DC Cancer Plan |
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Statement of Support
for As the
directors of the
As much as the cancer centers and cancer-related organizations in the District work to reduce the number of people being diagnosed with, suffering from, and dying from cancer, we realize that much more is needed. The Cancer Plan before you provides a blueprint for the next steps to be taken if we are to make meaningful progress toward reducing suffering and death from cancer. We must work together if we are to reduce the burden of cancer in our city. To that end, the DC Cancer Coalition, a broad partnership of public and private institutions, organizations, and advocates has developed a comprehensive, coordinated plan with specific strategies to have a greater impact on cancer in the District. Our institutions are committed to work collaboratively together and with the cancer community in implementing the Plan, and we invite all other concerned citizens and organizations to join us. Please become familiar with the Plan. Talk with your colleagues.
Then identify how your institution, agency, or organization can use the Plan as
a guide for your own activities and consider what role you can play in
implementing strategies for the greater good of the citizens of the
Lucile Adams-Campbell, PhD Steven
Patierno, PhD
Lawrence S. Lessin, MD Richard G.
Pestell, MD, PhD
Executive Summary: Creating
the District’s First Cancer Plan
In
2001, because the
The
Coalition is a partnership of medical centers, nonprofit organizations,
academic and research institutions, community groups, advocates, professional organizations,
and others. We have worked together for four years to produce the District’s
first Cancer Plan—an analysis of the present environment, a blueprint to reduce
the number of new cases of cancer and the number of cancer-caused deaths and to
improve the quality of life for cancer survivors in the nation’s capital.
As
you will see, the need is urgent.
Cancer
in the District: Portrait of Inequity
Our
city of 560,178 residents—the nation’s capital—has the highest cancer mortality
rate per population in the
These
high rates exist despite having four cancer centers, a total of 11 hospitals,
and an abundance of excellent cancer care services. But many of these services
are neither accessible nor affordable for many of DC’s citizens—the poor and
medically underserved (uninsured and underinsured), most of whom are Black or
Hispanic. About 58% of the District’s population is Black, 27% is
White and 3% Asian. About 10% of the population is of Hispanic origin (some
self-identifying as White, and some as Black). Another 2% describe themselves
as “two or more races or other.” [Thomson Medstat©2004] The Hispanic population
is the city’s fastest-growing and includes many of the poorest residents.
Hispanic residents are the least likely to have health insurance of any kind.
Key
factors influencing the high rates of cancer incidence and mortality include
• Lack of medical homes. Many of the District’s residents—about 300,000—live in a “Health Professional
Shortage Area (HPSA).” This includes many of the working poor. These residents
lack what is called a “medical home,” a primary care provider who knows their
health history and is a reliable source of routine medical care. The single
largest determining factor in the use of cancer services, from prevention
through treatment and follow-up, is having a primary care physician who makes
recommendations and provides assistance in navigating the health care system.
The DC Primary Care Association (DCPCA) links this lack of adequate primary
care to poorer health outcomes, higher health care costs, and overused, overcrowded emergency rooms.
“Because people can’t find a doctor,” • Screening
difficulties. Deaths from breast, cervical, colorectal, and
prostate cancer can be avoided or decreased through screening procedures.
However, facilities for cancer screening are few and far between in the
District’s poorer neighborhoods. Most screening resources are located north of
the
• Additionally, the
District underfunds • The
health care labyrinth. In addition to its many hospitals and
medical centers, the District prides itself on having many public and private
health care clinics. However, the clinics are only loosely linked to each other
and to other parts of the health care system. It can take people with symptoms
a long time to get a clinic appointment, and a patient who does manage to get
screened and receives a screening result indicating possible cancer may not get
appropriate • It can be very
difficult for any patient—rich or poor, highly educated or uneducated— • Information
deficit. The DC Cancer • Fragmented
health insurance system. The DC HealthCare Alliance, in
partnership with the DC Department of Health, private and nonprofit health
clinics, offers low-income residents access to an array of health care
services. Because the
• It should be noted
that, unlike most states, the
The bottom line is that many of the
District’s neediest residents cannot or do not take advantage of available
cancer care in the District. They struggle to navigate the convoluted health
care system, the programs designed to provide care often fail to do so, there
is no substantive public health structure—and as a result people are dying of
cancer at high rates, despite living near highly sophisticated cancer care
facilities.
Plan preparation and components The DC Cancer Coalition workgroups (including physicians, public health experts, community leaders and others) have developed specific research-based chapters of the Plan. In each chapter, we assess the cancer burden, address current resources, identify gaps in care, and set forth prioritized recommendations that we believe will set the District and the health care community on course to correct the problems presented.
What Must Be Done: Implementation The next step in addressing cancer control and prevention is
to use the Cancer Plan to move the District forward. We understand that
bringing the Cancer Plan to life is the work of years, and that with individual
and collaborative actions must come ongoing evaluation and mid-course
corrections as needed to respond to the changing Some of the work ahead will require examining public policy that affects cancer in DC. Other priorities demand new avenues of collaboration among the city’s health care providers, and securing the funding necessary to make collaboration possible and effective. These tasks are formidable, but the Coalition’s members are committed to doing everything in our power to relieve DC’s heavy burden of cancer incidence and mortality. Behind the statistics is great human suffering, and that suffering must be alleviated. Almost every part of cancer care as it relates to the
medically underserved majority of residents in the
Goals and Objectives
OVERARCHING GOAL AND PRIORITIES OF OVERALL GOAL: Reduce cancer incidence and mortality, reduce racial and ethnic disparities in cancer treatment, and improve the quality of life of cancer survivors by Improving access to care • Merge the DC Health Care
• Secure sufficient funding for the combined
• Ensure every resident has a “medical home” for primary care • Provide patient navigation for cancer screening and treatment • Coordinate cancer services by linking clinics and hospitals • Improve cancer-related transportation services • Improve cancer patients’ access to clinical trials Increasing rates of screening, particularly for breast, cervical, prostate and colorectal cancers, and providing all necessary follow-up cancer care Increasing
public awareness of healthy behaviors that prevent cancer
• Reduce tobacco use • Reduce obesity • Increase regular physical activity • Eat healthy food and avoid overeating Advocating with the City government on issues and funding relating to cancer Educating
health care providers about
• Early detection of cancers • Pediatric cancers • Rehabilitation • Palliative and end-of-life care Improving
the collection and use of DC data about cancer
• Improve quantity and quality of data collected about the Hispanic population Educating survivors and caregivers about resources and
follow-up care
Increasing awareness of and availability of palliative care
and end-of-life care
CHAPTER GOALS AND OBJECTIVES ACCESS TO CARE
GOAL: To improve access to primary and cancer care for DC residents. Objectives:
1) Create a coordinated patient navigation system by 2008. 2) Establish
affiliation agreements between the community health centers, hospitals, and
health 3) Improve access to public transportation for cancer patients by 2010. 4) Increase
the participation of eligible minority residents in cancer-related clinical
trials by 15% 5) Educate consumers about access to cancer screening, care, and other services by 2010.
PREVENTION
GOAL: Reverse the trend toward obesity and overweight by
increasing physical activity and the consumption of fruits and vegetables and
by reducing Objectives:
1) Reduce the prevalence rate of obesity among DC adults to 15% by 2010. 2) Reduce the prevalence of overweight adults to 40% by 2010. 3) Reduce the prevalence rate of overweight and obese children to 5% by 2010. 4) Increase to 60% the prevalence rate of adults who engage in regular, moderate physical activity for at least 30 minutes a day at least five days a week by 2010. 5) Increase to 40% the prevalence rate of high school students who engage in moderate physical activity 30 minutes or more, five or more days a week by 2010.
SMOKING-RELATED CANCERS <top> GOAL: Reduce mortality from smoking-related cancers in the
Objectives:
1) Reduce the level of smoking among high school
students from 13% to 10% by the year 2010.
2) Reduce the level of smoking in current Black and Hispanic smokers and those with low levels of education by 25% by the year 2010. 3) Reduce general exposure to secondhand smoke by creating a smoke-free environment in all public places by 2006. 4) Reduce racial disparities in smoking prevalence by 2010. HEAD AND NECK
CANCERS
GOAL 1: Reduce the mortality rate in DC from cancers of the head and neck by 10%. GOAL 2: Reduce the incidence of invasive cancers of the head and neck in DC by 10%. Objective:
Increase to 50% the proportion of head and neck cancers detected at the local stage for both men and women by 2010.
BREAST CANCER
GOAL: Reduce mortality rates from breast cancer in the District by 10%, especially among Black women. Objectives:
1) Reduce the incidence of invasive disease in DC by 10% by 2010. 2) Increase
the number of women aged 50 through 64 who are screened annually by 10% 3) Reduce the proportion of unstaged cases to less than 5% by 2010.
GYNECOLOGIC
CANCERS
GOAL 1: Identify a greater proportion of cervical cancer cases before the cancer has spread beyond the local stage. Objectives:
1) Increase the proportion of women diagnosed at the local stage to 90% by 2010. 2) Increase the rate of Pap screening to 90% (recent
screens) and 97% (ever-screened) in all GOAL 2: Make 50% of women aware that postmenstrual bleeding is
a possible GOAL 3: Increase public awareness of ovarian cancer symptoms. Objectives:
1) Reduce the incidence of late-stage diagnosis by 2010. 2) Improve the amount of accurate staging of ovarian cancer
and reduce the proportion of GOAL 4: Improve the quality of care for underinsured and
uninsured women in the Objective:
1) Increase information and support to DC clinics and providers treating the target population by 2010. COLORECTAL CANCER
GOAL 1: Reduce the mortality rate in DC from colorectal cancer by 10%. GOAL 2: Reduce the incidence of invasive disease in DC by 10%. Objectives:
1) Increase to 50% the proportion of colorectal cancer detected at the local stage for both men and women by 2010. 2) Increase
to 50% the proportion of the adult population that reports having had a fecal
occult
PROSTATE CANCER
GOAL: To reduce the mortality rate from prostate cancer in DC by 10%. Objectives:
1) By the year 2010, increase to 65% the percentage of Black men 45 years or older who are annually screened for prostate cancer. 2) By the year 2010, reduce the proportion of unstaged prostate cancer cases to less than 5%.
PEDIATRIC CANCERS
GOAL: To ensure that all
Objectives:
1) Develop a system for coordinating research and the dissemination of information about diagnosis, clinical trials, treatment, follow-up care and supportive services to health care providers in DC by 2010. 2) Ensure that all DC childhood cancer patients and their families have access to culturally relevant information and services, from diagnosis through survivorship or end-of-life and bereavement services by 2010. 3) Establish a system to ensure that accurate data on incidence, survival, and mortality rates for pediatric cancers are collected and are available for health care providers, researchers, and the public by 2010. PALLIATIVE CARE
GOAL 1: Integrate palliative care into the District’s health care system and increase public understanding of palliative care and its role in cancer care. Objectives:
1) Provide education about palliative care for health care providers and the public by 2010. 2) Promote the development of palliative care programs in health care facilities and community- based settings throughout the District by 2010. 3) Develop innovations and changes in the health care delivery system that promote palliative care services by 2010. GOAL 2: Improve the availability of,
and access to, palliative care services for the underserved and culturally
diverse population of the
Objectives:
1)
Strengthen the health care delivery system, including palliative care for
underserved and diverse populations in
the
2) Target public service messages about palliative care to specific
underserved populations by 2010. CANCER SURVIVORSHIP <top> GOAL: Improve the quality of life for DC cancer survivors. Objectives:
1) Implement a coordinated patient navigation system by 2008. 2) Increase demand-responsive public transportation for low-income cancer survivors by 2007. 3) Assess current resources for survivors and caregivers by 2006. 4) Promulgate clinical practice guidelines for each stage of cancer survivorship, from diagnosis through long-term treatment and end-of-life care by 2007. 5) Establish a database on cancer survivorship by 2008. 6) Educate corporate, academic, and community policymakers and decision-makers about key health care issues for cancer survivors by 2008. 7) Develop a community awareness program for cancer
survivors by 2007. CANCER
REHABILITATION
GOAL: Increase awareness of
cancer rehabilitation services in the
Objectives: 1) Create a
repository of information on cancer rehabilitation services in the
2) Increase awareness and knowledge of fellows in training, oncology physicians, and oncology nurses about cancer rehabilitation and services by 2008. 3) Increase public awareness of cancer rehabilitation and services available by 2009. 4) Develop liaisons among area hospitals and community organizations to conduct research on effective cancer rehabilitation assessment and treatment by 2010.
Introduction:
To address the problem of very high rates of cancer in the
Committed to addressing the District’s very high cancer rates—the highest cancer death rates in the nation—the Coalition is a broad-based partnership, including medical centers, nonprofit organizations, academic and research institutions, community groups, advocates, professional organizations, and others. All have an interest in cancer prevention and control. Our objective has been to develop a comprehensive cancer control plan that could serve as a blueprint for reducing the number of new cancer cases in the District and the number of deaths from cancer. We have followed the CDC’s model of creating “an integrated coordinated approach to reducing cancer incidence, morbidity, and mortality through prevention (primary prevention), early detection (secondary prevention), treatment, rehabilitation, and palliative care.” The Plan is designed to • Identify the strengths and weaknesses of current cancer prevention and control efforts in DC • Identify barriers that hinder prevention and control efforts and offer strategic options for surmounting them • Provide a set of goals and objectives for cancer control based on a review of DC data • Identify strategies for meeting those objectives. Disparities in cancer care in DC: The District is home to an abundance of medical care facilities and providers, but equal access to cancer care services is significantly undermined by the physical location of those providers. Access to cancer screening, treatment, and follow-up care is, in some measure, influenced by where a District resident lives. Geographically, the District is divided into four quadrants: northwest, northeast, southwest, and southeast. Politically, it is divided into eight wards (see Figure 1). Wards 1, 3, and 4 are in the northwest quadrant; Ward 2 straddles northwest and southwest; Ward 5 is mainly in the northeast (and a bit of northwest): Ward 6 is in northeast, southwest, and southeast; Ward 7 is in both northeast and southeast; and Ward 8 is in the southwest and southeast quadrants. Many cancer-related
health care facilities are located in northwest
full-service hospital located beyond the
The inequitable distribution of infrastructure for cancer care in the District is reflected in the city’s cancer incidence and mortality rates. Disparities in access to care and in the quality of care are seen in every aspect of cancer control: screening, early detection, incidence, treatment, quality of care, and survival. Disparity issues are considered in nearly every chapter of the Cancer Plan. We expect implementation of the Plan to facilitate the creation of an effective local infrastructure for reducing these disparities, for reducing high cancer incidence and mortality rates in the District, and for improving the quality of life of cancer survivors—wherever in the city they may live. Ethnicity. As of 2004, DC’s population Income. Although the city’s population is
distributed roughly equally among the eight wards, income distribution is
unequal. A Education. Almost 300,000 Washingtonians—
Developing the Cancer Plan To develop the Plan, the Coalition created Primary focal points. The Plan’s primary focus
was on strategies known to reduce the number of cases of cancer and to reduce
deaths from the disease. Recommendations for cancer screening were based mainly
on those of the American Cancer Society, although recommendations from the
Preventive Services Task Force and other professional organizations were also
reviewed. A secondary focus was to identify resources to assist people with
cancer, including support groups, educational programming, and other community
opportunities. These resources are presented in a separate publication, the Based on data about the burden of cancer and available health
care resources in the Priorities were based on scores of four factors: • The extent of a particular cancer burden • Whether intervention was important • Whether intervention was feasible • Whether intervention would have a measurable impact (that is, reduce incidence and/or mortality rates). The burden of deaths from smoking-related cancers, for
example, is sizable. Effective intervention is feasible, and its impact would
be large and measurable. Similarly, the burden of prostate cancer is the
District is both heavy and inequitable, and effective intervention is solidly
feasible and measurable. Breast cancer interventions are a priority because the
cancer burden is heavy, mammography is For each type (or anatomical site) of cancer, we looked at
risk factors, gaps in and barriers to cancer control, and the best-known The chapters were reviewed for accuracy In the summer 2005, the DC Cancer Coalition held a series of five town hall meetings in neighborhoods around DC to introduce the Plan, to listen to residents’ thoughts and reactions to the Plan and to encourage residents to get involved in fighting cancer in the District. The Department of Health also held a series of Health Disparities Town Halls at which they announced the Plan and invited residents to become involved in implementing the Plan. The Coalition is pleased to present this Plan to the
citizens, community leaders, and city authorities of the
Great therapeutic developments over the past few decades have
led to more effective and less disfiguring cancer treatments. But not every
American has benefited from this In 2004, the number of insured nationally rose to 45.8 million, compared to 45.0 million in 2003 and 39.8 million in 2000. A continuing decline in employer-sponsored plans is a major cause. The percent of working adults (18 to 64) who were uninsured climbed from 18.6% in 2003 to 19.0 percent in 2004, an increase of more than 750,000 people. Nationwide, African Americans (20%) and Hispanics (33%) were much more likely to be uninsured than White, non-Hispanic people (11%). Reducing cancer incidence and mortality
rates in the District of Columbia will require eliminating barriers to primary
and cancer Barriers to care in the District Demographics—insurance coverage, poverty, Lack of health insurance. Whether DC In 2004, the number of insured nationally rose to 45.8
million, compared to 45.0 million in 2003 and 39.8 million in 2000. A continuing
decline in employer-sponsored plans is a Proportionately, more DC
citizens are covered by employer-sponsored insurance than the national average
because of the concentration of federal agencies and offices in the District.
Of DC’s non-elderly adults, 70% have employer- Of those
with no health insurance, 4% are
enrolled in the DC HealthCare Alliance, a public-private partnership
established after DC
Who are the uninsured?
• In 1999, 60% of DC
adults may have
qualified for Medicaid or DC HealthCare • In 1999, 36% of DC adults over age 65 had income that fell below 200% of the federal poverty level, possibly qualifying them for Medicaid. • The number of Medicaid enrollees in DC represented 81% of the eligible population in 2001, according to the Centers for Medicare and Medicaid Services. • Many of the “working poor” are uninsured: 72% of uninsured DC residents are part of family households in which at least one household member works part- or full-time, and 48% of the uninsured have family members who work full-time, year-round. • The largest group of
uninsured adults (29,500) is 30-to-49-year-olds, but another age group, the
19-to-29-year-olds, has the greatest percentage of uninsured. The two groups
with the most uninsured members are Hispanic residents (about 13,800 • Undocumented aliens have no health
insurance. Although they can receive free or low-cost health care at a
community health center, the center will ask them to apply for Medicaid so it
can recover some of its costs. Undocumented residents are reluctant to apply
for a public program because it • In the year 2000, 13%
of DC residents worked for small-business employers, who were less likely to
offer insurance because • Some low-wage earners have to forfeit health insurance benefits because they cannot afford the employee’s share of the premium. • About one-third of
DC’s non-elderly adults went without health insurance for all or part of the
two-year period from 2002 to 2003. Adults with no insurance and those with
Medicaid are more likely than adults with • Residents with some
health insurance may not have coverage for pharmaceuticals,
durable medical equipment, nutritional
supplements, sub-acute care, long-term care, or mental health services.
Medicare • Some adults don’t seek treatment
or care because they can’t afford the cost of co-payments or out-of-pocket
expenses for items that are not covered.
Poverty, race, and socioeconomic status. Race
and ethnicity themselves are not Levels of education and literacy, especially health literacy,
are important aspects of social status that affect health outcomes. The Socioeconomic status is also a factor. Socioeconomic status also appears to affect the quality of care. People from lower socioeconomic groups also have poorer survival rates, possibly because of such factors as inadequate staging evaluation and delays in treatment. Regardless of treatment, cancer patients from lower socioeconomic groups with advanced cancer report less symptom control and less use of palliative and supportive care services (especially hospice) than patients from higher socioeconomic groups. The percentage of uninsured in DC (13%) is lower than the
national average (19%), but the
(12.4%). Although the city’s population is distributed
roughly equally among eight wards, income and relative insurance status are Unfortunately, the poverty gap—the gap
between the wealthy and poor—is as wide in DC as in any other major
The adult populations in DC most likely to be uninsured are poor, male, and Hispanic or Black. The Hispanic population is particularly vulnerable, having the highest uninsured rate, being poorer than non-Hispanic Blacks or Whites, and having worse health indicators than both groups.
Language. Residents of the
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Developing
a Cancer Control Plan 
