3 ^ ^ Mm. rfo/fw Hs*o« iSoSV ,/ Spotlight on Cancer in Massachusetts * UMASS/AMHERST * immunity Health • Massachusetts Department of Public Health • Fall 1993 150 Tremont Street • Boston MA 0211 1 • 617-727-124&- 31E0bb QEfll ssb? ^ rlioo Old for Breast Cancer Screening? In general, there is no reason not to recommend • ceasing to have mammograms. Any decision to mammography for older women unless individual stop getting mammograms should be made by the factors including age, life expectancy orir,Mt r,QpiQ^£|ff$roman, based on the best medical advice you can comorbidities make screening nd^^hhwmle^-^Q^ give her. In 1990, American women who reached the, 65 could expect to live another 18.3 ye^r$>' Free Mammograms for Uninsured Women who reached 75 could expect another 12 years. Women who reach 85 years could expect If you have patients who are without health another 7 years. (U.S. Bureau of me*Census) insurance or are underinsured, free mammograms are available through programs offered by the Biological aging frequendy differs from American Cancer Society and the Massachusetts chronological aging. Because people age at such Department of Public Health. For programs in different rates, it would be a mistake to assume your area, call: 1-800-227-2345 that breast cancer screening, including mammography, is of limited value to all women over a certain age. Mammography Licensing If a woman's individual circumstances make it unlikely that she will benefit from early detection The state's far-reaching mammography licensing of breast cancer, discuss with her the option of regulations became effective in July 1993. Key requirements are detailed for the responsible physician, radiologic technologist, medical Risk factors physicist and interpreting physician. ~ Growing older especially older than 50 -- is the The regulations require the interpreting physician leading risk factor for breast cancer. Only 25% of to provide a report in lay language to the all breast cancer cases occur among women in referring physician or, in the case of a self- other risk categories. referring patient, to the patient. Other risk factors for breast cancer in women Also included are requirements for the physical include a family (sister or mother) or personal facility, optimum exposure ranges, equipment history of breast cancer, never giving birth or first standards, a quality assurance program and childbirth after age 30, late age at menopause, and equipment quality assurance. exposure to radiation. Benign breast lumps do not increase a woman's risk of developing breast Record keeping requirements include keeping cancer unless the lumps are caused by cell films and related records for 10 years. Patient changes. These cell changes must be confirmed by rights and confidentiality are also spelled out in a tissue sample. detail. Breast Cancer Detection Guidelines The American Cancer Society guidelines for Mammograms should be performed as a breast cancer detection in women 50 and older complement to the physical examination and are: should not be used as a substitute for palpation of the breast by a trained examiner, since • Breast self-examination monthly. mammography misses 5 to 15% of palpable breast cancers, depending on the density of the breast • Clinical breast examination every year by a and the location of the tumor within the breast. health professional. The combination of palpation and mammography • Screening mammograms every one to two years. misses approximately 10% of breast cancers - detected within a year of the examination a Medical practitioners should establish a reminder finding that emphasizes the importance of frequent system to promote screening at recommended examination and follow-up. intervals. Massachusetts Incidence Most breast cancers are found by women themselves between scheduled screening Massachusetts has the sixth highest mortality rate mammograms. Women should be encouraged to for breast cancer in the nation. In 1991, 1,365 perform a breast self examination monthly and women died of the disease. should be instructed in both proper technique and breast anatomy. Barriers such as forgetting and Breast cancer increased 30% in Massachusetts embarrassment need to be addressed in order to from 1982 to 1989. During this same period, increase compliance. national data showed an increase of 18%. Mammography is the only effective technique now For 1982 through 1989 the incidence rate for 20 available for detecting nonpalpable, highly curable to 44 year old women was 38.2 per 100,000 breast cancer. In women over age 65 the women. This increased to 254.7 per 100,000 for sensitivity of mammography is increased, and the women 45 to 64; 423.3 for women 65 to 74, and positive predictive value for mammography is 452.4 for women 75 to 84. For women age 85 and higher than for younger women. over the rate was 371.9 per 100,000. \WJ5. ^H/f«.\> Spotlight on Cancer in Massachusetts Bureau of Family & Community Health • Massachusetts Department of Public Health • Feb 1994 150 Tremont Street • Boston MA 02111 • 617-727-0945 Tobacco: The Leading Preventable Killer Tobacco is the leading cause of preventable death The median age for starting to smoke in and disease in Massachusetts, responsible for one Massachusetts was 17 with 25% starting at 15 or fifth of all deaths among residents age 35 and younger. Because many youths start smoking to older. Smoking is a risk factor for numerous mimic their parents, teachers and other role ~ cancers including lung, cervical, bladder, oral, models, all adult smokers should be urged to quit. esophageal, larynx and kidney cancers -- as well as for cataracts and diseases of the heart and circulatory system. Women who smoke during Quitliiie helps smokers quit pregnancy are at increased risk for low nC £u . birthweight babies, miscarriage^^emature births- To help patients stop smoking, urge them to take and prenatal deaths. ^ " C advantage of the Smoker's Quitline, a toll-free telephone resource: Yet 29% of Massachusetts young wo Wages to the 1991 Be%havoiforyaolunRgismkeFnacstmorokSeuragcwc0o*r*dir^>^*T*d|t^e0000.-8T.DRYE-JTAOL-OST(O1.P80(01--883030--5827596-)86i7n8)SpEanngilsihs,h, and 1-800-TDD-1477 (1-800-833-1477) for the conducted by the Massachusetts ^^Wrr^j^OT^^ hearing impaired. Public Health. More than 25% of all women of reproductive age (ages 18-44) said they smoked. Urge every patient who wants to stop smoking to call the Quitline will help them be successful. Studies have repeatedly shown that smokers Trained counselors will guide and support them are more likely to quit if their physician advises through the quitting process. them to and provides assistance and support. Quitline services include information on the Asking all patients if they smoke, urging smokers hazards of tobacco, self help quit guides, referral to quit and offering assistance may be the most to smoking cessation programs and telephone important things a physician can do for patients counseling on quitting. who smoke. If you mark all smokers' charts with a color coded dot or other readily identifiable The Quitline is staffed weekdays from 9am to sign, it will remind you to encourage them to quit 9pm and weekends from 10am to 3pm. smoking and offer advice each time the patient has an appointment. (The American Cancer The Quitline is operated by the American Cancer Society has free chart markers available.) Society, Massachusetts Division, and funded by the Massachusetts Tobacco Control Program at the Smokers can stop. The 1991 smoking prevalence Department of Public Health. for all Massachusetts residents was 23%, a 15% decline from the 27% of the population that smoked in 1986. Overall, approximately 50% of Massachusetts residents who ever smoked no lonser do so. Nicotine Replacement Guide Nicotine replacement is another tool physicians Nicbtrol by Parke-Davis can use to help patients stop smoking. Dose duration: 16 hours Nicotine per patch: 15, 10,5 mg Before prescribing nicotine replacement, make sure the individual truly wants to stop smoking. Prostep by Lederle Nicotine replacement only works when the Dose duration: 24 hours individual has a personal commitment to quitting. Nicotine per patch: 22, 1 1 mg Next, determine the patient's degree of addiction. To be successful, nicotine patch users need to A patient may be helped by a prescription for participate in a cessation program and be closely nicotine replacement if that individual meets one followed by their physicians. Patch users will be or more of the following criteria: more likely to succeed if they are given support and assistance by physicians or their staff. They • smokes one or more packs of cigarettes a day should feel free to call the physician's office for encouragement. Patch users can also call the • needs to smoke within 30 minutes of awakening Quitline for counseling or for referral to a smoking cessation program. Cessation programs • has experienced significant physical withdrawal vary as to length and cost. symptoms during the first week of previous quit attempts, including: severe craving, difficulty Once someone has succeeded in quitting smoking, concentrating, anxiety, irritability, headaches, they need to be congratulated and supported drowsiness or stomach upset during the first weeks they are smoke free. According to the Massachusetts Behavioral Risk • continues to smoke when too sick to do Factor Survey, 54% of all current smokers who anything else tried to quit, started smoking after one day. Relapse rates are similar for both men and There are currently four brands of transdermal women. Encourage those who are trying to quit. nicotine patch, which vary in nicotine dose and Let your patients know that even though they have recommended weeks of use. All brands not succeed in previous attempts to quit, they can recommend a higher dose for the first weeks. be successful. National data indicates persons There is also a nicotine gum which is also by make, on average, seven or more attempts to quit prescription. before they become permanently smoke free. Four nicotine patch products currently are approved by the US Food and Drug Administration: Habitrol produced by Ciba-Geigy Dose duration: 24 hours Nicotine per patch: 21, 14, 7 mg Nicoderm by Marion Merrell Dow Dose duration: 24 hours Nicotine per patch: 21, 14, 7 mg ' MASS- h\^>3o on Cancer Massachusetts Spotlight in Bureau of Family & Community Health • Massachusetts Department of Public Health « May 1994 150 Tremont Street • Boston MA 02111 • 617-727-0945 Colorectal Cancer Can Nonphysicians Do Screening? Two recent studies provide strong evidence that physician endoscopists be readily available for screening sigmoidoscopy can significantly reduce consultation should the need arise. mortalityfrom colorectal cancers. In addition to its impact on mortality, screening sigmoidoscopy also has the If the effectiveness and reduced cost of this approach are potential to reduce the incidence of colorectal cancer confirmed, use of nonphysician endoscopists offers a through the identification and removal of premalignant feasible meansofexpandingexisting resourcesto provide adenomatous polyps. Unfortunately, this approach has greater access to the populations at risk for colorectal not had a national impact largely because of poor patient cancers. acceptance and lack of widespread use by physicians. - PaulC. SchroyIII, MD 00 AssistantProfessorofMedicine Boston UniversitySchoolofMedicine flexible sigmoidoscopy has been advocated as a(jj\"*b^kr^^^^ju. i x CCnartll\yt Un/lo/S-y##n-»O/S-iIoiSo of addressing the problem of inadequate T^P Proponents argue that nonphysician endoscopistsj?eukj^ -Physicians must keep in mind that when screening expand availability of this examination while reducing indicatetfjgolonic pathology (occult blood or polyps on cost. ;1wBre^igmoidoscopy), the patient requires a complete $ v,. QSJ^ c workup by means of colonoscopy or air-contract To date at least five separate published sti *fvJ* barium enema. Unfortunately, many physicians have the examined the feasibility of this approach to colorectal misconception that several subsequent negative occult cancerscreening. These studies clearly demonstrate that blood testings eliminate the need for complete workup a variety of paramedical personnel -- including nurse after a single positive stool test for occult blood. It is now practitioners, physiciansassistants, endoscopyassistants, clear that many patients with a single positive hemocult registered nurses and practical nurses - can be trained will have colonic neoplasia. to perform safe, proficient examinations with adenoma and cancer detection rates comparable to those reported The primary treatment for colorectal cancer remains by physician endoscopists. There have been no extirpation. In the past, there was a misconception that complicationsand patientcompliance has been excellent. colorectal cancer patients required a colostomy and that survival was very limited. Preserving rectal function is a However, the use of paramedical personnel to perform major goal of current treatment; consequently, screening sigmoidoscopy has engendered considerable abdominioperineal resection with permanent colostomy is debate. Few, any, proponents advocate a role for seldom performed. if nonphysician endoscopists in the evaluation of symptomatic patients. Even if their role is restricted to Colorectal cancer is the most curable gastrointestinal evaluation of asymptomatic patients, opponents cite cancerwith survival rates farexceeding those forcancers quality control, liability issues, abuse potential, of the stomach, liver or pancreas. Radiation therapy and reimbursement concerns and deflated patient more recentlychemotherapy have an important role inthe expectations as major deterrents. To date these treatment of selected patients. Again, the need for concerns have been borne out in clinical trials. chemotherapy and radiation depends on the state of disease; the earlier the diagnosis, the less likely any The useofvideoendoscopywithvideotapedocumentation treatment other than surgery will be needed. provides a feasible means of ensuring quality control and -MarvinJ. Lopez, MD protecting against liability. It is also recommended that Chief, GeneralandOncologicalSurgery St. Elizabeth's MedicalCenter, Boston You Can Make the Difference Counsel your patients reduce to every 3 to 5 years. Urge them to: Any suspicious areas noted during sigmoidoscopy or •reduce dietary fats colonoscopy, should be biopsied. Although the etiology •increase dietary fiber of colorectal cancer is unknown, experts agree this •reduce alcohol (especially beer) intake cancerdevelopsfrom a small benign adenomathatgrows •quit smoking on the bowel in the lumen. When colon polyps are found to be adenomas, it is important to remove them. Review each patient's risk • The incidence of colorectal cancer increases steadily For persons who need more extensive examinations, with age. From age 40 on the risk doubles every 10 consider a barium enema with air contrast or colonoscopy. years. • A personal or family history of colorectal cancer, breast High risk persons should begin examinations at an early cancer, cancerofthe endometrium, familial adenomatous age, perhaps as early as age 20. polyposis, Gardner'sSyndrome, Peutz-JeghersSyndrome or inflammatory bowel diseases such as chronic Possible Symptoms ulcerativecolitisorCrohn's Disease indicates high riskfor • Change in bowel habits colorectal cancer. • Enlargement of the liver • Abdominal bloating • A high-fat, high-protein and low-fiber diet has been • Pain in the lower back associated with increased risk. Alcohol, especially beer, • Bladder symptoms may also be a risk factor. • Blood in the stool • Rectal bleeding •Two recent studies suggestthere may be an association • Lower abdominal pain which does not subside quickly. between smoking and colorectal cancer. Right-sided colon cancers tend to grow into the space Note that 85% of all persons diagnosed with colorectal within the bowel. Symptoms include: cancer have none of these risk factors except age. • Pain in the right side of the abdomen with a mass discernable by palpation Screening • Unexplained iron deficiency anemia. The National Cancer Institute and the American Cancer A chemical test for hemoglobin as well as a stool blood Society recommend screening for persons without test should be performed on all such persons. If these symptoms at the following intervals: are positive, further tests such as a colonoscopy should be performed. • A digital rectal examination every year for persons age 40 and older. This exam can reach one in seven large Left-sided colon cancers characteristically encircle the bowel cancers. bowel wall, constricting it and causing partial blockage. Symptoms include: • A stool blood test every yearfor persons over 50. (The • Increasing constipation, often with bloating and gaseous patient should be on a meatless, high-fiber diet free of distention of the abdomen vitamin C either in foods or supplements for previous 48 • Bleeding hours.) A positive test is not definitive since occult blood • Anemia, but less severe than in right-sided cancer. may be caused by diet or hemorrhoids. However, the presence of such blood indicates a need for further Rectal cancer symptoms include: • Diarrhea, often containing blood examination. • Sensation of incomplete stool evacuation. • A proctosigmoidoscopy examination every year for -Martha Crosier Wood CancerControlCoordinator patients over 50. After two initial negative proctos, Massachusetts DepartmentofPublicHealth Spotlight on Cancer in Massachusetts Bureau of Family & Community Health • Massachusetts Department of Public Health • Fall 1994 150 Tremont Street • Boston MA 0211 1 • 617-727-0945 Mammography Massachusetts Licenses Sites With an emphasis on patient protection, the new As of October 1, 1994, a total of 126 facilities Massachusetts mammography licensing have been inspected. Two were in complete requirements ensure excellence in breast imaging. compliance, 13 were in violation, and the remaining 111 had only minor deficiencies that The new regulations assure the referring physician will be corrected. that patients will receive a high-quality mammogram, a standard that includes the patient The Department urges all physicians to include receiving the lowest possible dose of radiation. screening mammography as part of annual physical examinations for all women 50 years old The regulations require that all machines used for and older. Mammography, along with a clinical mammography must be specifically designed to breast examination and monthly breast self perform mammography only. Each machine must examination, represent the best defense against be inspected and registered with the Department death due to the epidemic of breast cancer. All of Public Health. medical practitioners should establish a reminder system to promote breast cancer screening at The regulations, which apply to all facilities in the recommended intervals. Commonwealth, set qualifications and duties for the license holder, the responsible physician (the Mammography facilities are required to have physician designated by the licensee as responsible patient education materials available explaining for the quality assurance of the facility), the the importance of mammography, how a interpreting physician, the mammography mammogram is done, and screening mammogram radiologic technologist, and the medical physicist recommendations. for the facility. Patients will be asked to fill out a health The regulations set requirements for optimum questionnaire specific to breast cancer risk factors exposure ranges, annual evaluation and calibration at their first mammography appointment at each of the mammographic x-ray unit, and routine facility. Information collected documents any past quality assurance testing of all related equipment. history of breast cancer, family history of breast cancer, age of onset of menses and menopause, The Massachusetts Department of Public Health medication use, previous surgeries, time(s) and will inspect each of the state's 230 mammography place(s) of previous mammogram(s), and child facilities before issuing a license. Facilities must bearing history. This questionnaire will become be inspected annually. The regulations governing part of the patient's medical record which must be this program include 375 items to be inspected. maintained at the mammography facility. They cover all the requirements of federal agencies and the American College of Radiology In addition, all sites must provide each patient accreditation program, but are even more with a patient's rights statement informing her of comprehensive. her right: • to discuss radiation safety concerns prior to Digitized by the Internet Archive 2014 in https://archive.org/details/spotlightoncance9939mass Spotlight on Cancer in Massachusetts Bureau of Family and Community Health • Massachusetts Department of Public Health • 150 Tremont Street $V MA C Boston, 02111 • 617-727-0945 v Fall, 1995 Cervical Cancer Incidence Remains Steady In Massachusetts, 3,307 new cases of invasive HMOs, ambulatory surgery centers, freestanding cervical cancer were reported between 1982 and radiation therapy centers, freestanding medical 1992. During that period the age-adjusted oncology centers, freestanding pathology incidence rate for Massachusetts females was 8.1 laboratories, and physicians' offices (such as per 100,000, according to the Massachusetts oncologists, dermatologists, urologists and Department of Public Health Cancer Registry. gynecologists) in the Commonwealth will be required to report cases. The annual number of invasive cervical cancer cases has varied only slightly during the decade, This fall the Cancer Registry will publish Cancer averaging 330 cases per year in Massachusetts. Incidence in Massachusetts 1982-1992 providing statewide information. During the winter a Although cervical cancer is often considered a companion publication providing incidence data cancer for younger women, 1982-1992 by municipality will be published. These Massachusetts Cancer Registry data shows older publications will be available by calling the women are at highest risk for invasive cervical Cancer Registry at 617-727-9291. cancer. The peak ages for diagnosis of invasive cervical cancer in the state were 60 and older. The highest incidence rate was 20.5 per 100,000 Patient Education Materials, for women 70-74. The rate was 20.1 per 100,000 Professional Education Training for women 60-64 and 19.7 for women 65-69. The rates were only 1.6 per 100,000 for women 20-24; Available From State Program 5.9 for women 25-29; 11.4 for ages 30-34; and 13.2 for ages 35-39. The Massachusetts Department of Public Health's Breast and Cervical Cancer Initiative (BCCI) has National data shows that older women are the resources for patients and providers on cervical most likely to die of cervical cancer. health and Pap smears. Videos, pamphlets and posters are available. Print materials are available Since 1982 all Massachusetts hospitals have been in non-English languages. For more information, required by law to report cancers to the Cancer call Janine Cory at 617-727-7222. Registry. However, as health care provision patterns move increasingly toward more outpatient BCCI conducted four professional education care, some types of cancers, including cervical training workshops on cervical cancer detection cancer, are probably being underreported. and protocols in the spring of 1995. If you would Beginning with cases diagnosed as of January 1, like information regarding future training 1995, all persons or entities diagnosing, evaluating opportunities, call Janice Mirabassi at or treating cancer patients, such as private clinics, 617-727-7222. State Funds Screening Programs Family Planning Offers Gyn the only source of health care. In FY 1994, these clinics provided services to 85,599 clients. About 25% Exams, Paps, Colposcopies were less than 20 years old, 67% were between the ages of 20 and 34, and 8% were 35 years or older. Many of those seeking services from family planning About one-third of all clients were Hispanic, black or clinics are the women at highest risk for cervical Asian, and approximately 20% spoke a language other cancer: adolescents with early initiation of sexual than English. intercourse, as well as women and teens who have had multiple sex partners. For the family planning clinics nearest you, or for more information, call the DPH Family Planning The Massachusetts Family Planning Program, Program at 617-727-5121. supported by the Massachusetts Department of Public Health (DPH) and the US Department of Health and BCCI Programs Screen Older, Human Services (DHHS) Title X, is committed to Uninsured Women Statewide providing comprehensive family planning and reproductive health care to low income women, Older women may be reluctant to have a Pap smear, adolescents and men. Program goals are to prevent because they do not want to undergo a gynecological unintended pregnancies and abortion, halt the transmission of HIV/AIDS and sexually transmitted examination, believe that cervical cancer is a disease of younger women, or are concerned about cost. The diseases, prevent cervical cancer and promote general Massachusetts Department of Public Health Breast and good health. Cervical Cancer Initiative offers free health services across the state for women age 40 and older who are Services include complete medical and gynecological uninsured or underinsured (including the Medicare "off examinations; screening for breast and cervical cancer and STDs; provision of contraceptives; health year") and those under age 40 who are at high risk for breast cancer. education; and counseling. The program provides Pap smears, colposcopies and In response to the increasing rates of abnormal Pap smears, coupled with the lack of access and availability cervical biopsies. It also provides clinical breast of low cost colposcopy in high-risk populations, two examinations, screening mammograms and breast family planning clinics are using DPH family planning diagnostic services. Other funding mechanisms, funds to subsidize colposcopies for uninsured women including the free care pool, are tapped for additional services and follow-up. and adolescents. Several other clinics also provide colposcopy on a limited basis. Each program offers education and outreach services In Fiscal Year (FY) 1995, 125 women received which can provide additional support to women subsidized colposcopies through the two sites. reluctant to seek screening or follow-up. Approximately 15% were adolescents 19 years or younger and the mean age of all the women seen was Since cervical cancer has a long latency period, older 23.4 years. A biopsy was performed with a women, including women 70 years old and older, colposcopy in 95% of the women who were part of the should have a Pap smear if they have ever had sexual pilot program. Among the 119 women who had a intercourse. As Cancer Registry data shows, many Massachusetts women with invasive cervical cancer are biopsy, 73 (61%) received treatment and follow-up, including either cryosurgery, LEEP or outside referral. older; however, older or post-menopausal women are often not referred for Pap smears. Low income women, especially minorities and teens, are the most frequent consumers of publicly-funded The program funds 37 health agencies statewide to family planning services in Massachusetts. For the provide services. For the site nearest you, or for more majority of these consumers, many of whom are information, call 1-800-ACS-2345. uninsured, family planning clinics are often