Chapter Objectives

• Identify leading modifiable risk factors for certain cancers
• Identify leading causes of cancer cases by site
• Identify leading causes of cancer deaths by site
• Comprehend the role of genetic screening in cancer diagnosis
• Summarize recommended cancer screenings by age group
• Comprehend leading health disparities related to cancer
• Comprehend how cancer is staged
• Recognize the role of the community health worker in public health initiatives for cancer screening
• Explain how the Affordable Care Act impacted cancer detection
• Discuss primary and secondary prevention for leading causes of cancer

INTroduction

Cancer is essentially a disease of the body cells. Humans are made-up of trillions of cells. Cells that have like characteristics combine to become tissues. Most of the time these cells are healthy and pose no risk to us. Some cells, however, including cancer cells, are unique in that they lack contact inhibition.

There are a few terms that are synonymous with abnormal cell growth. A neoplasm or tumor refer to a mass of cells with no physiological function. Typically, a neoplasm is not anything life-threatening, and does not spread to other parts of the body. Tumor, as a general term just refers to a swelling, and just like neoplasm, a tumor is not always synonymous with cancer. Tumors can be either malignant or benign. Malignant tumors are associated with cancer because they have the ability to spread or metastasize from their initial site of growth to other parts of the body. Benign tumors do not have the ability to metastasize and are typically harmless unless they invade and obstruct tissue, leading to discomfort, and may need to be removed.

Tumors they are often classified by the tissue in which they occur. For example, if a tumor originated in the lymph nodes, it would be a lymphoma. If a tumor originated in the blood, it would be leukemia. Eighty five percent of all tumors are carcinomas which are tumors of the epithelium.

Risk factors

Eighty percent of cancers are diagnosed in individuals ages 55 and over. Cancer causes many years of potential life lost (YPLL) that was defined in Chapter 2. YPLL is defined as the age at the time of death subtracted from 75. For example, if someone dies from lung cancer at age 60, their YPLL is 15. Cancer has a higher YPLL than heart disease, meaning people die younger of cancer than they do heart disease. YPLL often is used in public health research to measure the impact of cancer. According to 2017 data, 52% of YPLL due to cancer included deaths from lung bronchus (21% of YPLL due to cancer), colo-rectal (10%), breast (9%), pancreatic (7%), and liver/bile duct (5%) (Song, et al., 2020). Modifiable and non-modifiable risk factors have been identified for every type of cancer. The prominent ones are discussed in this section.

Modifiable Risk Factors

One-third of all cancer is caused by modifiable risk factors including tobacco use, poor nutrition, lack of physical activity, and obesity. Public health efforts aim to reduce the population’s risk for these modifiable factors by promoting proper nutrition, regular physical activity, maintaining a healthy weight, limiting alcohol consumption, avoiding exposure to ultraviolet (UV) rays, reducing transmission of viral infections, and decreasing tobacco use.

Tobacco use is still the leading cause of preventable cancer occurrence and death in the United States. Although prevalence of cigarette smoking has decreased in certain populations, it remains high in others, including American Indians and Alaska Natives, sexual minority groups (e.g. gay, lesbian, transgender), those who live in the southern US, those who have lower socio-economic status, and those with have a history of mental illness.

Obesity is another leading cause of preventable cancer death. Obesity is linked to 13 different cancer sites, including but not limited to various gastrointestinal (GI) sites, uterus, cervix, ovaries, breast, gallbladder, and endometrium. Breast cancer in postmenopausal woman is 50% higher in obese women, colon cancer risk is 40% higher in obese men, and gallbladder and endometrial cancer risks are five times higher in obese individuals.

There is a link between infectious agents and cancer. As discussed in the STI Chapter, HPV is strongly linked to cervical cancer. Anywhere between 95 to 100% of cervical cancer cases are caused by HPV meaning we don’t know another cause of cervical cancer other than HPV. There is an association between liver cancer and Hepatitis B and C. Asian Americans have lower rates of most cancers compared to other racial and ethnic groups with the one exception of liver cancer. Hepatitis B also is more common in Asian Americans. Hepatitis B is the leading cause of liver cancer. Stomach or gastric cancer are linked to the bacterium Helicobacter pylori. HIV is connected to Kaposi’s sarcoma.

UV exposure is strongly linked to all forms of skin cancer, the most common form of cancer in the US. Basal cell carcinoma, squamous cell, carcinoma, and melanoma are the three types of skin cancer, in increasing order of invasively. Spending extended time in the sunlight and using tanning beds/booths increase the risk for getting any type of skin cancer.

Excessive alcohol use, which includes binge drinking and heavy alcohol consumption (defined as consuming more than eight drinks a week for women and 14 drinks a week for men), is linked to several types of cancer: breast, liver, oral-pharyngeal, colo-rectal, and esophageal. The less a person drinks the lower their risk for cancer.

Non-Modifiable Risk Factors

In addition to the modifiable risk factors mentioned above, biological factors can increase a person’s risk for cancer. One factor is genetics. If someone has a primary relative, which is an immediate family member of the same sex (e.g. mothers and sisters for females and fathers and brothers for males) who has been diagnosed with a certain cancer – especially at a younger age – that increases risk for getting that cancer. Cancers with a strong genetic link are breast, stomach, prostate, uterine, ovarian, and lung. Genetic testing is available to screen for certain genetic markers that may increase a person’s risk for specific cancers. The key word is “risk”, the presence of a genetic mutation does not mean a person will get cancer. According to the American Society for Clinical Oncology, “only some people with a gene mutation will develop cancer. What does this mean? A woman may have a 45% to 65% chance of breast cancer. But she may never develop the disease. Meanwhile, a woman with a 25% chance may develop breast cancer,” (2018, para. 5). Click here for more information about genetic testing for cancer.

Genetic testing for hereditary breast and ovarian cancers is endorsed by the United States Preventive Services Task Force and the CDC as a “frontline public health approach used to identify individuals at risk for hereditary breast and ovarian cancer (HBOC) syndrome” (Veitinger et al., 2022, p. 1249). Breast and ovarian cancer have a genetic link. About 10% of all breast cancer cases are linked to genetics. If someone is interested in exploring genetic screening for cancer, the first step is typically genetic counseling, which involves you and a healthcare provider discussing your family history. If the results of the genetic counseling indicate further screening, genetic testing is the next step. The genetic test for breast and ovarian cancer is a simply blood test “covered by most insurance companies” (Ninan, 2022, para. 6). This quote implies that most people have health insurance. But according to the US Census, in 2020, 28 million people living in the United States did not have any health insurance during the entire year of 2020. Public health efforts are being implemented to address gaps in access to genetic screening, and are discussed later in the chapter.

cancer disparities

Cancer affects all populations in the United States, but certain groups have higher rates of cancer cases, deaths, and related health complications. These disparities are frequently seen in people with low socioeconomic status, less education, certain racial and ethnic populations, and those who live in certain geographical areas.

While white American women have the highest rate of breast cancer diagnosis, African American women exponentially are more likely to die from breast cancer than American white women. The highest rates of kidney cancer and death in the US occur among American Indians and Alaska Natives. Liver cancer rates are highest among American Indians, Alaska Natives, and Asian and Pacific Islanders. African American men are more than twice as likely as American white men to die from prostate cancer. Women living in rural areas are nearly twice as likely to die of cervical cancer compared to women living in suburban or urban areas. African Americans are twice as likely as white Americans to be diagnosed with and die from multiple myeloma. What is important to note is most of these cases are not based on anything biological. For instance, it is not due to a biological difference that African American men are at a higher risk to die from prostate cancer compared to a white American man. These disparities are associated with social determinants, such as access to health care, socioeconomic status, and cultural norms. Click here to read more about cancer health disparities.

cancer prevalence

Based on current cancer statistics from the American Cancer Society (ACS), the leading sites for new cancer cases (excluding skin cancer) in males are prostate, lung and bronchus, and colo-rectal. The leading sites for new cancer cases (excluding skin cancer) in females are breast, lung and bronchus, and colo-rectal. The leading sites for new cancer deaths in males are lung and bronchus, prostate, and colo-rectal. The leading sites for new cancer deaths in females are lung and bronchus, breast, and colo-rectal.

Also noteworthy in this figure is pancreatic cancer. Pancreatic cancer is low on the new cancer cases lists, only contributing to three percent of all new cancer cases in males and females. But, it is the fourth cause of cancer deaths in males and females. This is partially because pancreatic cancer is very aggressive, and typically it is so aggressive that by the time symptoms are shown it is approaching Stage 4.

Cancer Prevalence by Site (click here and scroll to Figure 3 on p. 10)

screening guidelines

ACS provides a list of cancer screening guidelines by age group. Click here to read the recommended guidelines for each age group. To summarize, for the 21-29 and 30-39 age groups, there are recommendations regarding colon, breast, and cervical cancers in these younger groups. By the 40-49 age group, men with a higher than average risk also have prostate screening recommendations. A lung cancer screening is available for smokers 50-64 in the form of a low-dose CT scan that can detect early lung cancer. Finally, for the 65 and over group, it is recommended to maintain all of the applicable screenings.

In addition to the selected cancer sites included in the ACS screening guidelines, there are also recommended self-examinations for breast cancer, testicular cancer, and skin cancer.

Monthly breast cancer self-examinations (BSE) are recommended for all women and men. Males and females follow the same exam directions, and instructions on how to perform a BSE can be found here.

Testicular cancer is considered a young man’s cancer, because the average age of diagnosis is 33, and 50% of men are diagnosed between ages 20 and 34. Risk factors for testicular cancer include having HIV, an undescended testicle, or if you’ve had a history of cancer in one testicle. Click here to learn how to perform a testicular self-examination (TSE).

Individuals can also perform regular skin cancer checks following the ABCDE formula, these letters stand for asymmetry, border, color, diameter, and evolution. Click here to learn how to perform a skin self-examination.

The acronym of CAUTION is used to identify potential warning signs of cancer. C stands for changes in the bladder and bowl habits. These might be indicative of bladder cancer, colorectal cancer, pancreatic, or liver cancer. A stands for a sore throat that doesn’t heal, and might be indicative of oral cancer or cancer of the larynx or the pharynx. U stands for unusual bleeding or discharge anywhere from the body. This may be indicative of many cancers such as lung, skin, colo-rectal, and breast. T stands for a thickening or lump that could indicate several cancers, such as breast or testicular. I stands for ingestion or difficulty swallowing which could be indicative of esophageal or other type of GI cancer. O stands for obvious changes in a wart or mole which might be indicative of skin cancer. N stands for nagging cough or hoarseness which would be indicative of esophageal cancer, lung cancer, or another cancer affecting the respiratory system.

stages of cancer

There are many ways to stage a cancer, but the most common is the TNM method. The T stands for the original tumor. N is associated with whether the cancer has spread to nearby lymph nodes (N = node). M relates to whether the cancer has metastasized (M = metastasize). Click here to learn how each of the T, N, and M are staged.

There are generally four stages association with the progression of cancer. Stage I usually means that a cancer is relatively small and still localized to its original organ. Stage II usually means the cancer is still localized but the tumor is larger and nearby lymph nodes may have some cancer cells in them. Stage III means the cancer is larger and the cancer has metastasized (spread) at least to the lymph nodes. Stage VI means that the cancer has spread aggressively to other parts of the body.

Public health efforts

“Increasing cancer screening and education among minority and other underserved groups is a critical strategy to reducing population-level cancer rates” (Riehman, et al., 2017, p. 735). Current public health efforts are focused on decreasing health disparities and increasing access to preventative measures (e.g. screenings) and treatment. The National Cancer Institute is addressing cancer disparities by conducting clinical trials using diverse populations, implementing programs that address cancer care delivery and diverse communities, and training to increase diversity in cancer research and cancer disparities.

Based on current public health practice, community health workers (CHW) are commonly used to facilitate access to cancer screenings. CHW are members of the community who do not hold post-secondary degrees, but rather share “a common racial, ethnic, or cultural identity with the communities they support,” (Riehman, et al., 2017, p. 735). “CHW roles vary, and can include activities such as translation services, provision of culturally appropriate health information, and assistance in getting individuals needed health services, or what is termed navigation to health services,” (Riehman, et al., 2017, p. 735). CHW have been effective in linking the people they serve with needed cancer prevention services. Studies have also shown CHW to be effective in delivering precision care post cancer diagnosis (Wood et al., 2022). Recently published studies have shown CHW are effective in: 1). providing culturally relevant cancer information to tribal communities, 2). reducing cancer screening disparities in the southeastern US, and 3). integrating precision care among low-income Latinx populations diagnosed with cancer (Cueva, et al, 2022; Riehman, et al, 2017; Wood et al., 2022). Additional interventions aim to bridge gaps to screenings, such as using patient navigation to increase colo-rectal cancer screenings among low-income black populations and state-based programs to increase colo-rectal cancer screenings in the four corner states (i.e. Arizona, Colorado, New Mexico, and Utah) (Martin, et al., 2017; Rodman, et al., 2022).

The Affordable Care Act (ACA) and its Influence on Insurance Coverage & Cancer Screening

Enacted in 2010, the ACA was a comprehensive reform law that increased insurance coverage for many uninsured people and changed the health insurance market (AMA, 2022). According to the U.S. Department of Health & Human Services, the ACA had three main goals, “Make affordable health insurance available to more people.… expand the Medicaid program to cover all adults with income below 138% of the [federal poverty level]…. Support innovative medical care delivery methods designed to lower the costs of health care generally” (HSS, n.d., para 2). 38 states and D.C. have adopted the Medicaid expansion program, and to date, 12 states still have not adopted the expansion (KFF, 2022).

Private insurers and Medicare are required to cover costs of some cancer screening tests through the ACA. Huguet et al. (2019) explored the prevalence of cervical and colorectal cancer before and after the Medicaid expansion. Researchers found that “female patients had 19% increased odds of receiving cervical cancer screening post- relative to pre-ACA in expansion states” and “23% increased odds in non-expansion states” (p. 91). For colorectal cancer screenings, Huget et al. (2019) reported that “prevalence increased from 11% to 18% pre- to post-ACA in expansion states and from 13% to 21% in non-expansion states” (p. 91). Fedewa et al. (2019) also explored the rates of colorectal cancer screening following the Medicare expansion, as well as breast cancer screenings. Like Huget et al (2019), Fedewa et al. (2019) found that cancer screenings increased. Colorectal cancer screening “increased by 8.8%, 2.9%, 2.4%, and 3.8% among low-income adults in [very early], early, late, and non-expansion states, respectively” (p. 3).  The researchers reported that breast cancer screenings “increased by 5.1%, 4.9%, and 3.7% among low-income women in [very early], early, and non-expansion states, respectively” (Fedewa et al., 2019, p. 3). There is still much to be studied on the ACA’s effect on quality and access of care for cancer patients.

The ACA Medicare expansion and requirement to cover some cancer screening tests was a step to make healthcare more affordable. Though a caveat of this coverage, as noted by the American Cancer Society, is “even if plans do cover cancer screening tests, it’s important to know that they might not cover the screening tests according to the recommended schedule….” (ACS, 2021, para 6). Additionally, individual insurance plans may not consider for early testing for people who are outside the typical screening guidelines due to age, gender, family history or race. For any questions about coverage and costs, it is best to ask your insurance provider.

recall quiz

discussion questions

1. Refer to the multi-causation model in Chapter 2, and link cancer to as many of the causes noted on the model as possible. Justify your answers.
2. Summarize the ACS screening guidelines by age group. Did any of them surprise you? Why/why not?
3. Explain the role of the community health worker in secondary cancer prevention.
4. Explain how the ACA impacted cancer rates and screening.
5. Describe at least one primary and one secondary prevention strategy for the each of leading causes of cancer in males and females: Lung/bronchus, prostate, colo-rectal, breast.

chapter activities

1. The National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results Program, also known as SEER, tracks statistics related to cancer. Click here to access SEER data. On the website, at the top of the page there is a menu titled “get started with a cancer site”, and select “compare cancer sites” from the drop-down menu. On the top right, find the “choose a statistic to explore” menu. Select “SEER incidence”. List the three cancer sites with the highest incidence rate from highest to lowest. Do the same with “SEER prevalence”. Compare the results.

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