity with cancer-related behaviors must be conceptually broadened to include
considerations of the influence of socioeconomic class, immigrant
status, culture, discrimination, and health care access on cancer
outcomes (55, 67). These “upstream” influences on health behaviors may have powerful influences on cancer incidence and outcomes at a societal level because of their ubiquitous application to
large segments of the population (68, 69). The new discoveries in
molecular biology that have more limited application to high-risk
populations may have dramatic impact for the individual but less
at a societal level, yet they require our concerted attention. We will
support new initiatives on the social and cultural influences in
cancer outcomes simultaneously with our parallel emphasis on
biomedical innovations.
Within the new structure for cancer control research, we
now have the opportunity to harness the informatics and communication revolution to improve cancer outcomes. Innovative
forms of health communication include, for example, tailored
print communications, interactive kiosks, CD-roms, and an
ever-growing array of new technologies. Increasingly, in an era
of mass customization, these tailored strategies allow cancer
control scientists to individualize and personalize cancer control messages and to offer people choices about the kinds of
information they want and need. To date, the evidence of
effectiveness in this area is very promising (70, 71).
A program is being built in cancer survivorship to conduct
research on the identification, prevention, treatment, and care of
the broad spectrum of conditions experienced by cancer survivors.
The Office of Cancer Survivorship has the mandate to foster new
research programs that recognize the unique needs of individuals
who have been treated for cancer and who face many unanswered
questions during an increasingly long period of survivorship. The
cancer survivorship program will build on the opportunities provided by the associated programs in epidemiology, behavioral
research, and surveillance while working closely with the cancer
survivor and cancer advocacy communities. It will seek to under-
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Cancer Epidemiology, Biomarkers & Prevention
stand risk factors for recurrence, enhancements to the quality of
life, the role of the family in survivorship, and the prevention of
second malignancies and the sequelae of cancer treatment. Finally,
the survivorship research program will include health services
studies of the impact of the cancer diagnosis on the ability of
survivors to obtain health insurance and be productive members of
the work force.
The current surveillance research program at the NCI, which
includes the SEER program and other related applied research
activities, is the standard for high-quality cancer surveillance. This
program has developed the statistical and methodological data
resources that enable a more definitive interpretation of cancer
patterns and trends. Although cancer surveillance describes the
cancer burden in this country admirably, it must be better able to
explain the reasons for trends in the burden. As we expand the
scope of cancer surveillance, new tools must be developed, and the
SEER system must be connected to other data collection systems.
Together these will help us understand cancer trends and, ultimately, the causes of cancer in defined populations. With the focus
on population-based systems in cancer registration, from SEER
programs or other high-quality cancer registries, additional data
collection from cancer patients themselves needs to be supported
to advance our knowledge about the outcomes of cancer treatments, including the quality of care and quality-of-life assessment.
In addition, in these defined populations, innovative ways to connect risk factor and screening data to cancer outcomes need to be
developed to better understand the link between population level
changes in the determinants of cancer and these cancer outcomes.
Sound methodological research to develop standardized, reliable,
and accurate measures will be central to future progress. Further
research will be expanded in statistical methods and modeling to
provide quantitative estimates of the effects of recommendations,
interventions, or population trends. This research expansion has
particular value in answering questions that cannot be resolved by
existing data. SEER and other high-quality cancer registries can
also extend their traditional role in providing information and
subjects for epidemiological studies by the wider application of
rapid case ascertainment systems and by collecting biospecimens
for genetic epidemiological studies. New infrastructure supporting
cancer research in a network of large, established health maintenance organizations provides an opportunity for expanded health
services and outcomes research. Finally, to fully exploit the opportunities that are offered by the expanding area of cancer surveillance research, training opportunities need to be developed for
new investigators at the NCI as well as at academic centers around
the country.
Need for Partnerships to Put Research into Action
The nation’s goals for cancer control will not be readily achieved
without the collaboration of the multiple agencies and organizations concerned with the control of cancer. There already is a
functioning network of organizations and individuals deeply committed to cancer control in this country, each with their own
purposes and objectives. This enterprise has many partners, and we
will name only a few. They include other federal agencies, such as
the CDC, the Agency for Health Care Policy and Research (72),
and the Health Care Financing Administration; voluntary organizations, such as the ACS; foundations, such as the Robert Wood
Johnson Foundation; and numerous professional associations including the American College of Surgeons, the American Society
for Preventive Oncology, the American College of Radiology, the
American Society for Clinical Oncology, the American Association for Cancer Research, and the Society for Behavioral Medicine. Collaborations with these partners take several forms, includ-
ing the development of research infrastructure (e.g., the linkage of
the SEER and Medicare databases with Health Care Financing
Administration); programs to disseminate proven interventions
(e.g., collaborative efforts by the CDC and the ACS that include
the American Stop Smoking Intervention Study and the “5 A Day
Program”); and planning efforts (e.g., NCI’s coordination with the
North American Council of Central Cancer Registries, CDC,
American College of Surgeons, and ACS to develop a national
cancer surveillance program). The ACS and the NCI also have
jointly sponsored major research programs and complement each
other in the dissemination of cancer information to health care
professionals and the public. A vital training and educational
function is shared by the NCI and many professional organizations.
The basic premise of cancer control requires the “useful
application of results” of cancer research (12). If we are to
achieve a real impact on the cancer burden across the United
States, the results of the cancer control research that NCI and
other agencies support must be applied in programs that have
wide-scale acceptance by states, localities, and health care
systems. The interdisciplinary nature of the cancer control
research endeavor is clear, as evidenced by the variety of
strategies that we need to pursue. Scientists from diverse fields
of biomedical research must effectively interact with behavioral
scientists within the public health model if we are to make
further advances in reducing the cancer burden on a broad scale.
We now appear to have cancer on the run. The challenge before
us is to use this new strategy for cancer control research to
sustain a long-term and accelerated decline in the threat posed
by this dreaded disease.
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A New Strategy for Cancer Control Research
Robert A. Hiatt and Barbara K. Rimer
Cancer Epidemiol Biomarkers Prev 1999;8:957-964.
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