Community Health
Management
on
Cancer
July, 1999
Jerry Allison, Jennifer
Florendo, Rebecca Martillan, Cynthia Perez, Irma Sedanto
BCCM Year Level II
Dr. Charina Rebanco and Dr.
Reynaldo O. Joson
Facilitators
Legazpi City, Albay,
Philippines
Text
Introduction
In the United States cancer is the third leading cause of death below cardiovascular and respiratory diseases, and its incidence is still rising. In developing countries, the death rates from cancer are also increasing. This is particularly true in areas where the morbidity and mortality from communicable diseases is on the decline. Although it is proven that certain behaviors can reduce the risk of cancer, there is no absolute way to guarantee a cancer free life. However, by recognizing and modifying our behavior as individuals and as a group we may be able to reduce the morbidity and mortality from cancer for our families, our communities, and ourselves.
Purpose
The purpose of Community Health Management is to develop a primary health care approach that will use community involvement, linkages, indigenous resources, and local support systems to provide primary and secondary cancer prevention programs. Such programs will incorporate individual awareness, behavior modification, and environmental change strategies to achieve their goals.
Goals
The goals in a Community Health Management program should include:
Objectives
Strategies
Specific Cancer Prevention Programs:
Smoking Cessation and Smoking Prevention:
Diseases related to cigarette smoking represent a twentieth-century epidemic, now spreading globally. Smoking is the primary cause of cancer of the lungs, larynx, oral cavity, and esophagus (approximately 10-20 times the risk compared with non-smokers) and contributory to cancers of the pancreas, bladder, kidney, stomach, and cervix and to leukemia (about 2 times the risk). Smoking acts synergistically with chemical and radiation carcinogens in the lung and with alcohol in the esophagus in the oral cavity. Former smokers, after a lag of up to four years, show a progressively lower relative risk compared with continuing smokers and even compared with the slowly rising rate as never-smokers age. However, the absolute risk of lung cancer probably never declines, in sharp contrast to coronary heart disease endpoints. Low-tar, low-nicotine, and filtered cigarettes have had little or no protective effect, because the smokers tend to inhale more deeply and more frequently.
Smoking Cessation:
A huge literature attests to the difficulty of helping smokers quit. About 5% "quit" by themselves (for at least a six-month period) each year, but others relapse. Physicians play a key role in urging smokers to quit and in guiding them to self-help materials, classes, or pharmacologic quitting aids. Worksite, family, and community reinforcement are essential; increased taxes on tobacco products reinforce as well. Prevention of smoking, especially in young people, minorities, and women, can be enhanced by organized community and school programs as well as regulatory actions.
Moderation of Alcohol Intake:
The National Cancer Institute Dietary Guidelines recommended that consumption of alcoholic beverages, if any, should be moderate. Alcohol intake is highly associated with cancers of the esophagus, oral cavity, pharynx, and larynx, and less strikingly with liver, rectal, pancreatic, and breast cancer. It acts synergistically with cigarette smoking.
Diet:
Guidelines for healthy diets strongly recommend decreases in fat and increases in fiber intake, most easily described as "five-a-day" fruits and vegetable portions. Such advice aims at preventing cancers, heart disease, and bowel disorders, too. The typical US diet has 39% of calories from fat or about 150 grams/day. Dietary fat intake correlates positively with incidence and mortality rates of breast, prostate, and colon cancers. International, migrant, and time-trend data indicate that reduction in dietary fat to 20% of caloric intake would reduce breast cancer risk by 2/3. Unfortunately, most case-control (retrospective and cohort) prospective epidemiological studies have found less striking correlations or none at all. Similar inconsistencies underlie positive associations of fat intake with colorectal and prostate cancers. Fat intake involves many variables, including percentage of calories, grams per day, saturated vs. unsaturated and fatty acids, overweight and duration of diet. Each type of cancer possesses other confounding or interacting risk factors. Experimentally studies in rodents show that dietary fat may exert tumor-enhancing or -promoting effects on the breast directly through changes in cell membranes or indirectly through neuroendocrine systems. In the colon, fat may influence bile acids, sterol substrates, and fecal microflora.
Increased Physical Activity:
Overcoming sedentary or inactive lifestyles benefits cardiovascular, respiratory, muscular, cognitive, and metabolic systems. Increased physical activity seems to offer significant protection against colon cancer.
Reduction in Exposures to Environmental Carcinogenic Chemicals:
Asbestos fibers, inorganic arsenic compounds, bis-chloromethyl ether, chromium compounds, mustard gas, nickel dusts, and polycyclic aromatic hydrocarbons from coal and gasoline combustion are lung carcinogens; vinyl, chloride causes a distinctive angiosarcoma of the liver; some pesticides are associated with the development of non-Hodgkin's Lymphoma; aromatic amine dyestuffs can cause bladder cancer; leather production and isopropyl alcohol manufacturing are associated with nasal cancers; and benzene can cause acute myelocytic leukemia. Tobacco is the most prevalent chemical carcinogen, possibly followed by charbroiling of meats and fish.
Physical Agents:
Ultraviolet radiation is the primary cause of skin cancers, including melanoma and lip cancer. Ionizing radiation, including radiotherapy increases rates at essentially all exposed sites. Non-ionizing radiation and electromagnetic fields have been suspected of increasing leukemia and brain cancer and possibly breast cancer rates, but the data are not consistent and the relationship is far from demonstrated.
Drugs:
Alkylating agents can cause leukemias; androgen anabolic steroids, liver cancer; chlornaphazine, bladder cancer; estrogens (1) (possibly also "environmental estrogens"), cancers of the vagina and cervix (diethylstilbestrol (2)), endometrium (postmenopausal estrogens), or liver and cervix (steroid contraceptives); azathioprine (3) and cyclosporine (4) immunosuppressants, non-Hodgkin's lymphoma; and phenacetin-containing analgesics, renal pelvic tumors.
Summary
Primary prevention programs would be the ideal mechanism to prevent morbidity and mortality from cancers. These types of programs may be extremely difficult because they require awareness, which is the easiest to provide but the least effective; behavior modification which is the most effective and most difficult to achieve; and environmental change which is effective but generally costly. Behavior modification may be difficult to achieve because of denial of the risk of the problem. Environmental change may be difficult because of the economic impact.
Secondary programs do not prevent cancer. These programs are designed to detect cancers at their earliest stages so that effective treatment may reduce long term morbidity and mortality. Most secondary prevention programs are accessible, available, and affordable. However, this still requires cooperation from the community and the health care system.
In many of the communities in the Philippines, even if we were able to implement successful secondary prevention programs, many of the patients would not be able to afford the healthcare cost associated with treating their cancers. Without a doubt, primary prevention is the best approach for reducing morbidity and mortality and lessening the economic burden on the health care system.
Primary prevention must be implemented at the community level and the community must take responsibility for its success. It is the responsibility of the community, In cooperation with the health care system, to assess the cancer situation, identify goals, implement programs, and evaluate the results of the programs. This process must be done through community involvement, use of existing and new linkages, use of indigenous resources, and use of existing and new support systems. It is not until we embrace this concept that we will truly see a decline in the morbidity and mortality of cancer and other community diseases.
BCCM Directory of Community Health Management Plans