Comprehensive Cancer Control · 2011. 5. 5. · detection cancer screening tests, and increase the...

ComprehensiveCancerControl

2006 - 2010Plan

MISSION STATEMENT

he mission of the AlabamaComprehensive CancerControl Coalition(ACCCC) is to develop

and sustain an integrated and coordi-nated approach to reducing cancerincidence, morbidity, and mortalityand to improving quality of life andcare for cancer patients, their fami-lies, and their caregivers. ACCCCfulfills its mission by improvingaccess, reducing cancer disparities,advocating for public policy, andimplementing the AlabamaComprehensive Cancer ControlPlan, which addresses prevention,early detection, treatment, follow-upcare, palliation, and behavioral andclinical trials research.

■ ACCCC will coordinate,enhance, and strengthen theefforts of public agencies, academ-ic institutions, and community-based private and public organiza-tions that are concerned withcancer prevention, control, andcare in Alabama.

■ ACCCC will assist with dissemi-nation and utilization of state reg-istry data as well as the sharing ofother information procured byvarious entities concerned withcancer-related issues throughoutthe state.

■ ACCCC will continue to work inpartnership with the AlabamaDepartment of Public Health(ADPH) and other institutionsand organizations to improvecancer prevention, control, andcare in Alabama; to evaluate areasof greatest need; and to find theresources to meet the identifiedneeds.

■ ACCCC will educate and advisepolicy and decision makers aboutcancer issues facing Alabama.

■ ACCCC will act as a clearing-house for information on cancercontrol activities across the stateand will develop partnerships tominimize duplication of effortamong involved entitiesstatewide.

■ ACCCC will develop andevaluate methods to track theprogress of comprehensive cancercontrol in Alabama.

T

This publication was supported in part by Grant Number U55/CCU 421939 from the National Comprehensive CancerControl Program at the Centers for Disease Control and Prevention. Its contents are solely the responsibility of thecontributing authors and do not necessarily reflect the official views of the National Comprehensive Cancer Program atthe Centers for Disease Control and Prevention.

he 2006 – 2010 AlabamaComprehensive CancerControl Plan is dedicatedto Samuel O. Moseley,

M.D., for his countless hours ofservice in trying to protectAlabamians from cancer. He is atrue servant leader who has alwayskept the needs of the citizens ofAlabama in the forefront andadvocated tirelessly for them.

Dr. Moseley’s pioneering efforts inestablishing community-based can-cer programs have led to the currentcancer control efforts in Alabama.He served as the first Chair of theAlabama Comprehensive CancerControl Coalition and a member ofthe workgroup who drafted theoriginal Alabama ComprehensiveCancer Control Plan.

Dr. Moseley’s gentle nature andpositive attitude have endeared himto his patients and colleagues andhave been a guiding light to those ofus continuing his quest for cancercontrol. The citizens of Alabamawill ever be in his debt and he willalways hold a special place in ourhearts.

DEDICATION

T

February 3. 2005

Greetings:

There are few of us who have notin some way been touched by atragedy of cancer. Having lost myeldest daughter Jenice to cancer, Iam well aware of the pain and sacri-fice of this disease on its victims andtheir families.

Across the United States andbeyond, tremendous strides havebeen taken to prevent cancer andtreat those individuals diagnosedwith the disease. 1 am confident thatwith the shared commitment topreserve our health and battle thisdisease we are on the brink of abreakthrough. Our continued dedi-cation to include medical research,clinical care, support services, andearly detection programs will make apositive and valuable difference inthe lives of many in the state ofAlabama.

I commend the AlabamaComprehensive Cancer ControlCoalition for developing this verythorough and much needed actionplan for the state of Alabama. Thisdistinguished group of individualsand organizations brought togethertheir collective knowledge andexpertise for the good of allAlabamians. Living a life with

cancer can be filled with pain anddiscomfort, with little to no opportu-nity to experience the joys of life. Iwholeheartedly support and admirethe efforts of the AlabamaComprehensive Cancer ControlCoalition for acknowledging thisissue and taking a stance to helpindividuals have a more fulfilled andjoyful existence.

It is incumbent upon the citizensof Alabama to work together aspeople and as a state to increaseresearch into understanding thecauses, into finding effective screen-ing and prevention strategies, andinto developing improved therapiesfor cancer patients. The Coalitionhas shown that working together, wecan ensure a healthier future for thepeople of Alabama.

BR/sl/cbj

FROM THE GOVERNOR

June 2, 2005

Dear Colleague:

I am pleased to introduce the2006 – 2010 AlabamaComprehensive Cancer ControlPlan produced by the AlabamaComprehensive Cancer ControlCoalition. This plan addresses theburden of cancer and the reductionof cancer incidence and mortality inAlabama.

Each year, 24,000 Alabamians arediagnosed with cancer and an addi-tional 10,000 deaths are attributedto this disease. Reduction in therates of cancer in Alabama will beaccomplished through lifestylechanges that eliminate tobacco use,improve dietary habits, increasephysical activity, maintain a healthyweight, avoid harmful ultravioletlight, increase the adherence to earlydetection cancer screening tests, andincrease the receipt of appropriateand timely cancer treatment.

The Alabama ComprehensiveCancer Control Coalition is com-prised of a diverse group of statewideorganizations and partners who arecommitted to the reduction of thecancer burden. Through the hardwork and dedication of each mem-ber, the 2006 – 2010 Alabama

Comprehensive Cancer ControlPlan was developed. It is our hopethis plan will become the drivingforce behind cancer controlactivities in the state.

Finally, I encourage you tobecome involved in reducing thecancer burden on Alabama residents.You are invited to join the AlabamaComprehensive Cancer ControlCoalition to help with this impor-tant task. For more informationabout cancer control activities inAlabama, please visit our website atwww.adph.org.

Sincerely,

Donald E. Williamson, M.D.State Health Officer

DEW/hj

FROM THE STATEHEALTH OFFICER

i Alabama Comprehensive Cancer Control Plan 2006-2010

Acknowledgements ............................................................................................ 1

Executive Summary............................................................................................ 6

Evaluation........................................................................................................... 8

Alabama Facts and Figures................................................................................. 10

Healthy People 2010 .......................................................................................... 10

Alabama Demographics ..................................................................................... 11

The Burden of Cancer in Alabama ................................................................... 14

Economic Burden of Cancer in Alabama.......................................................... 15

Disparities in Alabama....................................................................................... 16

New and Emerging Research ............................................................................. 18

Advocacy ............................................................................................................ 20

Format of the 2006-2010 Alabama Comprehensive Cancer Control Plan...... 21

Implementation and Priority Setting................................................................. 22

PREVENTION ...................................................................................................... 24

Tobacco.......................................................................................................... 26

Nutrition and Physical Activity.................................................................... 33

Ultraviolet Light Exposure............................................................................ 43

Research......................................................................................................... 48

EARLY DETECTION ............................................................................................. 52

Breast and Cervical Cancer........................................................................... 54

Colorectal Cancer ......................................................................................... 65

Prostate Cancer ............................................................................................. 72

Research......................................................................................................... 76

TABLE OF CONTENTS

Alabama Comprehensive Cancer Control Plan 2006-2010 ii

SURVIVORSHIP .................................................................................................. 80

Treatment....................................................................................................... 83

Follow-up ....................................................................................................... 88

End-of-Life Care ............................................................................................ 91

Research......................................................................................................... 97

ENVIRONMENTAL, MEDICAL, AND OCCUPATIONAL EXPOSURE ................... 100

Ionizing Radiation Exposure ......................................................................... 102

Risk Assessment and Toxicology................................................................... 106

Research......................................................................................................... 109

SURVEILLANCE .................................................................................................. 112

NEW AND EMERGING RESEARCH .................................................................... 118

REFERENCES....................................................................................................... 122

APPENDICES ...................................................................................................... 126

Appendix A: Abbreviations Used ................................................................ 127

Appendix B: Glossary of Terms..................................................................... 132

Appendix C: 1988 Cancer Committee Members......................................... 135

Appendix D: Example of Logic Model ......................................................... 136

Appendic E: ACCCC Monitoring Form...................................................... 137

Appendix F: Joining the ACCCC................................................................ 139

1 Alabama Comprehensive Cancer Control Plan 2006-2010

he development of the 2006 – 2010 Alabama Comprehensive CancerControl Plan is the result of ongoing collaboration among statewideorganizations and individuals who are committed to improve thestate’s cancer incidence and mortality rates. Since 1988, many have

dedicated their time and expertise to establishing and promoting the AlabamaComprehensive Cancer Control Coalition (ACCCC). Special thanks are extend-ed to the individuals who participated in the first statewide strategic planningprocess, without whose vision and insight, ACCCC would not have beensuccessful. The names of each of these 1988 Cancer Committee members can be found in the appendix.

In addition, the Executive Committee and the project staff have played aninvaluable role in developing the Plan’s content and laying the groundwork forthe eventual achievement of the Plan’s objectives.

EXECUTIVE COMMITTEE MEMBERS:

ACKNOWLEDGEMENTS

T

■ Kenneth C. Brewington, MDChairperson

■ Linda Goodson, RNVice-Chairperson

■ Lori BlantonSecretary

■ Diane Beeson, MBAPrevention Chair

■ Pam BostickEarly Detection Chair

■ Susan Baum, MSWSurvivorship Chair

■ Cheryl Browder, MBAEnvironmental, Medical, &Occupational Chair

■ John Waterbor, MD, DrPHSurveillance Chair

■ Isabel Scarinci, PhD, MPHResearch Chair

PROJECT STAFF:■ Mary Evans, MA

Technical Consultant

Finally, great appreciation is due to ACCCC members for their energy,interest, and dedication to improving the cancer prevention and control efforts in Alabama.

■ Cheryl Holt, PhDEvaluator

Alabama Comprehensive Cancer Control Plan 2006-2010 2

ACCCC MEMBERS:Stacey Adams ..............................................................Alabama Department of Public Health,

Public Health Areas VII and IXShauntice Allen, MA.................................................University of Alabama at Birmingham,

Community Health Advisors in Action ProgramWilliam P. Allinder.......................................................Alabama Department of Public Health,

Bureau of Environmental ServicesRowell Ashford, MD .........................................................................Cooper Green HospitalLinda Austin, RN......................................................Alabama Department of Public Health,

Arthritis Prevention BranchMax Austin, MD .......................................................Alabama Department of Public Health,

Medical Advisory CommitteeLekan Ayanwal, PhD............................. Tuskegee University, School of Veterinary MedicineTom Babington ..................................Alabama Department of Public Health, Pharmacy UnitMack Barnes, MD ...................University of Alabama at Birmingham, Gynecologic OncologySusan Baum, MSW ..........................University of Alabama, Division of Preventive MedicineDiane Beeson, MBA..................................................Alabama Department of Public Health,

Tobacco Control DivisionRosemary Blackmon................................................................Alabama Hospital AssociationSheila Blackshear...........................................................Alabama Social Workers AssociationLashon Blakely ..........................................................U.S. Environmental Protection AgencyLori Blanton ....................................................................................American Cancer SocietyAngie Blevins ...................................................... Alabama Primary Health Care AssociationLaura Booth ..............................................................Alabama Cooperative Extension SystemPam Bostick ....................................................................................American Cancer SocietyViki Brant, MPA.........................................................Alabama Department of Public HealthKenneth Brewington, MD ...................University of South Alabama, Gynecologic OncologyCheryl Browder, MBA ..............................................Alabama Department of Public Health,

Risk Assessment and Toxicology BranchKathryn Chapman .....................................................Alabama Department of Public Health,

Center for Health StatisticsDavid Chhieng.....................University of Alabama at Birmingham, Department of PathologyJanice Cook, MBA ....................................................Alabama Department of Public Health,

Cardiovascular Health BranchDonnie Cook, PhD...................................................Alabama Cooperative Extension SystemGay Coughlin ..............Alabama Department of Public Health, Bureau of Family Health ServicesDebbie Davis ..................................................................................American Cancer SocietyRon Dawsey................Alabama Department of Public Health, Bureau of Environmental ServicesMark Dignan, PhD...........................University of Kentucky, Center for Prevention ResearchRegina Dillard .................................................................Alabama Statewide Cancer RegistryLakeshia Dotson, MPA .......................Alabama Cooperative Extension System and National

Cancer Institute, Cancer Information Services Lynn Dyess, MD .......................................................................University of South AlabamaLelia Edwards...............................................................University of Alabama at BirminghamLaurie Eldridge-Auffant, MPH ................................Alabama Department of Public Health,

Worksite Wellness DivisionBill Eley..................................................................................Alabama Pharmacy Association


Shannon Ellis ............................................................Alabama Department of Senior ServicesRaenetta Ellison................................University of Alabama, Division of Preventive MedicineBonnie Embry, MD....................................................Alabama Department of Public Health,

Medical Advisory CommitteeMary B. Evans, MA ..............University of Alabama at Birmingham, School of Public HealthRonnie Floyd ....................................................... Governor’s Commission of Physical FitnessMona Fouad, MD .............................University of Alabama, Division of Preventive MedicineAl Fox ...................................................................Alabama Primary Health Care AssociationBrenda Furlow ..............Alabama Department of Public Health, Health Care Facilities DivisionShyrell Gehman .....................................................Sovereign Nation of Poarch Creek IndiansLinda Goodson, RN ..............University of Alabama at Birmingham, School of Public HealthYolanda Graham ..........................................................University of Alabama at BirminghamBrenda Guthrie.............................................................Alabama Department of Public Health,

Bureau of Family Health ServicesDiane Hadley...................................................................Alabama Statewide Cancer RegistryDollie Hambrick ............................Alabama Department of Public Health, Social Work UnitChristopher Hamlin, MD ...........................................University of Alabama at BirminghamSig Harden, PhD .......................................................Alabama Department of Public Health,

Bureau of Health Promotion and Chronic DiseaseGail H. Hardin, MS, CHES ............National Cancer Institute, Cancer Information ServicesJessica Hardy, MPH ..................................................Alabama Department of Public Health,

Office of Women’s HealthClaudia M. Hardy, MPA ...........................................University of Alabama at Birmingham,

Deep South Network for Cancer ControlMichael Harris .............................................................University of Alabama at Birmingham,

Division of Preventive MedicineDorothy Harshbarger, MS ........................................Alabama Department of Public Health,

Center for Health StatisticsHeidi Hataway ...........................................................Alabama Department of Public Health,

Nutrition and Physical Activity UnitJack Hataway, MD ....................................................Alabama Department of Public Health,

Chronic Disease Prevention DivisionJohn Higginbotham, PhD .........................University of Alabama, Department of Behavioral

and Community MedicineNina Hollingsworth, MS, RD ................................Alabama State Department of EducationMartha Holloway ....................................................Alabama State Department of EducationCheryl Holt, PhD........................................................University of Alabama at Birmingham,

Division of Preventive MedicineKaren Hood..................University of Alabama at Birmingham, Division of Preventive MedicineFrancine Huckaby .................University of Alabama at Birmingham, School of Public HealthSandra Hullett, MD ...........................................................................Cooper Green HospitalSanford Jeames ............................University of Alabama at Birmingham, Division of UrologyHaley Justice, MPH ..................................................Alabama Department of Public Health,

Cancer Prevention DivisionDennis King ....................................................................................................House of HopeBeverly Laird, PhD.....................................................................3D Medical Concepts, LLCJudy Lang ............................................................................................Baptist Medical Center

Acknowledgements continued


Lori Langner....................................................................................American Cancer SocietyLucille Latham ..........................................................Coffee County Family Health Services,

Avon Foundation Breast Cancer FundFrank Lawrence, III, MPH ........................................University of Alabama at Birmingham,

Division of Preventive MedicineGwendolyn Lipscomb, RN, MSN ............................Alabama Department of Public Health,

Division of Minority HealthMichael Maetz, DVM ................................................University of Alabama at Birmingham,

School of Public HealthSharmilla Makhija, MD .............................................University of Alabama at Birmingham,

Division of OncologyCharlotte Mayo, PhD..................................................University of Alabama at Birmingham,

Division of Preventive MedicineJulia McCollum ........................................................Alabama Cooperative Extension SystemPatricia McGaughey...........................................................................Cunningham PathologyJim McNees, MS........................................................Alabama Department of Public Health,

Office of Radiation ControlJim McVay, DrPA......................................................Alabama Department of Public Health,

Bureau of Health Promotion and Chronic DiseaseHolley Midgley .........................................................Alabama Academy of Family PhysiciansThomas Miller, MD, MPH ..........................................Alabama Department of Public Health,

Bureau of Family Health ServicesGary D. Monheit, MD .....................................................................................DermatologistCarolyn Morgan ..........................................................Alabama Department of Public HealthPatty Moriarty, RHIT ..................................................................Crestwood Medical CenterVicki Nelson....................................................................Alabama Statewide Cancer RegistryCarrie Nelson-Hale.......................................................................SISTAs Can Survive, Inc.Stacey Neumann........................................................Alabama Department of Public Health,

Tobacco Prevention and Control DivisionJennifer Newsome......................................................University of Alabama at Birmingham,

Center for Palliative CareMaria Norena...............................................................University of Alabama at Birmingham,

Division of Preventive MedicineSondra M. Parmer ........................................................Alabama Cooperative Extension System,

Nutrition Education ProgramEdward Partridge, MD ...............University of Alabama at Birmingham, OB/GYN OncologyDiane Payne ..........................................................................................New Beacon HospiceDeborah Pennington, RN ............................................Alabama Breast and Cervical Cancer

Early Detection ProgramSteve Pettitt ..........................................................Sovereign Nation of Poarch Creek IndiansMolly B. Pettyjohn, MS, RD, LD............................Alabama Department of Public Health,

Nutrition and Physical Activity UnitJohn Pinkston, MD .....................................................Baptist Montclair - Princeton HospitalSuzanne Reaves, MPA, MPH...................................Alabama Department of Public Health,

Cancer Prevention DivisionSondra Reese ...............Alabama Department of Public Health, Behavioral Risk Factor Survey UnitPat Reyman, RN ...................................................................................Oncology Consultant


Kyle Reynold, DrEd ..................................................Alabama Department of Public Health, Steps to a Healthier Alabama

Sandra F. Richardson, RHIA..................................Alabama Quality Assurance FoundationBlake Roper ..........................................Alabama Department of Environmental ManagementNasser Said-Al-Naief, MS.........................................University of Alabama at Birmingham,

Department of PathologySamuel Saliba, MD ...................................................Baptist Health Systems, Family PracticeTeri Salter............................................................................................Baptist Health SystemsEarl Sanders, MPH .....................................................University of Alabama at Birmingham,

Comprehensive Cancer CenterAnita Sanford, RN ....................................................Alabama Department of Public Health,

Nutrition and Physical Activity UnitSamuel Sawyer, MD ............................................................................Sawyer Surgery ClinicIsabel Scarinci, PhD, MPH ........................................University of Alabama at Birmingham,

Division of Preventive MedicineJohn Searcy, MD ..........................................................................Alabama Medicaid AgencyXuejun Shen....................................................................Alabama Statewide Cancer RegistryCyndi Signor.........................................................Alabama Primary Health Care AssociationRachael Sims ..............................................Auburn University, Harrison School of PharmacyPatti Stadlberger, RN........................Alabama Department of Public Health, Pharmacy UnitRosanna Smith ...........................................................Alabama Department of Public Health,

Cancer Prevention DivisionDavid Stone, MSW ................................................................Alabama Hospice OrganizationSarah Strawn .............................................................Alabama Department of Senior ServicesBarbara Struempler, PhD .............................Auburn University, College of Human SciencesMarc Sussman ...............................................Cooper Green Hospital, Balm of Gilead CenterKim Swinney-Morgan..............................................................Alabama Hospital AssociationKathleen Tajeu, PhD ................................................Alabama Cooperative Extension SystemTracey Taylor ..................................................................Alabama Statewide Cancer RegistryCharlie Thomas, RPh .......................Alabama Department of Public Health, Pharmacy UnitDeborah Thomasson ..............Alabama Department of Public Health, Public Health NursingJoanice Thompson......................................................University of Alabama at Birmingham,

Recruitment and Retention Shared FacilityBrooke Thorington....................................................Alabama Department of Public Health,

Tobacco Prevention and Control DivisionTim Turner, PhD ................................................Tuskegee University, Department of BiologyTheo Vaughn-Smith ..............University of Alabama at Birmingham, School of Public HealthSusan Volker, MPH ....................................................University of Alabama at BirminghamJohn Waterbor, MD, DrPH ......................................University of Alabama at Birmingham,

School of Public HealthKirk Whatley...................Alabama Department of Public Health, Office of Radiation ControlArica White, MPH .........................................................Alabama Statewide Cancer RegistryBeth Williams.........................Alabama Breast and Cervical Cancer Early Detection ProgramCharmaine Williams ....................................................University of Alabama at BirminghamShirley Williams ..............................................................Alabama Statewide Cancer RegistryTheresa Wynn, PhD ...................................................University of Alabama at Birmingham,

Division of Preventive Medicine

Acknowledgements continued


labama continues tobuild on its very success-ful history of cancercontrol. This second

statewide cancer plan covers years2006 - 2010 and addresses issuesacross the cancer continuum. Astatewide approach to cancer controlis the most effective way to tacklesuch a monumental public healthconcern. No single agency or organi-zation can meet the challenge alone.

Comprehensive cancer controlhas been defined as an integratedand coordinated approach to reduc-ing cancer incidence, morbidity, andmortality through prevention, earlydetection, treatment, and palliation.This comprehensive approachinvolves systematic assessment ofstate cancer concerns to ensure thatimportant priorities are identified,resources are used efficiently, gaps ineducation and services are identified,and duplication of efforts is avoided.

Development and implementa-tion of the new AlabamaComprehensive Cancer ControlPlan (ACCCP) involves a statewidepartnership among the AlabamaDepartment of Public Health(ADPH), other public health agen-cies, academic and research institu-tions, and community-based privateand not-for-profit volunteer organi-zations. Alabama’s strength lies inthe ability of key stakeholders to col-laborate to further reduce the burdenof cancer.

While Alabama, along with therest of nation, has made progressreducing cancer incidence and mor-tality, significant challenges are stillahead. By tailoring educational mes-sages to groups where the greatestcancer disparities exist and increas-ing screening and early detectionservices for the underserved, thestate will continue to see excitingprogress. An example is, for the firsttime ever, African American womenin Alabama are receiving mammo-grams at a higher rate than theirCaucasian counterparts.

As cancers are detected at earlierstages and treatments become moreeffective, people are living longer, anachievement that is reflected in theexpanded section on Survivorship inthe 2006 - 2010 Plan. Also, a muchgreater emphasis will be placed oncancer prevention over the next fiveyears, including proper nutrition andweight management, regular physicalactivity, tobacco prevention or cessa-tion, and over exposure to ultravio-let light.

Lifestyle choices will be thehealth focus for the 21st century.Peer education, community-basedinterventions, and better access topreventive health care will supportAlabamians in making betterlifestyle choices and help the statecontinue to make progress in thebattle against cancer.

EXECUTIVESUMMARY

A


Alabama’s commitment to cancercontrol began in 1988 when theADPH conducted an organization-wide strategic planning process thatproduced the first statewide compre-hensive plan for cancer control. Theoriginal Cancer Control StrategicPlanning Committee consisted ofeight members appointed by theState Health Officer and includedrepresentation from ADPH, academ-ic medical institutions, and clinicalprofessionals. Additional individuals,organizations, and agencies wereconsulted during the development ofthe plan to assure the appropriate-ness and inclusiveness of the goals,objectives, and strategies addressed.Appendix C contains a list of the1988 Cancer Control StrategicPlanning Committee.

In 1998, the Cancer PreventionBranch of ADPH initiated a revisionof the 1988 plan to carry Alabamainto the next century. Original mem-bers were invited to participate inthe review and to assist with thedevelopment of the process by whichthe update would be conducted.Additional key members wererecruited to represent the explosionof cancer prevention and controlresearch, programs, organizations,and activities across the state.

The newly formedComprehensive Cancer ControlCore Work Group (CWG) providedthe vision and leadership to expandthe scope of the original plan. Thework continued until the fullAlabama Comprehensive CancerControl Coalition met in September2001 to adopt the 2001 - 2005 Plan.A cooperative agreement awardedthe same year between the Centers

for Disease Control and Prevention(CDC) and the ADPH provided thenecessary funding to begin statewideimplementation.

The 2001 - 2005 Plan forAlabama has provided the frame-work to expand ACCCC member-ship, target implementation ofevidence-based cancer controlprograms, and refine evaluation andreporting processes of the Plan.Based on the collective experienceof the coalition, it is clear that toimpact cancer in Alabama the fol-lowing major needs must beaddressed:

■ Maintaining existing partner-ships and assuring communica-tion across existing programs,partnerships, and cancer controlorganizations.

■ Broadening partnerships and the community role in cancercontrol.

■ Investigating and implementingnew cancer control strategies.

■ Providing linkages for cancercontrol research.

■ Expanding resources andincreasing use of early detectionand treatment services byunderserved populations.

■ Enhancing surveillance activitiesto monitor and evaluating cancerprevention and control activities.


CCCC partners with theUniversity of Alabama atBirmingham (UAB)Division of Preventive

Medicine to evaluate implementationof the Plan as well as the ongoingactivities and operations of theCoalition.

The evaluation component of theAlabama Comprehensive CancerControl Plan assesses program imple-mentation and program outcomes atthe short-term, intermediate-term, andlong-term levels. The evaluation isguided by use of logic models (seeAppendix D), which reflect the con-tent of the Plan. Objectives withineach section of the Plan are examinedto determine the degree to which theyare realistic and measurable. In addi-tion, it is recognized that it may not

be possible at this time to evaluateevery objective in this comprehensiveplan. A degree of flexibility is to beexpected, and the evaluation plan isbased on priority areas and availabledata. There is, however, increasedimportance placed on process/implementation of the Plan activities(strategies). Data are collectedthrough use of a Monitoring Form (see Appendix E) and are compiled forthe evaluation report. Implementationdata, coupled with surveillance data,provide a more comprehensive pictureof Plan activities. Evaluation reportsare prepared on an annual basis withinput by members of the EvaluationTeam as well as other primary stake-holders. These reports are used in afeedback loop to improve andstrengthen the Plan.

EVALUATION

A


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Evaluation continued


he U.S. Department ofHealth and HumanServices released HealthyPeople 2010 as an effort

for states, communities, professionalorganizations, and others to helpimprove the health of the nation.This initiative includes a set ofhealth objectives for the nation toachieve over the first decade of thenew century. The effort is designedto achieve two overarching goals: toincrease the quality and years ofhealthy life and to eliminate healthdisparities.

In response to this effort, theAlabama Department of PublicHealth established a HealthyAlabama 2010 steering committee.The committee developed Healthy

Alabama 2010 to identify the specificneeds of the state in achieving thegoals and objectives listed by HealthyPeople 2010. In addition to objec-tives and strategies used in theHealthy People 2010 report,Alabama developed a set of objec-tives to reduce racial disparities inhealth outcomes and to improve theoverall health status of Alabamians.

ACCCC plays an important rolein addressing the objectives in thesepublications since many are relevantto cancer prevention, early detec-tion, and survivorship. The AlabamaComprehensive Cancer ControlPlan used these objectives as a guidefor developing strategies and measur-ing progress in the outcomes.

T

CCCC partners with theAmerican CancerSociety (ACS) and theAlabama Statewide

Cancer Registry (ASCR) to producethe 2005 Alabama Cancer Factsand Figures, which will report 2003data. This is the third edition ofAlabama Facts and Figures; it hasbecome an important document foranyone with an interest in cancer.The publication illustrates a varietyof factors that affect cancer preven-tion, detection, and quality of life byproviding not only data but alsointerpretation of how these factorsaffect one another.

Alabama Cancer Facts and Figuresprovides accurate and timely cancerdata and cancer risk factor informa-tion to key Alabama stakeholders atall levels. The document also servesas an essential planning andevaluation tool for the AlabamaComprehensive Cancer ControlPlan.

An additional benefit is that itserves as another mechanism fordistributing the Plan, which can befound in an abbreviated format atthe end of the document.

ALABAMA CANCER FACTS AND FIGURESAND HEALTHY PEOPLE 2010

A

ccording to the 2000U.S. Census, Alabama isthe 23rd most populousstate, with 4,447,100

residents.1 Between 2000 and 2003,Alabama’s population grew 1.2 per-cent, adding 53,652 new residents,but Alabama’s growth was lowerthan the national rate of 3.3 percent.The racial make-up of the state is 71percent Caucasian, 26 percentAfrican American, and 3 percentother.1

AFRICAN AMERICAN POPULATIONIn 2000, 26.3 percent of

Alabamians were African American,over twice the national rate of 12.2percent.1 Federal poverty rates arehigher among African Americans,along with lower levels of privateinsurance and access to health careservices.2 In 2003, 30 percent ofAlabama high school graduates wereAfrican American, significantlylower than their Caucasian counter-parts.3 Postsecondary educationamong the African American popu-lation is significantly lower thanamong Caucasian counterparts.4

GROWING HISPANIC POPULATIONAccording to a 2004 report by the

U.S. Census, the nation’s Hispanicpopulation continues to grow atmuch faster rates than the popula-tion as a whole. The nationalHispanic population reached 39.9million on July 1, 2003, accounting

for about one-half of the 9.4 millionresidents added since the 2000 U.S.Census. This 13.0 percent growthrate for Hispanics over the 39-monthperiod was almost four times that ofthe total population. The number ofpeople in the United States whoreported being Asian grew from 11.9million to 13.5 million.5

Within Alabama, Hispanicsaccount for the fastest growing seg-ment of the population. In 1990, 0.6percent of Alabama’s residentsreported being of Hispanic origin. In2000, 1.7 percent of the populationwas Hispanic.1 The northeast andsoutheast counties have higher pro-portions of Hispanic residents thanother counties in the state. Residentsin almost 4 percent of households inAlabama report speaking a languageother than English in the home.

AGING POPULATIONAlabama has declining birth and

death rates, and, like the rest of theUnited States, its population isaging. The median age ofAlabamians in 2000 was 35.8 years,1

compared to 32.9 years in 1990. In2000, 13 percent of Alabama’s popu-lation was 65 years and older; this ishigher than the national rate of 12.4percent.1 The female population islarger than the male populationthroughout the age span.1 Over halfof Alabama’s population is female,and women also typically have alonger lifespan than men. The

ALABAMA DEMOGRAPHICS

A


population of Alabamians 65 andolder is 60 percent female and 40percent male.1

EDUCATIONAL ATTAINMENTThe recent report America’s

Health: State Health Rankings, issuedby the United Health Foundation,the American Public HealthAssociation, and the Partnership forPrevention ranked Alabama 46th inthe nation for high school comple-tion. Only 57.2 percent of incomingninth graders graduate with a highschool diploma in four years.7

POVERTYThe median Alabama household

income reported to the 2000 U.S.Census was $34,135 per year, 19percent below the national average.1

Shelby County had the highestmedian household income ($55,440)followed by Madison County($44,704). The lowest incomes were

in Wilcox ($16,646) and Sumtercounties ($18,911).1

UNINSURED POPULATIONThe majority of individuals who

live below the poverty thresholdhave no health insurance. In 2003,the Kaiser Family Foundation report-ed that 13 percent of Alabamians areuninsured. For those with healthinsurance, 59 percent were coveredby private or individual insuranceand 27 percent were covered byeither Medicare or Medicaid.3

Adequacy of the coverage, however,is less clear. Presumably people wholive in Alabama, like residents ofmany other states, may have grouphealth insurance limited to wageearners only, may have highdeductibles, or may be onlycatastrophic coverage. The degree ofsignificance to which lack of healthcare insurance contributes to poorhealth outcomes and economic


American Indian &Alaskan Native

0.5%

Caucasian71.8%

Asian0.7%

Native Hawaiian &other Pacific Islander

0.0%

Other races0.7%

African American

26.3%

Produced by the Center for Health Statistics, Alabama Department of Public Health

Figure 1. Distribution of Racial CategoriesAlabama Census 2000

LAUDERDALE

LIMESTONEMADISON

JACKSON

DEKALBMARSHALL

LAWRENCE

JEFFERSON

CULLMANWINSTONMARION

LAMAR

PICKENS

FAYETTEWALKER

BLOUNT

MACON

LEE

RANDOLPH

CALHOUN

TALLADEGA

DALLAS

CHILTONCOOSA

SHELBYTUSCALOOSA

ST. CLAIR

TALLAPOOSA

CHEROKEE

WILCOX

ELMOREAUTAUGA

ESCAMBIACOVINGTON

BUTLER

MONTGOMERY

BULLOCK

CRENSHAW

GENEVA HOUSTON

DALE

MONROE

GREENE

MARENGO

CHOCTAW

WASHINGTON

MOBILE

BALDWIN

SUMTER

HALE

LOWNDES

BIBB

COFFEE

PIKE

PERRY

CLAY

RUSSELL

BARBOUR

CONECUH

CLARKE

CHAMBERS

CLEBURNE

ETOWAH

FRANKLIN

COLBERT

MORGAN

HENRY

0.4 - 8.19.8 - 18.520.4 - 34.236.6 - 51.759.0 - 84.6

Source: US Census Bureau, Census 2000 Summary File 1, Matrices P1, P7.

Figure 2. Percent of Persons Who areAfrican American Alone, 2000

hardship in Alabama cannot beoverstated. Screening and earlydetection services are not readily

available to this population, whichcauses increased suffering fromconditions that could be prevented.

LAUDERDALE

LIMESTONEMADISON

JACKSON

DEKALBMARSHALL

LAWRENCE

JEFFERSON


LAMAR

PICKENS

FAYETTEWALKER

BLOUNT

MACON

LEE

RANDOLPH

CALHOUN

TALLADEGA

DALLAS

CHILTONCOOSA

SHELBYTUSCALOOSA

ST. CLAIR

TALLAPOOSA

CHEROKEE

WILCOX

ELMOREAUTAUGA

ESCAMBIACOVINGTON

BUTLER

MONTGOMERY

BULLOCK

CRENSHAW

GENEVA HOUSTON

DALE

MONROE

GREENE

MARENGO

CHOCTAW

WASHINGTON

MOBILE

BALDWIN

SUMTER

HALE

LOWNDES

BIBB

COFFEE

PIKE

PERRY

CLAY

RUSSELL

BARBOUR

CONECUH

CLARKE

CHAMBERS

CLEBURNE

ETOWAH

FRANKLIN

COLBERT

MORGAN

HENRY

0.6 - 0.91.0 - 1.41.5 - 2.22.6 - 3.35.3 - 7.4

Source: US Census Bureau, Census 2000 Summary File 1, Matrices P1, P8.

Figure 3. Percent of Persons Who areHispanic or Latino (of any race), 2000

Number of People of Hispanic OriginAlabama 1990 - 2000

Total Hispanic Population

0 20000 40000 60000 80000

19902000

OtherHispanicor Latino

Cuban

Puerto Rican

Mexican

Source: US Census Data, 1990, 2000

Figure 4. Number of People of HispanicOrigin, Alabama 1990 and 2000


0 40 80 120 160 20004080120160200

85+

80-84

75-79

70-74

65-69

60-64

55-59

45-49

40-44

50-54

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0-4

FemaleMaleAge

Source: Population data is based on Census populations as modified by NCI (released December 2003).

Figure 6. Age Distribution, All RacesAlabama, 2001

0

50000

100000

150000

200000

250000

300000

350000

Pop

ulat

ion

Age (years)

outine screening is animportant factor whichdecreases cancer morbidi-ty and mortality rates.

Cervical cancer is almost 100 percentpreventable if women are properlyscreened. Breast, colorectal, andprostate cancers have a high survivalrate when detected at an early stage.Unfortunately, funding for earlydetection programs is not adequate toreach populations who are uninsuredor underserved. Lung cancer is a sub-stantial problem in Alabama, with anincidence rate of 73.4 per 100,000from 1996-2002.8 To decrease theincidence and mortality rates of lungcancer, priority should be placed onestablishing or enhancing effectivesmoking prevention and cessationprograms.

Today, more than 150,000 indi-viduals throughout Alabama areliving with or surviving a cancer

diagnosis. According to theAmerican Cancer Society (ACS),more than 24,000 individuals, or 66Alabamians per day will be diag-nosed with cancer each year.9

Prostate, breast, and lung cancers arethe most frequently diagnosed can-cers in Alabama. It is estimated thatthere will be more than 10,000cancer-related deaths in Alabama, or27 per day, making cancer the state’ssecond leading cause of death in2005, following heart disease.6

Scientific evidence suggests that60 percent of new cancer cases and33 percent of cancer deaths could beprevented through lifestyle changessuch as eliminating tobacco use,improving dietary habits, exercisingregularly, maintaining a healthyweight, avoiding exposure to ultravi-olet light, obtaining cancer screen-ing for early detection, and seekingtimely and appropriate treatment.10

Lung31.7%

All Other39.1%

Colorectal9.1%

Breast6.9%

Prostate5.5%

Pancreatic5.1%

Ovarian2.6%

Source: Alabama Department of Public Health, Center for Health Statistics, 2005

Figure 7. Leading Causes of Cancer Deaths, Alabama 2003

THE BURDEN OF CANCER IN ALABAMA

R


n addition to the distressingloss of lives, cancer exacts agreat economic toll onAlabamians. ACS estimates

the direct and indirect cost of cancerin the United States was $189.8 bil-lion in 2004. This estimate includedabout $69.4 billion in direct medicalcosts. Indirect costs for 2004, con-sisting of productivity or time lost orforegone by patients, families andother informal caregivers, were esti-mated to be $120.4 billion. Thesecosts include approximately $16.5billion in indirect morbidity costs(lost productivity due to illness) and$103.9 billion in indirect mortality

costs (lost productivity due to pre-mature death)11. This means thatwith a population estimated to be4.53 million in 2004, the economiccost of cancer in Alabama was over$2.9 billion or approximately $646for each person.

In part, the costs in cancer carecan be attributed to lack of healthinsurance and barriers that preventAlabamians from accessing the serv-ices needed for cancer preventionand early detection. To preventincreasing costs of cancer-relatedillnesses, it is important to focus on screening and early detectionstrategies.

Direct Care,$1,070.6

Lost ProductivityDue to Illness,

$254.5

Lost Productivity Due to Premature Death

$1,602.9

Total Cost of Cancer in Alabama, 2004 = $2,928.0 Million

Source: Alabama Department of Public Health, Center for Health Statistics, 2005

Figure 8. Direct and Indirect Costs of CancerAlabama, 2004 ($Millions)

ECONOMIC BURDEN OF CANCER IN ALABAMA

I


ubstantial progress has led toadvanced methods of cancerdetection, diagnosis, andtreatment. Unfortunately,

not all populations have reapedbenefits from this progress. Theincidence and mortality rates ofcancer show disparities among ruraland minority populations withinAlabama. These populations are morelikely to experience the following:

■ Be diagnosed with and die frompreventable cancers.

■ Be diagnosed with late-stagedisease for cancers detectablethrough screening at an earlystage.

■ Receive either no treatment ortreatment that does not meet cur-rently accepted standards of care.

■ Die of cancers that are generallycurable.

■ Suffer from cancer without thebenefit of pain control and otherpalliative care.12

Health disparities are more promi-nent in rural, underserved areas. Ofthe 67 counties in Alabama, 45 areclassified as rural. Within these coun-ties, health insurance enrollmentrates are low and health care facilitiesand providers are sparse. A ruralregion known as the Black Belt hasan age-adjusted prostate cancer deathrate of 58.4 compared to 38.0 for theremainder of the state. Location ofhealth care facilities and providers

creates a burden for those who seekcancer services. Many of these areashave only one or two primary carephysicians within the county.

Cancer incidence rates are loweramong minorities; however, theirmortality rates are higher. Major con-tributors to this disparity are the lackof access to early detection and lowquality health care. Minorities, espe-cially African American andHispanic populations, are less likelythan Caucasians to have privatehealth insurance. The number ofuninsured African Americans inAlabama in 2003 was 22 percent,compared to 13 percent ofCaucasians.5 Studies show that peoplewithout health insurance are diag-nosed with cancer at later stages anddie from cancer at higher rates thanthose with insurance. To lower therate of cancer-related deaths, it isimportant to increase awareness andavailability of cancer screeningservices.

The Alabama Breast and CervicalCancer Early Detection Program(ABCCEDP) has helped to increasebreast cancer screening rates amongminority women. In 2002, moreAfrican American than Caucasianwomen in Alabama reported havinghad a mammogram in the past year.13

Unfortunately, this screening ratedoes not hold true for all types ofcancer.14 In 2002, only 10 percent ofAlabama’s African Americans andHispanic adults reported ever having

DISPARITIES IN ALABAMA

S


a fecal occult blood test, flexible sig-moidoscopy, or colonoscopy.13 Whendiagnosed at a localized stage, col-orectal cancer has a five-year survivalrate of 90.1 percent. Colorectal can-cer mortality rates in Alabama arehigher among African Americans.15

High quality health care facilitiesand systems are less available forminority or underserved communities.The Institute of Medicine reportedthat minorities, particularly AfricanAmericans, frequently receive lowerquality health care than Caucasians,even when access-related factors werecontrolled. Individuals living in theseunderserved communities may beunable to derive benefit from servicesbecause of communication barrierssuch as language, health literacy, andhearing or visual impairment.16

A patient’s understanding of anillness may be different from aprovider’s perspective. An individual’sbeliefs are not always compatible withevidence-based medical practices. Toincrease compliance rates amongminorities and the underserved,cultural competency of health careprofessionals must become a priority.

Solutions to eliminate cancerdisparities are complex and requireintensive and multidisciplinaryapproaches that unite research andcommunity outreach strategies. TheAlabama Comprehensive CancerControl Coalition is dedicated toworking with health care profession-als, community-based organizations,government agencies, and academicand research institutions to develop amulti-faceted approach to lowercancer incidence and mortality ratesamong these populations.

LAUDERDALE

LIMESTONEMADISON

JACKSON

DEKALBMARSHALL

LAWRENCE

JEFFERSON


LAMAR

PICKENS

FAYETTEWALKER

BLOUNT

MACON

LEE

RANDOLPH

CALHOUN

TALLADEGA

DALLAS

CHILTONCOOSA

SHELBYTUSCALOOSA

ST. CLAIR

TALLAPOOSA

CHEROKEE

WILCOX

ELMOREAUTAUGA

ESCAMBIACOVINGTON

BUTLER

MONTGOMERY

BULLOCK

CRENSHAW

GENEVA HOUSTON

DALE

MONROE

GREENE

MARENGO

CHOCTAW

WASHINGTON

MOBILE

BALDWIN

SUMTER

HALE

LOWNDES

BIBB

COFFEE

PIKE

PERRY

CLAY

RUSSELL

BARBOUR

CONECUH

CLARKE

CHAMBERS

CLEBURNE

ETOWAH

FRANKLIN

COLBERT

MORGAN

HENRY

Source: Center for Business and Economic Research The University of Alabama

Figure 10. Traditional Counties of theAlabama Black Belt


Figure 9. Factors That InfluenceCancer Disparities

Economic

Social Cultural

■ Prevention■ Early Detection■ Diagnosis/Incidence■ Treatment

■ Post-TreatmentQuality of Life

■ Survival andMortality

Source: adapted from: Freeman, HP. Commentary on the meaning of race andscience and society. Cancer Epidemiology Biomarkers Prev 12(3): 2325-65, 2003,and Institute of Medicine. Unequal Treatment: Confronting Racial and EthnicDisparities in Health Care. Washington, DC: National Academy Press, 2002

Disparities in Alabama continued

esearch is responsible forthe remarkable progressthat has been made incancer prevention and

control since the War on Cancer wasdeclared over 30 years ago. Ongoinggroundbreaking scientific discoveriesoffer an incredible array of opportu-nities to accelerate progress.

New and emerging scientificresearch is the driving force behindcancer prevention, improved earlydetection methods, and successfultreatment options. The number ofcancer deaths and cases has beendeclining in the U.S. for over adecade, but our greatest achieve-ments are yet to come.

CHEMOPREVENTION Chemoprevention involves the use

of either natural or synthetic sub-stances to reduce the risk of develop-ing cancer or to reduce the risk ofcancer recurring. Studies over thepast 25 years have identified agents(drugs, vitamins, hormones, or dietarycompounds) which have shown sig-nificant success in helping achievethese goals.

Prevention usually denotes stepspatients can take on their own toreduce the chance of cancer develop-ment (dietary changes, smoking ces-sation, weight control, decreased sunexposure, etc.). Cancer treatmentinvolves the administration of provenmethods to slow or stop cancer.Chemoprevention has been found to

bridge the gap between preventivemeasures and cancer treatment.

Currently there are five basicclasses of agents – selective estrogenreceptor modulators (SERMs) liketamoxifen and raloxifene, calcium,retinoids (substances related tovitamin A), glucocorticoids, andnon-steroidal anti-inflammatorydrugs (NSAIDs).

Currently NCI has over 40 trialsunderway and many more beingconducted by pharmceutical compa-nies. These trials require very largenumbers of participants to prove astatistically valid result. With successin this area will come a reduction innew cancers as well as a reduction inthe number of recurrent cancers.

GENOMICSGenomics specific to cancer is the

study of the functions and interac-tions of the cancer genes within thegenome, including interactions withenvironmental factors.17 It is estimat-ed that 5 to 10 percent of cancer iscaused by autosomal dominantinherited genetic changes, such asBRCA1 and BRCA2 mutations inbreast and ovarian cancers.18

Research on the cancer genome hasalready shown an increased risk forindividuals with a first-degreerelative with cancer, and much moreis being learned every day. The influ-ence of the emerging fields of genet-ics and genomics on cancer controlcannot be ignored.

NEW AND EMERGINGRESEARCH

R


Family history is known to be arisk factor for many chronic diseases– including coronary heart disease,cancer, and diabetes – but its use inpreventive medicine has been de-emphasized compared to modifiablerisk factors such as smoking and diet.According to the results from theHealthstyles 2004 Survey, conductedby the CDC, 96 percent ofAmericans believe that knowingfamily history is important to theirhealth.19 The survey also shows,however, that only one-third ofAmericans have ever tried to gatherand organize their families’ healthhistories.

In November 2004, the U.S.Department of Health and HumanServices launched a public educationcampaign urging all Americans toknow their family medical historyand to discuss it with health careprofessionals using an online familyhistory collection tool.20 This freecomputer program organizes impor-tant health information into a print-out that can be taken to office visitsto help determine whether a patientis at a higher riskate for disease. Theprintout can also be placed in apatient’s medical record. The newcomputerized tool, called “MyFamily Health Portrait,” can bedownloaded athttp://www.hhs.gov/familyhistory/.Using family history as a risk assess-ment tool is an important compo-nent within cancer genetics and oneof the most amenable public healthapplications of genomics at thistime.21

PROTEOMICSProteomics, in its modern form, is

relatively new and takes over wheregenomics ends. Proteomics technolo-gy is being used in cancer diagnosisand treatment, which involvessearching for proteins that may serveas biomarkers of early disease, orresponsiveness to therapy, or of thelikelihood of relapse after treat-ment.22 At this point, none of theproteomics analyses is matureenough to be used in the clinic as ascreening tool, but these small stud-ies point to the promise of pro-teomics as a diagnostic maker.

GENETIC ADMIXTUREIn many disease outcomes, adjust-

ment for socioeconomic factors doesnot completely eliminate health dis-parities, therefore suggesting a rolein genetics. An emerging techniquecalled genetic admixture looks close-ly at the differences in ethnic andracial groups to explore the compo-nents that cause genetic predisposi-tion to certain types of chronic dis-eases. Ancestry-informative markershelp answer questions by estimatingwhat fraction of an individual’sgenome was inherited from Africanancestors, what part came fromEuropean ancestors, and what frac-tion descended from pre-Columbianaboriginal populations.23 Past studieshave looked into the biology of obe-sity traits and insulin-resistance syn-drome. This technique is currentlybeing considered for application tocancer research.


New and Emerging Research continued

ancer is not just a medicalissue, it is also a psycho-logical, social, and eco-nomic issue. The disease

becomes political when elected offi-cials make policy decisions that affectthe lives of cancer survivors, theirfamilies, their career opportunities,and other potential cancer patients.Cancer advocates in Alabamaaddress all these issues at various lev-els and in their own unique ways.Some groups have paid consultantswhile others influence decision mak-ers by their personal testimonies.

Through implementation of theAlabama Comprehensive CancerControl Plan these various approach-es will be combined to increaseAlabama’s capacity to positivelyinfluence programs to help preventcancer, broaden access to quality can-cer treatment and follow-up care, andimprove the quality of life for thoseaffected by the disease. Each of thePlan sections (Prevention; EarlyDetection; Survivorship;Environmental, Medical, andOccupational Exposure; Surveillance;and Research) contains advocacyobjectives along with strategies tohelp achieve success.

Strong partners, such as theAmerican Cancer Society (ACS),train individuals and groups to beadvocates for their own issues as wellas provide a voice for people who arenot usually heard. ACS initiativesrely on the combined efforts of a

community-based, grassroots networkof cancer survivors, caregivers, volun-teers, staff, health care professionals,public health organizations, andother collaborative partners whohave successfully influenced or sup-ported policies, laws, and regulations.

Recent achievements that havebeen brought about by advocacyefforts in Alabama include:

■ Adopting the Breast and CervicalCancer Prevention andTreatment Act.

■ Increasing the state tobacco taxand increasing penalties for thosewho sell tobacco to minors.

■ Passing a statewide clean indoorair act without preemption.

■ Passing local clean air ordinancein Prattville, Montgomery,Birmingham, Dothan, andAuburn, with initiatives pendingin Huntsville and Mobile as wellas numerous smaller citiesthroughout Alabama.

■ Passing a mandated optionrequiring that insurance compa-nies offer the full range ofcolorectal screenings throughprivate insurance.

■ Advocating for an adequate andsustained funding source forMedicaid to ensure access tocancer care and prescriptiondrugs for Alabama’s medicallyindigent cancer patients servedby the state Medicaid program.

ADVOCACY

C


he AlabamaComprehensive CancerControl Plan is dividedinto sections that address

topics relevant to cancer control inAlabama:

■ Prevention■ Early Detection■ Survivorship■ Environmental, Medical, and

Occupational Exposure■ Surveillance■ Research

The narrative material that intro-duces each section and subsectioncovers information about currentprevalence and mortality, and onparticular activities and programsthat are working to decrease cancerincidence and mortality rates in thestate.

The goals and outcomes of eachsection are based on the most cur-rent data available. Significant con-sideration was given to each goal,objective, and strategy to ensure allpopulations were addressed. Eachsection includes the following: anoverall goal, individual sub-sectiongoal statements, outcome measureswith data sources, objectives, andstrategies. The goal statements

reflect long-term aspirations and aremeant to guide the direction ofAlabama’s cancer control activities.Outcome statements provide targetmeasures the ACCCC will work toaccomplish by the year 2010. Whereapplicable, these measures are basedon Healthy People 2010 recommen-dations. Some outcome statementsdo not include baseline data; inthese cases, ACCCC has plans toestablish these baselines and setappropriate targets to be met by theend of the five-year period. Toaccomplish each specific outcomemeasure, comprehensive objectivestatements are included. Strategiesare specific activities designed toaccomplish the objectives andinclude information on agencies§,other partners and programs§, andlinkages§ whose efforts and resourcesaddress the need.

Cancer control research is amajor component in the Plan.ACCCC has included specificresearch goals, outcomes, and objec-tives in each section to allow for acloser dialogue with researchers.Each committee includes a researchliaison who will be responsible forreporting ongoing efforts in cancerresearch to their respective commit-tees and to the Research Committee.

§ Defined in Glossary, see Appendix B

FORMAT OF THE 2006 – 2010 ALABAMA COMPREHENSIVE CANCERCONTROL PLAN

T


s Alabama enters thesecond five-year cycle ofPlan implementation,valuable lessons have

been learned and numerous goalshave been achieved: growth insection committee numbers, higherlevels of commitment by members,and a better understanding of what acollaboration such as this actuallymeans. Perhaps the most valuablelesson learned is that no one groupor organization can hope to under-take all the very complex issuesassociated with cancer preventionand control.

Plan implementation will be theresponsibility of all coalition mem-bers, ad hoc committees, and theadvisory council as well as grassrootsindividual and small groups aroundAlabama. Linkages among the vari-ous groups are necessary to ensurecoordination and success.

Scientific data and research willbe used systematically to identifypriorities and to assist with decisionmaking. Objectives will be priori-tized based on sound scientificevidence that interventions areeffective in reducing cancer inci-dence and/or mortality, especially inareas where evidence-based inter-ventions are underutilized. TheAlabama statewide plan will bereviewed annually and relevant data,expanded scientific knowledge,improved technology, and availableresources will guide future priorities.All ACCCC partners are dedicatedto the mission of reducing the bur-den of this relentless disease.

The Plan is comprehensive andwill consider all cancers in allpopulations, but an emphasis willremain on populations that suffer thegreatest burden of morbidity andmortality – rural, minority, andmedically underserved Alabamians.

IMPLEMENTATION AND PRIORITY SETTING

A


PREVENTION


Overall Goal:

Alabama cancer cases will decline because of adoption

of healthy lifestyle choices and modification of social and cultural risk factors.

n the past, the majority ofdiseases and illnesses thatkilled Americans werecommunicable. Diseases, such

as smallpox, have been eradicatedworldwide and polio from theUnited States by implementation ofpublic health programs. During the21st century, it will take lifestylechanges and healthy behaviors toprevent or cure the most prevalentchronic diseases, including cancer.

The majority of Americans feelthat a cancer diagnosis is inevitablyfatal; however, current researchshows this is untrue. The AmericanCancer Society estimates that more

than 60 percent of cancer deathscould be prevented if Americansmaintained a healthy lifestyle andfollowed recommended cancerscreening guidelines.8

This year more than 24,000Alabamians, or 66 per day, willreceive a diagnosis of cancer, and anestimated 10,000 Alabamians, or 27per day, will die from cancer.6 Todecrease cancer incidence andmortality rates, Alabamians areencouraged to modify their lifestylechoices – quit using tobacco, eatbetter, get more physical exercise,and avoid overexposure toultraviolet light.

0% 5% 10% 15% 20%

Tobacco

Poor Diet andPhysical Inactivity

Alcohol

Microbial Agents

Toxic Agents

Motor Vehicle

Firearms

Sexual Behavior

Illicit Drug Use

18.1%

16.6%

3.5%

3.1%

2.3%

1.8%

1.2%

0.8%

0.7%

Source: Centers for Disease Control and Prevention (CDC)

Figure 11. Actual Causes of Deathin Alabama, 2002

Diet, Obesity,Sedentary Lifestyle

35.0%

Tobacco Use30.0%

Other25.0%

Family History5.0%

Occupational Factors5.0%

Source: Harvard Report on Cancer Prevention, Cancer Causes and Control, 1996

Figure 12. Factors Causing Cancer in the United States

INTRODUCTION TOPREVENTION

I


HEALTH EFFECTS OF SMOKINGCigarette smoking is responsible

each year for more than 440,000deaths in the United States – morethan alcohol, car accidents, suicide,AIDS, homicide, and illegal drugscombined.24 Half of Americans whosmoke will die because of their habit.

At least 30 percent of all cancerdeaths are caused by cigarette smok-ing. It is the major cause of cancersof the lung, larynx (voice box), oralcavity, pharynx (throat), and esopha-gus and is a contributing cause in thedevelopment of some leukemia andcancers of the bladder, pancreas,liver, uterine cervix, kidney, stomach,colon and rectum.22

Lung cancer is currently the lead-ing cause of cancer death in bothmen and women in Alabama.Detection of lung cancer at an earlystage, when it is most treatable, is dif-ficult. Compared to nonsmokers,men who smoke are about 23 timesmore likely to develop lung cancerand women who smoke are about 13times more likely to do so. Smokingcauses about 90 percent of lung can-cer deaths in men and almost 80 per-cent of lung cancer deaths inwomen.22 Fortunately, lung cancer islargely a preventable disease.

The harmful effects of smoking donot end with the smoker. Womenwho smoke during pregnancy havechildren who are at increased risk forlow birth weight, sudden infant deathsyndrome, and serious respiratoryconditions such as asthma.

Secondhand smoke is dangerous toall who are exposed. Primarilybecause of exposure to secondhandsmoke, each year an estimated 3,000nonsmoking Americans die of lungcancer and an additional 35,000 dieof heart disease. An estimated150,000 to 300,000 children youngerthan 18 months have recurring respi-ratory tract infections because ofexposure to secondhand smoke.

BURDEN OF TOBACCO USE INALABAMA

In 2004, the Centers for DiseaseControl and Prevention (CDC)reported that 46.2 million adults inthe United States smoke cigarettesdespite broad public awareness of theconsequences this behavior has onhealth.25 According to the 2003Alabama Behavioral Risk FactorSurveillance System (BRFSS), 25.3percent of Alabamians reportedbeing current smokers, higher thanthe national rate of 22.7 percent.Each year in Alabama, 12,000 youngpeople under the age of 18 becomenew regular smokers.26 Althoughsmoking rates have steadily decreasedin recent years, the prevalence ofAlabama’s youth who smoke remainshigher than national rates. Currently,13.1 percent of Alabama middleschool students and 24 percent ofhigh school students smoke,27 whilenational smoking rates for these pop-ulations are 10.1 percent and 22.9percent, respectively.28

TOBACCO


Smokers, businesses, nonsmokers,and society bear the burden of costsfrom cigarette use. Increasing statehealth care expenditures have result-ed in increased taxes to pay for thecost of state Medicaid and Medicareprograms. In addition, many healthinsurance companies have raised pre-miums for clients who smoke, basedon the excessive costs of healthcarecompared to nonsmokers.

Alabama spends more than $1.17billion each year in direct medicalexpenses to treat smoking-related dis-eases, while it allocates less than 10percent of minimum funding recom-mended by the CDC to address theproblem of tobacco use through pre-vention and cessation. Alabamaranks 36th in the nation in terms ofper capita funding to address tobaccouse prevention and control, yet one-fourth of Alabamians smoke.

DISPARITIESSmoking prevalence varies by race

and ethnicity, age, gender, and edu-cational attainment. Alabama hashigher rates of current smokers thanthe national average. Alabamiansages 45 to 54 have a higher preva-lence of smoking than other agegroups 18 and older. Caucasian menin Alabama are more likely to smokethan any other gender or racialgroup. Prevalence decreases wheneducational attainment and annualincome increase.29

EXAMPLES OF CURRENT ACTIVITIESTO REDUCE TOBACCO USE ANDEXPOSURE

To address these issues, in 1998ADPH convened the AlabamaTobacco Use Prevention andControl Task Force (Tobacco TaskForce) to develop and implement acomprehensive state plan to addressAlabama-specific tobacco issues. In2003, the Tobacco Task Force adopt-ed CDC’s Evaluation Plan to monitorprogress toward accomplishingAlabama’s goals and objectives. In2004, the Tobacco Task Force priori-tized activities to reach objectives,based on available resources. TheAlabama Comprehensive CancerControl Plan complements this planby adopting projects not targeted byother agencies.

Currently, state governmentresources to prevent and controltobacco use in Alabama are primarilyincluded in three agencies: ADPH,the Alabama State Department ofEducation (ALSDE), and theAlcoholic Beverage Control Board(ABC Board). The ADPH TobaccoPrevention and Control Divisionfunds a tobacco control program in

0

5

10

15

20

25

30

Grades 6-8 Grades 9-12 Adults 18+

AlabamaUS

Source: CDC YTS, BRFSS

Figure 13. Current Cigarette Smokers, by Age Group, Alabama and US, 2000


Tobacco continued

each of the state’s 11 public healthareas, employing 11 Tobacco UsePrevention and ControlCoordinators who provide technicalassistance to seventeen local tobaccocontrol coalitions. The Division alsofunds 14 minigrants statewide thepurpose of which is to empoweryouths to strengthen policies in theircommunities regarding tobacco use,exposure, and treatment. The Courseof Study developed by ALSDErequires that students be taught therisks of tobacco use and exposure tosecondhand smoke. Through theSafe and Drug-Free SchoolsProgram, schools are monitored toenforce the Alabama AdministrativeCode that requires school campusesto be tobacco free. Safe and Drug-Free Schools Coordinators also par-ticipate on local tobacco controlcoalitions and provide tobacco useprevention programming in theirschools. The ABC Board is responsi-ble for enforcing youth access totobacco products by providing mer-chant education, permitting fortobacco vendors, and enforcing statelaws regarding sales of tobacco prod-ucts to minors.

In April 2005, ADPH launchedthe first statewide Tobacco Quitlineavailable to all Alabamians free ofcharge. The 1-800-QUIT-NOW toll-free line offers counseling for nico-tine dependence as well as discountcoupons for nicotine replacementtherapy. Callers receive an informa-tion packet which is called a “QuitKit” and can receive additional coun-seling as they set a quit date anddevelop a plan to give up cigarettesor spit tobacco. Data shows that,with counseling, users are twice aslikely to be able to quit tobacco forgood. The line takes live calls from

8 a.m. to 8 p.m., Monday throughFriday. Callers can leave a message24 hours a day to receive moreinformation or a call back.

In 1993, the U.S. EnvironmentalProtection Agency developed areport on the respiratory healtheffects of secondhand smoke. Thissame report classified secondhandsmoke as a Class A Carcinogen, onewhich is known to be a cancer caus-ing agent in humans. To address theissue of Clean Indoor Air legislation,organizations across the state haveformed local coalitions and are work-ing within their municipalities tostrengthen clean indoor air laws. Atthe state level, a bill has been intro-duced in the current 2005 legislativesession to ensure that restaurantsacross the state are smoke free. TheAmerican Cancer Society and otherorganizations are spearheading effortsto support the passage of this bill.

EVIDENCE-BASED INTERVENTIONSTO REDUCE TOBACCO USE ANDEXPOSURE TO SECONDHANDSMOKE

The goal of comprehensive tobac-co control programs is to reduce dis-ease, disability, and death by prevent-ing the initiation of tobacco useamong youth, promoting quittingamong young people and adults, elim-inating nonsmokers’ exposure to sec-ondhand smoke, and identifying andeliminating the disparities among dif-ferent population groups related totobacco use and its effects.30 TheCDC’s Guide to Community PreventiveServices provides a list of evidence-based interventions for communityleaders, policy makers, and decisionmakers to consider. These interven-tions are recommended because theyhave been shown to have an impact


in tobacco use prevention andcessation.

CONCLUSIONS AND FUTUREDIRECTIONS

A significant decrease in the preva-lence of Alabamians who use tobaccoproducts depends on the implementa-tion of these evidence-based strategiestargeting the school-age population.Decreases in the incidence andmortality attributed to lung cancerwill then occur as this generation agesand reaches adulthood.

Public policy is the most effectivetool for tobacco prevention. Cleanindoor air legislation has been passedin some cities and is being consideredin many more. Ensuring smoke freeenvironments are available to allAlabamians will decrease not only

the rate of environmental tobaccosmoke health outcomes, but also thenumber of tobacco users. Advocacyfor legislation that addresses all pub-lic places in Alabama is a priorityissue for ACCCC and organizationsthroughout the state.

Current tobacco users in Alabamashould have access to effective smok-ing cessation aids. Insurers andemployers need to be educated onthe importance of smoking cessationaids as an adjunct to quitting, andthe increased savings that occurwhen these tools are available andutilized. Cessation of tobacco productuse will save the insurer and employ-er in costs attributed to loss ofproductivity and treatment oftobacco-related diseases.

Intervention RecommendationStrategies to Reduce Environmental Tobacco Smoke

Smoking bans and restrictions Recommended (strong evidence)Strategies to Reduce Tobacco Use Initiation

by Children, Youth, and AdultsIncreasing the unit price for tobacco Recommended (strong evidence)Media campaigns combined with appropriate interventions Recommended (strong evidence)

Strategies to Increase Tobacco CessationIncreasing the unit price for tobacco products Recommended (strong evidence)Media campaigns combined with appropriate interventions Recommended (strong evidence)Interventions appropriate for health care systems – Recommended (sufficient evidence)provider reminder systems aloneInterventions appropriate for health care systems – Recommended (strong evidence)provider reminder systems plus provider education (with or without patient education)Interventions appropriate for health care systems – Recommended (sufficient evidence)reducing patient out-of-pocket costs for effective treatments for tobacco use and dependenceInterventions appropriate for health care systems – Recommended (strong evidence)patient telephone support (quit lines) when combined with other interventions

Table 1: Evidence-based strategies to reduce tobacco-related diseases

Adapted from Guide to Community Preventive Services: Tobacco Use Prevention and Control. URL: http://www.thecommunityguide.org/tobacco/tobac.pdf


Tobacco continued

GOAL: All Alabamians will abstain from using tobacco products.

OUTCOME: By 2010, decrease from 20% to 15% the percentage of tobacco prod-uct sales in Alabama that are noncompliant of laws prohibiting salesto minors.

Data Source: 2003-2004 SYNAR Report

OUTCOME: By 2010, decrease from 13% to 10% the proportion of Alabamayouths in grades 6-8 who smoke cigarettes.

Data Source: 2004 Middle School Alabama Youth Tobacco Survey (ALYTS)*

OUTCOME: By 2010, decrease from 24% to 16% the proportion of Alabamayouths in grades 9-12 who smoke cigarettes.

Data Source: 2004 High School ALYTS

OUTCOME: By 2010, decrease from 25% to 21% the proportion of Alabama adultsage 18 and older who smoke cigarettes.

Data Source: 2004 Behavioral Risk Factor Surveillance System (BRFSS)*

OUTCOME: By 2010, decrease from 7% to 1% the proportion of Alabama youthsin grades 6-8 who use spit tobacco.

Data Source: 2004 Middle School ALYTS

OUTCOME: By 2010, decrease from 12% to 1% the proportion of Alabama youthsin grades 9-12 who use spit tobacco.

Data Source: 2004 High School ALYTS

OUTCOME: By 2010, decrease from 21% to 12% the proportion of Alabama adultsage 18 and older who use spit tobacco.

Data Source: 1997 BRFSS

OBJECTIVE 1: Decrease the number of tobacco product sales to minors.Data Source: SYNAR Report

STRATEGY 1-1: Educate merchants, particularly those who are not members of merchant associations, about tobacco sales laws and theconsequences of noncompliance.

Principal Agency/ies: ABC/Responsible Vendor

Other Partners and Programs: ADMHMR/Substance Abuse; ADPH/HealthPromotion & Chronic Disease; ADPH/Tobacco Prevention

Linkages: Alabama Association of Convenience Stores; Alabama Oilman’sAssociation; Alabama Retail Association

* All BRFSS and ALYTS data are self-reported.

TOBACCO


STRATEGY 1-2: Educate clerks who sell tobacco products about tobacco saleslaws and the consequences of noncompliance.

Principal Agency/ies: ABC/Responsible Vendor

Other Partners and Programs: ADMHMR/Substance Abuse; ADPH/HealthPromotion & Chronic Disease; ADPH/Tobacco Prevention

Linkages: Alabama Association of Convenience Stores; Alabama Oilman’sAssociation; Alabama Retail Association

OBJECTIVE 2: Increase awareness about the risks of tobacco use and exposureamong youths in grades 6-12.

Data Source: ALYTS; YRBS

STRATEGY 2-1: Develop and implement a Public Service Announcementcampaign to inform youths about the risks of tobacco use,including spi

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