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1998-1999 Annual Report Commonwealth of Pennsylvania cancer control program Message from the Secretary I am pleased to present the 1998-99 State Fiscal Year Annual Report of the Pennsylvania Department of Health’s Cancer Control Program. This Report highlights initiatives the Department has undertaken in the areas of breast, cervical, lung, prostate, skin, and colorectal cancers. • Funding of prostate cancer studies, The fact that the numbers of both newly diagnosed cases of cancer and cancer deaths are dropping is a tribute to all the organizations involved in cancer control and research. We must continue our collective efforts and explore every opportunity for further progress. Here in Pennsylvania some of our successful initiatives include: services initiated through our statewide HealthyWoman Project. • Eleven researchers funded by Pennsylvania’s Breast and Cervical Cancer Income Tax Checkoff Option are working on cutting-edge research to reduce the burden of cancer. • Continuing commitment to educate the public regarding the importance of breast and cervical cancer screening, with expanded media efforts to include skin cancer awareness. • 271,553 hits since 1995 at the Helping People Cope: A Guide for Families Facing Cancer website at www.oncolink.upenn.edu/ psychosocial/books/cope • Ongoing promotion of Operation Hat Check, the Cancer Prevention and Control Program’s skin cancer initiative designed to promote sunprotective hats. • Skin cancer awareness activities continued in all state-funded immunization clinics. 1 the promotion of colorectal cancer screening, initiation of a worksite cancer screening demonstration project, and support for youth and adult tobacco cessation. • Breast and cervical cancer screening Nationally, Governor Tom Ridge is playing a prominent role in the National Dialogue on Cancer (NDC). He is leading an NDC initiative through the National Governors’ Association to facilitate the sharing of cancer prevention, education, research, and early detection best-practice models among the states. You can learn more about the National Dialogue on Cancer by visiting its website at www.ndoc.org. We are very proud of the successes of the Cancer Control Program and hope you enjoy reading about these initiatives. We invite you to learn more about the Department and its programs by calling 1-877-PA-HEALTH or visiting the Department of Health website at www.health.state.pa.us. Robert S. Zimmerman, Jr. Secretary of Health Chair’s Message Every day we learn more about cancer as scientists continue to unravel the complexities of this disease. As we approach the end of the decade and prepare to face the challenges of the new millennium, it is clear that Pennsylvania will continue to be a leader among states in the fight against cancer. For two decades, the Pennsylvania Department of Health Cancer Control Program has been developing cutting-edge initiatives to address the needs of Pennsylvanians. The initiatives that you will read about in this Annual Report exemplify how we have mobilized energy and resources to make measurable health improvements in Pennsylvania. The Board and I look forward to working with Governor Ridge, the American Cancer Society and the National Governors' Association to develop a National Dialogue on Cancer. With Governor Ridge's leadership, we will set the tone for an effective cancer control agenda for the state and the nation. I am confident that through our continued commitment we will make a difference in the lives of Pennsylvanians. Let us all continue to do our part in the fight against cancer. Mary Simmonds, M.D. Chair Pennsylvania Cancer Control, Prevention and Research Advisory Board 2 More than 40,000 Pennsylvanians used the breast and cervical cancer research line on their income tax returns in 1997, donating over $280,000 for breast and cervical cancer research. In 1997, Governor Tom Ridge signed Act 7, which enabled individuals to contribute to breast and cervical cancer research by either donating a portion of their state refund or contributing directly to the Department of Health. Because of Pennsylvania taxpayers' generosity, 11 cancer researchers received funding to fight these deadly diseases. "Breast and cervical cancer remain major threats to the lives and health of women in Pennsylvania and to the wellbeing of their families and friends," said Pennsylvania First Lady Michele Ridge at a news conference with the Governor to announce the grant recipients. "That's why so many concerned citizens work to educate the public about early detection and treatment of cancer, and why the importance of cancer research cannot be emphasized enough." State Distributes Funds for Breast and Cervical Cancer Research Microtubule-Stabilizing Agent (+)Discodermolide as an Anti-Breast Cancer Agent Kent W. Hunter, Ph.D., Fox Chase Cancer Center, Genetic Mapping of a Putative Mammary Tumor Susceptibility Gene in a Mouse Model Abass Alavi, M.D., University of Pennsylvania, Imaging Breast Cancer with a Dedicated Positron Emission Tomography Instrument Michael Cascio, Ph.D., University of Pittsburgh, Molecular Basis of TCRMucin Interaction Phouthone Keohavong, Ph.D., University of Pittsburgh, p53 Mutations as Biomarkers for Breast Cancer: The Topographic Genotyping of Fixative Breast cancer is the leading cancer diagnosed among Pennsylvania women. More than 10,700 women were diagnosed with breast cancer in 1996. The first income tax checkoff grant recipients are: Isabella Verdinelli, Ph.D., Carnegie Mellon, Department of Statistics, Beyesian Procedures for Breast Cancer Clinical Trials Raghbir S. Athwal, Ph.D., Temple University School of Medicine, Cloning and Characterization of a Cellular Senescence Gene for Breast Cancer Jean J. Latimer, Ph.D., MageeWomens Research Institute/MageeWomens Hospital, DNA Repair and Somatic Mutation in Breast Cancer Victor Vogel, M.D., University of Pittsburgh, Effect of the Selective Estrogen Response Modulator Raloxifene on MRI Density of the Breast in Premenopausal Women Billy W. Day, Ph.D., University of Pittsburgh, Evaluation of the Novel 3 Treated Breast Biopsy Specimens Hannah Rabinowich, Ph.D., University of Pittsburgh, Regulation of Death and Survival of Lymphocytes in the Presence of Fas Ligand-Expressing Breast Carcinoma Cells Michael F. Verderame, Ph.D., Pennsylvania State University College of Medicine, The Role of the Protein Tyrosine Kinase pp60c-src in Breast Cancer Progression to Estrogen Independence Pictured at the Income Tax Checkoff Grant Awards Press Conference at the Fox Chase Cancer Center are Governor and Mrs. Ridge,grant recipients, and other dignitaries. State Supports Community-based Tobacco Prevention Coalitions More than 22,000 Pennsylvanians die from tobacco-related diseases each year, causing tremendous emotional toll on individuals and families and creating an enormous drain on the Commonwealth's medical and health resources. To combat tobacco use and treat tobacco related illness, the Commonwealth has invested in state tobacco prevention and control programs that are comprehensive and make use of community partnerships. In January 1997, the Pennsylvania Department of Health granted a $2.8 million, five-year contract to the American Cancer Society, Commonwealth Division, to establish the Pennsylvania Tobacco Prevention Network. The Network organizes and supports statewide, community-based tobacco use prevention and control coalitions. Composed of youth and adult volunteers, the coalitions work to reduce the impact of tobacco use in their communities through youth and adult networks. Network support of these coalitions includes mini- (less than $5,000) and maxi- ($5,000 - $20,000) grants to address the issues of clean indoor air (such as secondhand tobacco smoke), youth access to tobacco products, medical and other advocacy issues, travel, school, and sports programs for youth, and training. Currently, there are 60 community-based tobacco use prevention coalitions in the Commonwealth. Initially, the Network awarded over 100 mini- and ten maxi-grants totaling $462,897. An additional ten maxi-grants totaling over $174,000 were awarded for clean indoor air and counter tobacco advertising. The Network also hosted a statewide youth conference attended by over 450 youth and adults and collaborated with STAT (Stop Teenage Addiction to Tobacco), a nationally recognized advocacy training organization, for the delivery of three community workshops. In addition to facilitating ten regional coalition meetings and workshops, the Network developed an alternative sponsorship program so that Pennsylvania's 4-H program would not have to accept tobacco industry financial support. Approximately $100,000 is also available to the state's Cooperative Extension agents through this effort. Department Funds New Tobacco Initiatives Working with local and regional partners is one of the most effective ways that the Department of Health reaches the public about the dangers of cigarette smoking. In Pennsylvania, 24% of those age 18 and older smoke cigarettes. Almost 30% of high school seniors, 18% of ninth-graders, 7% of seventhgraders, and 2% of sixth-graders reported that they smoke at least one cigarette every day. The Department of Health recently awarded contracts to two community partners to prevent and reduce addiction to tobacco. The Health Promotion Council of Southeastern Pennsylvania, Inc., received a three-year contract to implement an intensive smoking cessation program in Delaware County targeting youth and adults. Specific goals are to develop, implement, and evaluate a recruitment strategy to encourage youth and adults to enroll in smoking cessation programs. The effort will also include tobacco-cessation programs for youth, strategies for maintenance of tobacco use cessation, and a system for physicians' offices to initiate conversations with smoking clients to encourage them to quit. The Coalition for a Smoke-Free Valley, through Lehigh Valley Hospital, also received a three-year contract for a variety of approaches to help persons who use tobacco break their addiction. These include: • • • • • Providing youth cessation and prevention initiatives Instituting adult intervention/professional education and consultation services Promoting smoke-free policies in the workplace and public venues Promoting local tobacco addiction services Collecting, analyzing, and disseminating tobacco-use related data and information State Looks at the Cost of Smoking The availability of timely, accurate, and useful information is a key factor in planning and implementing public health projects. Data collection permits a broad assessment of local health status as well as the development of community priorities and partnerships with the Department of Health. During the past fiscal year, the Department's Bureau of Chronic Diseases and Injury Prevention funded the Pennsylvania State Data Center to gather information illustrating the health and economic costs of smoking for the people of Pennsylvania. The project was conducted in three phases. In phase one, the Data Center surveyed 850 people. Phase two included a report on the health and economic costs of smoking at the state level and fact sheets on the health and economic costs of smoking at the county level. The final phase focused on a report on the health and economic costs of smoking by Pennsylvania state legislative district. This effort required the careful development of a plan for data collection and sharing, which recognizes and supports both the need for a core of comparable data and the need for communities to have flexibility in their ability to collect and study data. The Department is currently analyzing the data for planning future initiatives. The data will also be made available to government programs and community partnerships. 4 Program Provides Free Breast and Cervical Cancer Screening Year Round PAP Testing in STD Clinics Targets High-Risk Women The Cancer Control Program has participated in the National Breast and Cervical Cancer Early Detection Project since 1994. Administered by the Centers for Disease Control and Prevention, this project was established to provide needed breast and cervical cancer screening services to women who were unable to access such services because of inability to pay for the services. The Cancer Control Program has a long history of supporting efforts to reach Pennsylvania's underserved populations through effective public health programs. As a part of this effort, the Program provides funding to the Department's Sexually Transmitted Disease (STD) Program for Pap testing of high-risk women. pelvic examinations, and Pap tests. Procedures such as ultrasound and colposcopy are also covered. Through nine major service providers with over 200 screening sites, more than 8,000 women received potentially life-saving cancer screening tests through the HealthyWoman Project during this past year. Now in its sixth year of funding, the Commonwealth's HealthyWoman Project provides breast and cervical cancer screening services to women 40 to 64 years of age with no or limited insurance and low-to-moderate incomes. Services include clinical breast examinations, mammograms, breast self-examination education, State Monitoring Former Employees of the Drake Chemical Company Since 1994, the Cancer Control Program has funded the Drake Health Registry Study, an important preventive public health project that monitors former employees of a small chemical manufacturing plant in Lock Haven, Pennsylvania. The Drake Health Registry provides free notification, screening, and diagnostic services to detect early signs of bladder cancer in 407 workers who are at high risk for bladder cancer because of possible past exposures to certain chemicals at the plant. The Registry maintains a database that provides epidemiological analysis of morbidity and mortality among the workers, who were 5 employed by the now defunct Drake Chemical Company and its predecessor, the Kilsdonk Company. To date, the Drake Health Registry has identified seven men diagnosed with bladder cancer. Since the former employees are aging and many are approaching the 20-year period for developing bladder cancer, this is a critical period for monitoring. Most of the workers still live within a 50-mile radius of Lock Haven. Funding for this study is expected to continue for at least two additional years. According to a 1997 survey to determine the behavioral health risks of Pennsylvania adults, women with less education and lower incomes were significantly less likely to have had Pap tests. Although all sexually active women are at risk for cervical cancer, the disease is more common among women of low socioeconomic status, those with a history of multiple sex partners or early onset of sexual intercourse, and smokers. Many of the women who use these free, confidential STD clinics have had multiple sexual partners or sexually transmitted infections, making them an extremely important population to target for cervical cancer screening. In 1998, 47 of the 82 STD clinics in the state participated in cervical cancer screening. These clinics saw a total of 17,309 women, and 2,537 (14.7%) received Pap tests. These numbers represent a modest but noticeable increase over the past year. By reaching more women in this underserved population, the Department aims to increase awareness about the importance of Pap testing and, as a result, compliance with recommendations for screening. Facing Breast Cancer In Pennsylvania The Pennsylvania Department of Health fosters education as part of its goal to prevent and ultimately eradicate breast cancer in Pennsylvania. With these goals in mind, the Department-through the Pennsylvania Breast Cancer Coalition-sponsors the traveling photo exhibit "67 Women - 67 Counties: Facing Breast Cancer In Pennsylvania." The exhibit provides an excellent focal point around which to organize regional education and information forums, celebrating and recognizing the life, courage, hope, and dignity of women living with breast cancer in Pennsylvania. This touching tribute provides a reminder of the emotional and physical toll of breast cancer on women and their families and features at least one woman from each county, including women of all ages, races, and backgrounds. Currently in its fifth year of touring, the exhibit has been displayed in nearly 30 communities. In the 1998-1999 fiscal year, the exhibit was displayed in the following counties: Allegheny, Clearfield, Philadelphia, Luzerne, Snyder, Blair, and Armstrong. 6 The Great Solar Survival Test Through multi-faceted community education campaigns, the Department is raising Pennsylvania's awareness about the need for sun protection year round. The sun is a contributing factor in approximately 90% of all skin cancers, which is the most common form of cancer in the United States. An estimated one million cases of skin cancer will be diagnosed in the United States in 1999. The following programs are part of the Department's goal of educating the public about the risks for skin cancer. Media Campaign The Department's Cancer Control Program is developing a skin cancer media campaign to increase awareness of risk factors for skin cancer and to help people pass "The Great Solar Survival Test." The "Test" is a way of reminding the public about what they can do to protect their skin from the damaging rays of the sun. Tips include using sunscreen, seeking shade from 10 a.m. to 4 p.m., and wearing sun-protective hats, sunglasses, and clothing. 7 Operation Hat Check Now in its second year, Operation Hat Check focuses on promoting the use of specially-designed hats to protect the face, ears, and back of the neck from sun exposure to individuals who spend significant time outdoors due to work or other activities. More than 10,000 hats, sunscreen, and lip balm are distributed every year to individuals who work or spend a significant amount of time outdoors. Individuals also receive educational materials about additional ways to protect themselves from the sun's harmful rays. Immunization Clinics In December 1998, the Department expanded its skin cancer initiative statewide to all statefunded immunization clinics. A skin cancer awareness questionnaire is completed by a parent or adult who brings the child in for immunizations. Clinic staff reviews the responses and provides educational material to the parent. At a subsequent visit, the adult completes a post-test evaluation to determine how much information has been retained and utilized. More than 3,500 surveys are being analyzed. Grade Schools and Day Care Centers It is a well-known fact that most damage to the skin occurs by the time a person reaches 18 years of age. As a result, the Department has contracted with the University of Pittsburgh Cancer Institute to develop skin cancer modules for use in elementary schools (kindergarten through sixth grade) and for presentations to groups of young adults in a variety of settings. Day Care Centers As part of the Department's skin cancer initiative targeting children, their parents, and caregivers, the Department surveyed all 3,048 state-certified day care centers in the state to determine baseline information on sun safe knowledge and behaviors. An excellent return rate of over 60% should provide important information about protecting children from the sun to child-care groups. The University of Pittsburgh is currently analyzing the survey results. A summary report will be provided to the day care centers to help them make their facility more "sun safe." County and Municipal Health Departments Nine of Pennsylvania's county and municipal health departments are under contract to the Department to conduct a variety of skin and colorectal cancer programs, replicating many of those developed by the Department. The wide-ranging efforts include educational programs and media campaigns to improve public awareness, knowledge, and attitudes about risk factors for skin and colorectal cancers, with a special emphasis on those at high risk. The Allentown Health Bureau conducted an educational program with 36 lifeguards employed by the city's Recreation Department to stress the importance of sunscreen, hats, sunglasses, shade, and clothing to help protect their skin. Bucks County Department of Health is using a puppet show with preschool children to teach them about the benefits and dangers of the sun. Rose Marie McDaid, age five months and 20 days, shows off the first Infant Sun Awareness Promotion Hat at the Forest County State Health Center. Lending a helping hand is her grandfather, retired Bill McDaid of Tionesta. 8 Twelve Years of Cancer Data Now Available Cancer Incidence Data The Pennsylvania Cancer Registry (PCR) now has 12 years of cancer incidence data. State-specific incidence and mortality data are published annually in the Pennsylvania Cancer Incidence and Mortality report, which includes the most recent five years of data. Data from this and other statistical reports are available on the Department of Health's web site at www.health.state.pa.us/hpa/Stats/stat_ res.htm. Requests for additional cancer data should be directed to: Director, Division of Health Statistics, Pennsylvania Department of Health, 555 Walnut Street, 6th Floor, Harrisburg, PA 17101-1900, or call (717) 783-2548. The National Program of Cancer Registries The PCR has participated in the National Program of Cancer Registries (NPCR) since 1994. Administered by the Centers for Disease Control and Prevention (CDC), the NPCR was established by Congress to promote statewide, population-based registries that collect uniform data elements in a standardized format and meet national standards for completeness, timeliness, and quality. Through combined efforts of the PCR and reporting facilities, Pennsylvania has made significant progress in meeting NPCR goals. PCR Activities and Accomplishments The PCR conforms to recognized national cancer registry data standards by collecting all recommended data items and using established codes, definitions, and record layouts for transmitting and accepting cancer data. Completeness calculations reveal the PCR is 97.8% complete for 1995 data. Cancer is reported by all 9 acute-care hospitals in the Commonwealth. PCR staff led the development of an electronic system for reporting by private pathology laboratories. This system is used for reporting by two major laboratories in Pennsylvania with implementation in the remaining laboratories anticipated by July 2000. Efforts are underway to adopt this electronic system as a national standard for laboratory reporting to central cancer registries. The PCR employs eight certified tumor registrars to collect, process, and insure the quality of cancer data collected and to perform case finding and re-abstracting audits at reporting facilities. Eighty percent of PCR cases are reported electronically. Software for the remaining 20% is being developed in conjunction with the CDC; hospital implementation is to begin in July 1999. The PCR is currently providing assistance to the CDC in the development of Registry Plus, a PCbased central cancer registry computer system to be implemented by the PCR over the coming year. PCR staff is also involved in developing a module to automate tumor linkage consolidation functions for incorporation into Registry Plus. This system will increase data editing capabilities by incorporating all recommended edits and associated data fields and will facilitate more timely processing of cancer cases and production of incidence statistics. Department Funds New Research Projects The Department of Health supports research that addresses some of Pennsylvania's most pressing health problems. The following are new studies funded by the Department of Health through the Cancer Control Program. Prostate Cancer Prostate cancer is the most common type of cancer diagnosed among Pennsylvania men. One in five American men will contract prostate cancer, which kills nearly 40,000 Americans each year. The Cancer Control Program has awarded the University of Pittsburgh a contract to use data to develop and evaluate methods for monitoring medical care factors related to prostate cancer detection and treatment. The study will gather data on prostate cancer occurrence rates and survival, study causes of death after prostate cancer diagnosis, and determine prostatectomy occurrence rates and hospital mortality after radical prostatectomy. The investigation will also survey 600 men (60-79 years old) with localized prostate cancer and ask about information received at time of diagnosis, treatment selected, and health-related quality-of-life outcomes. Survey results will shed light on the extent to which prostate cancer survivors recall receiving the information needed to make informed decisions about treatment. Other expected outcomes include identifying areas of large occurrence where the Cancer Control Program may direct specific interventions. The Cancer Control Program funds two prostate cancer studies at the Fox Chase Cancer Center. The first study will establish a Prostate Cancer Risk Registry, which offers a wide range of services, including the opportunity to investigate areas of controversy surrounding prostate cancer screening risks and benefits. The multifaceted study includes recruiting high-risk individuals for the Registry, establishing and expanding the computerized database system, identifying hereditary patterns of prostate cancer, and developing educational tools for primary care physicians at the community and public health level. Registry services will include risk analysis, screening, DNA testing, and assistance with treatment decision making. The second study will look at patients diagnosed with earlystage prostate cancer to determine factors affecting treatment decision making and sources of information to make decisions. The goal is to develop written materials and design an intervention which facilitates decision making and to help inform primary care urologists about the informational and psychological needs of newly diagnosed patients. Colorectal Cancer Colorectal cancer affects men and women equally and is the third leading cancer in Pennsylvania. Nearly 10,000 cases of colorectal cancer occur in Pennsylvania per year with more than 3,500 deaths each year. Through a contract with the Department of Health, the University of Pittsburgh will test the feasibility of promoting flexible sigmoidoscopy as a screening procedure for colorectal cancer on a community-wide scale. Data will focus on screening outcomes, including compliance with colorectal cancer screening recommendations, identity of providers, and satisfaction with screening flexible sigmoidoscopy. Worksite Cancer Education The Department of Health has awarded the Fox Chase Cancer Center a contract to improve employee participation in cancer education and screening and to modify behavioral risk for many types of cancer. The study will develop a series of worksite educational and screening programs; it also includes an annual analysis to determine changes in employee use of screening. Pennsylvania Cancer Control, Prevention and Research Advisory Board Membership Mary Simmonds, MD, Chairperson Rodrigue Mortel, MD Robert S. Zimmerman, Jr., Secretary of Health Michael Rackover, PA-C, MS Judith Baillis Samuel Bruner Karen Robinson, RN, MN Christine Szarka, MD Joyce Wilhelm, RN, MSN Julia Bucher, RN, PhD Patricia Halpin-Murphy 10 1998-99 Cancer Control {Program Funding Pennsylvania Department of Health (state funds) Centers for Disease Control and Prevention (federal funds) Contracts and grants Personnel/Operating Special Initiatives Breast and Cervical Cancer Research Breast and Cervical Cancer Early Detection Prevent Block Grant $ 3,595,000 $ 2,162,000 $ 2,000,000 $ 272,937 $ 3,275,000 $ 303,000 Fiscal Year 1998-1999 Contracts American Cancer Society $ 221,774 University of Pittsburgh Bucks County Health Department $ 48,000 Erie County Health Department $ 24,330 Skin cancer initiative $ 236,246 Montgomery County Health Department $ 37,797 Drake bladder screening $ 149,603 Philadelphia Department of Public Health $ 91,922 Wilkes-Barre City Health Department $ 27,794 $ 23,000 Annual report $ 8,000 Special contract $600,000 York City Bureau of Health Prostate and colorectal studies $ 402,350 Fox Chase Cancer Center Breast cancer research projects $ 124,964 Breast cancer research project Pennsylvania State University PA Cancer Pain Initiative Special contract Breast cancer research project $ 84,523 $ 600,000 $ 25,000 University of Pennsylvania Census/registry analysis Special contract Breast cancer research project Northeast Regional Cancer Institute $ 25,970 $ 600,000 $ 24,924 $ 200,000 Thomas Jefferson University Special contract Pap testing in STD clinics Jeanes Hospital $ 500,000 $ 45,900 $ 500,000 Allentown Health Bureau $ 21,166 Bethelem Health Bureau $ 23,000 11 Two prostate cancer projects; one work site $ 716,902 $ 23,049 Lehigh Valley Hospital/Coalition for a Smoke-Free Valley $ 125,000 Health Promotion Council of Southeastern PA $ 117,981 Allegheny University of the Health Sciences $ 100,000 The Neiman Group $ 600,000 The Pennsylvania Breast Cancer Coalition $ 80,835 Penn State Data Center $ 64,226 Magee-Womens Research Institute $ 25,000 Carnegie Mellon University $25,000 Temple University School of Medicine $25,000