A Call to Action 2014-2020 - North Carolina Comprehensive Cancer Control Plan - CDC
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A Call to Action
North Carolina Comprehensive Cancer Control Plan
2014-2020
Preface The North Carolina Comprehensive Cancer Control Plan 2014-2020: A Call to Action was developed by a large and diverse group dedicated to saving lives and improving the quality of life for North Carolinians affected by cancer. The effort to reduce the cancer burden in North Carolina will require a coordinated and collective effort of communities, public and private organizations and individuals. Representatives of the North Carolina Advisory Committee on Cancer Coordination and Control; North Carolina Cancer Partnership; North Carolina Department of Health and Human Services; Division of Public Health; Cancer Prevention and Control Branch and many others interested in reducing the cancer burden in North Carolina are listed in Appendix H.
Dear Fellow North Carolinians:
We are pleased to share the North Carolina Comprehensive Cancer Control Plan 2014-2020: A Call to Action. Cancer has been
the leading cause of death in North Carolina since 2009. We are all affected by cancer, and it has an enormous economic,
physical and emotional impact on North Carolinians. The purpose of this Cancer Plan is to reduce the cancer burden in our state.
This Cancer Plan is organized using the cancer continuum: prevention, early detection, care and treatment and focuses
on six specific cancers: lung, colorectal, breast, prostate, cervical and melanoma. It does not have detailed cancer information,
so comprehensive references are provided in the Appendices. An interdisciplinary collaboration of professionals from across
the state designed this plan to provide a framework for cancer prevention and control.
We hope that public health and healthcare agencies, community organizations and individuals across North Carolina will benefit
from using this Cancer Plan as they work together to address cancer prevention and control. One part of the Plan entitled:
“Everyone Has A Part to Play in the Fight Against Cancer” describes specific strategies for individuals, community organizations,
schools, businesses, healthcare professionals and policy makers.
We hope you find the Cancer Plan useful in your efforts to make a difference in the fight against cancer in North Carolina.
Regards,
Dr. Tom Shea, Chair Morgan Daven, Co-Chair
North Carolina Advisory Committee
on Cancer Coordination and Control
5505 Six Forks Road Raleigh, NC 27609
North Carolina Comprehensive Cancer Control Plan 2014-2020 i
Executive Summary North Carolina Comprehensive Cancer Control Plan 2014-2020: A Call to Action (Cancer Plan) is a statewide blueprint for cancer prevention and control in North Carolina. The Cancer Plan was developed through a collaboration of an interdisciplinary team of individuals who devoted many hours to designing a plan that is specific to the particular needs of North Carolina. Cancer has been the leading cause of death in North Carolina since 2009. As such, it has a huge psychological, social and economic effect on individuals and the state. The overarching purpose of the Cancer Plan is to reduce the morbidity and mortality associated with cancer in our state. There are five goals that are designed to help achieve this. They are preventing new cancers, detecting cancer at its earliest stages, treating all cancer patients with the most appropriate/effective therapy, enhancing the quality of life for every person affected by cancer and reducing cancer-related disparities in North Carolina. The six specific cancers that are the focus of this Cancer Plan are lung, colorectal, breast, prostate, melanoma and non-melanoma skin cancers and cervical cancer. In order to meet our goals, the Cancer Plan has specific objectives and strategies to address the cancer continuum and the six specific cancers. It also describes evaluation strate- gies to measure progress towards meeting our goals. Prevention: The Cancer Plan focuses on behaviors, policies and environmental changes that can reduce North Carolinians’ cancer risk. After describing the behaviors that place people at risk for cancer, the Cancer Plan provides guidance on ways to lower these risks by adopting healthy behaviors and promoting environmental changes. Recommendations made are for both individuals and organizations/systems. Early Detection: The focus of early detection is on promoting and delivering cancer screenings based on the guidelines and recommendations of the N.C. Advisory Committee on Cancer Coordination and Control. An emphasis in this area is on reaching people most at risk and those with limited access to screenings. Care and Treatment: The Cancer Plan provides guidance on ways to improve access to care, enhance care coordination and assure quality treatment for all cancer patients and their families. It describes professional and public education strategies that will provide information on patient navigation systems, cancer clinical trials and appropriate services for palliation and survivorship services. Woven throughout this Cancer Plan are ways to address disparities in cancer among populations experiencing a disproportionate burden of disease, disability and death. It is critically important that we reach underserved populations with cancer prevention, early detection and treatment messages and services. North Carolina Comprehensive Cancer Control Plan 2014-2020 iii
Everyone has a part in the fight against cancer. The grid on page 28 describes ways that individuals, community organizations, healthcare professionals and policy makers can help prevent, detect and treat cancer. It also suggests ways to advocate for policy changes that reduce the risks for cancer and promote good care for those with the disease. This Call to Action is designed to address the barriers to cancer prevention and care while outlining a plan of action. The action plan will be implemented by a diverse partnership of North Carolina cancer programs, organizations and individuals in order to assure North Carolinians timely and equitable access to healthcare throughout the cancer care continuum. We hope you find this a useful tool. iv North Carolina Department of Health and Human Services | North Carolina Public Health | North Carolina Cancer Prevention and Control Branch
Table of Contents
Introduction 1
North Carolina Cancer Burden 5
Unequal Burden in North Carolina 7
Access to Cancer Care 9
North Carolina Comprehensive Cancer Control Plan 11
Cancer Risk and Protective Factors 12
Poor Nutrition, Physical Inactivity, Overweight and Obesity 13
Tobacco Use and Exposure to Secondhand Smoke 15
Environmental Exposures 17
Ultraviolet Radiation Exposures 18
Viral Exposures 19
Alcohol Use 19
Cancer Prevention and Control Action Plan 20
Cancer Prevention 21
Early Detection 22
Cancer Care Continuum 23
Cancer Care 25
Cancer Survivorship 26
Everyone Has a Part in the Fight Against Cancer 23
N.C. Priority Cancers 32
Lung Cancer 33
Colorectal Cancer 34
Breast Cancer 35
Prostate Cancer 36
Cervical Cancer 37
Melanoma Skin Cancer 38
Cancer Surveillance 39
Cancer Plan Evaluation 40
North Carolina Comprehensive Cancer Control Plan 2014-2020 v
Summary 43
References 44
Appendices
Appendix A – North Carolina Cancer Prevention and Control Branch 47
Appendix B – Scientific Information Resources 48
Appendix C – Commission on Cancer Accredited Hospital Information and Maps 50
Appendix D – Body Mass Index Chart 58
Appendix E – North Carolina Table of Measurements 59
Appendix F – North Carolina Cancer Maps 61
Appendix G – Glossary 71
Appendix H – North Carolina Cancer Plan Contributors 74
vi North Carolina Department of Health and Human Services | North Carolina Public Health | North Carolina Cancer Prevention and Control Branch
Introduction together to address cancer prevention and
control.
discussed. The Appendices contain
detailed cancer information and
resources. The Cancer Plan with
The 2014-2020 North Carolina The purpose of the Cancer Plan is to reduce accompanying information and
Comprehensive Cancer Control Plan the cancer morbidity and mortality in North a community brochure that can
(Cancer Plan) provides not only current Carolina. The overarching goals are be copied and used locally, are
cancer information for North Carolina to prevent future cancers, detect cancer available on the N.C. Division of
but also provides a framework for action at its earliest stages, treat all cancer Public Health, Chronic Disease and
to reduce the effects of cancer. Cancer patients with the most appropriate and Injury Section Web site located
is a complicated disease with many effective therapy, enhance the quality at http://publichealth.nc.gov/
different signs and symptoms. Nearly of life for every person affected by cancer chronicdiseaseandinjury.
everyone knows someone who has been and reduce cancer-related disparities
affected by cancer – a friend, family in North Carolina. History
member, coworker or neighbor. Maybe
North Carolina’s commitment
you have had cancer or have been a Cancer Plan Organization to cancer prevention and control
caregiver for someone who has cancer.
The Cancer Plan is organized using the dates back to 1945 when the
According to the North Carolina Central cancer continuum: prevention, early leadership from the N.C. Medical
Cancer Registry 2011 data, approximately detection and care and treatment. It also Society and the American
140 people in North Carolina are newly emphasizes six specific cancers: Cancer Society (ACS) worked
diagnosed with cancer every day. Another with the North Carolina General
• the four most deadly cancers (lung,
50 people lose their lives daily to this Assembly to pass the Cancer
colorectal, breast and prostate),
disease.1 Control Act of 1945. This
• the most common cancers legislation created the first Cancer
(melanoma and non-melanoma skin Control Program in the nation
The Cancer Plan is not intended to provide
cancers) and and originally included funding
in-depth cancer information. This
information can be found in the resources • the cancer that can be prevented to assist indigent cancer patients.
listed in the Appendices. Instead, it serves through vaccination and early
as a working guide to help public health detection: cervical cancer. Legislation was passed in 1993
and healthcare groups, community to create the N.C. Advisory
organizations, institutions, agencies and The sections have information specific to Committee on Cancer Coordination
individuals across North Carolina work North Carolina and the priority cancers and Control (Advisory Committee)
North Carolina Comprehensive Cancer Control Plan 2014-2020 1
and the N.C. Comprehensive Cancer Evaluation, Surveillance and Research – Evaluation, Surveillance and Research
Program, which is part of the Cancer are listed below. Subcommittee
Prevention and Control Branch This subcommittee conducts an
in the Chronic Disease and Injury Prevention Subcommittee assessment of partners’ activities
Section, Division of Public Health, This subcommittee promotes healthy in meeting the goals and objectives
N.C. Department of Health and behaviors and environments that reduce related to the Cancer Plan. The
Human Services. the risk of developing cancer. Topics subcommittee provides surveillance
include nutrition and physical activity, in the monitoring and review of the data
N.C. Advisory Committee tobacco prevention and control, ultraviolet regarding the health of North Carolinians.
on Cancer Coordination radiation exposure, chemoprevention and This subcommittee also assists with
genetic testing. research for position statements,
and Control provides data for the Cancer Plan and
The mission of the Advisory Early Detection Subcommittee assists with writing white papers.
Committee is to facilitate the This subcommittee works to expand the
reduction of cancer incidence appropriate use of proven cancer-related Legislation and Education
and mortality in North Carolina early detection methods and appropriate Subcommittee
and to enhance access to quality follow-up of abnormalities. Foci include This subcommittee recommends policies
treatment and support services. colorectal, breast, cervical, prostate, skin on cancer-related issues. The
It also recommends a coordinated, and lung cancers. subcommittee is made up of legislators and
comprehensive cancer control Advisory Committee members, with the
plan to the Secretary of the N.C. Care and Treatment Subcommittee Advisory Committee Co-Chair serving as an
Department of Health and This subcommittee addresses a continuum ex-officio member.
Human Services. There are five of services from cancer diagnosis
subcommittees made up of to treatment, care, survivorship and The subcommittees also may prepare
members of the Advisory palliative care. Tasks of the Care position statements that are presented
Committee, the N.C. Cancer Subcommittee include identifying and to the Advisory Committee.
Partnership and the Cancer reducing financial, geographic and other
Prevention and Control Branch. barriers to cancer diagnosis, treatment and The N.C. Cancer Prevention and Control
The responsibilities of these healthcare services as well as pain control, Branch (Branch) provides staff for the
subcommittees – Prevention; Early patient navigation and survivorship. Advisory Committee. (See Appendix A
Detection; Care and Treatment; for Branch Information) The Branch
Legislation and Education and
2 North Carolina Department of Health and Human Services | North Carolina Public Health | North Carolina Cancer Prevention and Control Branchfocuses on prevention, screening and early detection, treatment and survivorship, as well as education efforts. They emphasize the importance of evidence-based measures to ensure that effective programs and policies are implemented to make efficient use of limited resources. N.C. Cancer Partnership The N.C. Cancer Partnership, a larger group of interested cancer survivors, organizations, individuals and professionals assists the Advisory Committee with its work. All members of the Advisory Committee, N.C. Cancer Partnership and Branch will work toward implementation of this Cancer Plan. North Carolina Comprehensive Cancer Control Plan 2014-2020 3
Between 2008 and 2012, there were over
2008 89,500
2012 cancer
2008
deaths. 2012
Nearly
18,412 of those deaths
occurred in 2012.N.C. Cancer Cancer Mortality and Incidence Rates
50
Burden and Lung and Bronchus
69 2012 Mortality Rate**
14
2014-2020 Colon and Rectum 38 2011 Incidence Rate**
Priorities Melanoma (Skin) 3
22
Breast (Female)* 21
159
Cancer has been the leading cause of
death in North Carolina since 2009.1 Prostate (Male)* 21
140
Between 2008 and 2012, there were over
Cervical (Female)* 2
89,500 cancer deaths. Nearly 18,412 of 7
those deaths occurred in 2012.1 Nationally * Sex-specific rates cannot be compared to other cancer site rates because the denominators represent different
and in North Carolina, cancer is the leading populations.
cause of death among 45-64 year olds, ** Rate per 100,000 population; Age-adjusted to US census NC Central Cancer Registry. Statistics and Reports.
and the second leading cause of death
for people 65 and over.1,2 In 2010, the North average of 8.2 years of life due to cancer.6 in 2003 in women. From 2006
Carolina age-adjusted death rate for cancer, (See Appendix F for a series of maps showing to 2010, rates decreased 2.9 percent
177.8 per 100,000, was higher than the 2010 cancer mortality and incidence rates by county) per year in men and 1.4 percent
national rate, 171.8 per 100,000.3 2010 is per year in women. This gender
the most recent national data. Priority Cancers difference in lung cancer deaths
reflects historical differences
Lung cancer has been the leading cause in patterns of smoking uptake and
Cancer has a huge economic effect
of cancer deaths in North Carolina for over cessation over the past 50 years.8
on individuals, the state and the nation.
two decades. Between 2008 and 2012, over
According to the National Institutes of
27,000 deaths were due to lung cancer Colorectal cancer was the second
Health (NIH), total cancer care cost the
in North Carolina. Of those, nearly 5,454 leading cause of cancer deaths
United States an estimated $125 billion
lung cancer deaths occurred in 2012.1 in North Carolina in 2012. There
in 2010.4 During the same period, the
According to the 2014 Surgeon General’s were 1,533 colorectal cancer deaths
average cost per cancer case in North
Report, 87 percent of lung cancer deaths in 2012 and over 7,550 deaths from
Carolina was $41,401.5 This total does
are preventable. Survival rates (20%) 2008-2012 in North Carolina.1
not account for indirect costs due to lost
for lung cancers are poor.7 According to the 2012 Behavioral
productivity from illness and premature
death. It is estimated that in 2010 North Risk Factor Surveillance System
ACS reports that lung cancer death rates (BRFSS), 70.6 percent of North
Carolinians under the age of 75 lost an
began declining in 1991 in men and Carolina adults over age 50
North Carolina Comprehensive Cancer Control Plan 2014-2020 5report “ever having had a are no established guidelines for preventing Cervical cancer (female only) was
sigmoidoscopy or colonoscopy pancreatic cancer and no screening tests. responsible for about 0.6 percent of all
screening for colorectal cancer.”9 cancer deaths in North Carolina in 2012.
It is estimated that between 2007 Prostate cancer (male only) was the fifth There were 117 cervix uteri (cervical)
and 2011, about 40 out of every 100 leading cause of cancer deaths among cancer deaths in 2012 and over 560 deaths
deaths from late-stage colorectal males in North Carolina in 2012. There from 2008-2012 in N.C.1 Cervical cancer
cancer could have been prevented were 844 prostate cancer deaths in 2012 can be prevented by HPV vaccine and
if all men and women aged 50 years and over 4,350 deaths from 2008-2012 in detected through Pap test screening and
or older were routinely screened.10 the state.1 Prostate cancer death rates the HPV test. If detected, early treatment
have been decreasing since the early 1990s of pre-cancerous conditions can prevent
Breast cancer (female only) was in men of all races and ethnicities, although cervical cancer. In 2012, 35.5 percent
the third leading cause of cancer they remain more than twice as high of girls and 8.6 percent of boys ages 13-17
deaths among North Carolina in African Americans as in any other racial in North Carolina completed three or more
females in 2012. There were 1,286 or ethnic group.8 In 2012, 31.6 percent of doses of the HPV vaccine.11
female breast cancer deaths men were told by a health professional
in 2012 and over 6,350 deaths of the advantages and disadvantages of Melanoma skin cancer was responsible
from 2008-2012.1 According to the a Prostate-Specific Antigen (PSA) test, a for 72.8 percent of all North Carolina skin
2012 BRFSS, 66.6 percent of North blood test used to check men for prostate cancer deaths in 2010. There were 289
Carolina women reported, “ever cancer.9 Almost 60 percent (58.9 %) of men melanoma cancer deaths in 2012 and over
having had a mammogram.”9 in the same group stated they had “ever 1,479 deaths from 2008-2012 in the state.
Between 2007 and 2011, 95 had a PSA test.”9 The rate of new melanoma diagnoses is
percent of women in North Carolina rising rapidly—with an average increase of
diagnosed in the earliest stage The two cancers discussed below are not more than five percent per year from 1995
of breast cancer survived five years in the top ten causes of cancer deaths to 2011.1
compared to 34 percent diagnosed in North Carolina but are important
in the advanced stages. Early to North Carolinians for different reasons. Childhood and Adolescent cancer
detection saves lives.10 Cervical cancer is included because it is According to the National Cancer Institute
preventable through the use of Human (NCI), cancer is the leading cause of death
Pancreatic cancer was the fourth Papillomaviruses Vaccine (HPV). It can by disease among United States children
cause of North Carolina cancer also be easily detected through screening between infancy and age 14. The causes of
deaths in 2012.1 In 2012, there and treated in early stages. Melanoma and most childhood cancers are unknown, and
were 1,175 pancreatic cancer other skin cancers are included because for the most part they cannot be prevented.
deaths. It is not included in this they are the most common cancers. The major types of childhood cancers are
Cancer Plan since there currently
6 North Carolina Department of Health and Human Services | North Carolina Public Health | North Carolina Cancer Prevention and Control Branchleukemia, lymphoma, brain and other • racial and ethnic minorities; disability and death through
central nervous system tumors. These prevention, early detection, care
• residents of rural areas including
account for more than half of new cases and treatment.
Southern Appalachia;
of childhood cancer. White and Hispanic
children are more likely than children • lesbian, gay, bisexual and Health Equity
from any other racial or ethnic groups transgender people,
Health equity occurs when every
to develop cancer.12 • older people, person has the opportunity to attain
• people with disabilities; his or her full health capability and
Although cancer is not as common
no one is blocked from achieving
in adolescents and young adults (AYA) as • people with low incomes and
this capability because of his or her
in adults, there are certain cancers that
• people who are uninsured.4 social position or circumstances.16
affect this group. These include lymphoma
The World Health Organization
thyroid, brain and central nervous system
Across all chronic health conditions, health states, “These circumstances are
cancers. AYA cancer patients are a
disparities exist. Cancer is no different. shaped by the distribution of money,
special group with unique challenges.
It is critical to work effectively with power and resources, which are
Among those are the need for school and
communities to eliminate all disparities. themselves influenced by policy
career counseling, fertility counseling and
This Cancer Plan addresses disparities choices.”17 The goal is to achieve
fertility protecting services, genetic
in cancer among populations experiencing the highest level of health possible
counseling and AYA-specific psychosocial
a disproportionate burden of disease, for all groups. Research shows
support.13
health outcomes for minorities –
Unequal Burden in North
North Carolina Cancer Incidence and Mortality Rates
Carolina by Race and Gender per 100,000 Population
Age-Adjusted to the 2000 US Census**
Health Disparities
White White Minority Minority
NCI defines health disparities as Total
Males Females Males Females
differences in the incidence, prevalence, Cancer Mortality
203.1 138.5 245.3 155.4 170.5
mortality and survival of a disease and the Rate 201214
related adverse health conditions that exist Cancer Incidence
521.9 444.4 550.6 424.2 476.7
among specific population groups Rate 201115
including: ** Note: The N.C. State Center for Health Statistics often publishes data by race for only two groups: white and
minority. The State Center recognizes and appreciates the various population groups in North Carolina and the need
for more details on race. A number of factors have hampered efforts to obtain accurate data on minority populations.
North Carolina Comprehensive Cancer Control Plan 2014-2020 7African Americans, American Build community Use a variety of culturally
Indians and Hispanic/Latinos – empowerment to address health competent media to market cancer
are worse than for Whites. Social disparities at the information to diverse populations
and economic factors such as in- local level. in a variety of settings.
come, education, racism, housing,
Encourage alternative ways of Educate about the benefits
employment, food accessibility,
thinking about public health of increased access to care
transportation and the environment
practice, such as dialogues for underserved populations
are key components in determining
on the impact of structural racism to include:
an individual’s health status.
on health. • healthcare coverage,
Therefore, it is necessary to address
these underlying factors in order Advocate, encourage and • increased funding for
to improve the health status support diversity within the preventive screening programs,
of individuals and eliminate workforce at all levels and positions. such as Breast and Cervical
health disparities. Increase funding for the Cancer Control Programs
development of initiatives (BCCCP) and colorectal
Health Equity Recommendations for addressing health disparities screening programs and
These health equity recommenda- and creating health equity. • increased access to nutrient
tions to reduce health disparities dense foods through the
in general are adapted from the Specific Cancer Recommendations elimination of food deserts.
Centers for Disease Control and The following recommendations are Develop research projects to study
Prevention (CDC) and the National designed to specifically reduce disparities the differences in participation
Association of County and City in cancer. in, and results from, cancer
Health Officials.18 prevention and care clinical trials
Improve early detection through
Identify/build strategic between minority/ ethnic and other
routine screenings.
partnerships with population groups.
community organizations Implement evidence-based
Increase funding for preventive
in a variety of settings community interventions designed
cancer screening programs.
to address social to improve the health of minority
populations. Increase access to nutrient dense
determinants of health
foods through the elimination of
such as employment,
food deserts.
transportation, housing and
public policy initiatives.
8 North Carolina Department of Health and Human Services | North Carolina Public Health | North Carolina Cancer Prevention and Control BranchAccess to Lack of transportation and insufficient
resources are major barriers to health care
Cancer Care in North Carolina’s rural communities
where access to primary care physicians
may be very limited.
Differences in survival between population
groups are influenced by many different The United States Census Bureau reports
factors. that between 2008 and 2012, 16.8 percent
of North Carolinians were living In 2012,
Lack of Medical Coverage in households whose income was
People with little or no health insurance at or below the federal poverty level.20
coverage have a serious problem getting
care. The North Carolina Institute of In 2012, approximately 22.7 percent of
Medicine report, Healthy North Carolina North Carolinians lived in rural areas.21
2020 states there are an estimated 1.7 Many cancer centers and doctors across approximately
22.7%
million uninsured individuals under the North Carolina provide cancer care and
age of 65 living in North Carolina.19 People treatment to rural patients close to home.
with little or no health insurance are more However, the need for specialized care
likely to be diagnosed with cancer at later or treatment away from home is needed
stages and, thus, have less chance of sometimes for rare kinds of cancer
cancer survival. or late-stage cancers. North Carolina
has several nationally recognized cancer of
centers that can give that specialized care. North Carolinians lived
Unequal Access to Cancer in rural areas.21
However, care at these centers often
Prevention, Early Detection requires traveling long distances, a
and Treatment particular challenge for low-income people.
Many North Carolinians face additional (See Appendix C for information on cancer
financial and physical barriers to receiving hospitals)
preventive health care and health
education as well as treatment for
existing health problems.
North Carolina Comprehensive Cancer Control Plan 2014-2020 9The cancer continuum, which includes prevention, early detection, care and
treatment and survivorship, is a useful framework to view plans, priorities
and progress as well as identifying research and resource needs.North Carolina Comprehensive Cancer Control Plan
The Cancer Plan is designed to address the barriers to cancer prevention and care while outlining a plan of action for cancer programs,
community organizations, policy makers and individual North Carolinians.
The overarching goals of the Cancer Plan are:
Prevent new cancers.
Detect cancer at its earliest stages.
Treat all cancer patients with the most appropriate/effective therapy.
Enhance the quality of life for every person affected by cancer.
Reduce cancer-related disparities in North Carolina.
In order to meet these goals, the Cancer Plan has specific objectives and strategies to address the cancer continuum, the six specific
cancers, cancer surveillance and plan evaluation.
The cancer continuum, which includes prevention, early detection, care and treatment and survivorship, is a useful framework
to view plans, priorities and progress, as well as identifying research and resource needs.
The Action Plan will be implemented by a diverse partnership of North Carolina cancer programs, organizations and individuals
in order to assure North Carolinians timely and equitable access to healthcare throughout the cancer care continuum.
North Carolina Comprehensive Cancer Control Plan 2014-2020 11Cancer Risk and Specific Risk Factors’ Relationship to Priority Cancers
Protective Factors
Lung Colorectal Breast Prostate Cervical Skin
Risk Factors
Family History
Risk factors increase a person’s
chances of developing cancers.
In addition to the risk factors listed Tobacco Use
in the chart, additional factors are
growing older and gender. Risk Unhealthy
factors such as growing older, Lifestyles
gender and family history of cancer
are beyond a person’s control. Environmental
Toxins
However, knowledge of family
history may help with early
detection of cancers with a strong Alcohol Use
genetic link. Cancers known to run
in families include melanoma skin Ultraviolet
cancer and cancers of the breast, Exposure
ovary, prostate and colon.
Viruses
Protective Factors
For cancers without a known
genetic link, a person can
significantly lower his or her risk
by adopting protective healthy
behaviors and improving the
environments where he or she lives.
Both risk and protective factors are
discussed in the following pages.
12 North Carolina Department of Health and Human Services | North Carolina Public Health | North Carolina Cancer Prevention and Control BranchCancer Risk Associated Poor Nutrition, Physical Inactivity people do. Physically active women
and/or Overweight/Obesity have a significantly lower risk of
with Poor Nutrition, Physical increases the risk for these breast cancer. In addition, cancer
Inactivity, Overweight cancers:22 survivors have a better quality of life
and Obesity breast prostate
if they are physically active
compared to survivors who are
About one third of the most common liver colorectal inactive.23
cancers in the United States can be
prevented by a healthy diet, physical esophageal kidney
The American Institute for Cancer
activity and weight management stomach lung Research recommends meeting
according to the American Institute of pancreas physical activity and healthy eating
Cancer Research.22 recommendations in addition
endometrial (uterine)
to maintaining a healthy body
Overweight and Obesity mouth, pharyngeal
weight.22
and laryngeal
The percentage of overweight and obese
adults and children has increased All adults should avoid inactivity.
markedly over the past few decades. Some physical activity is better than
In general, the higher the number, the more
In North Carolina, more than two-thirds none at all.
body fat a person has, although there are
of adults are overweight or obese.24 exceptions. BMI in a range from 18.5 to 24.9
is considered healthy. Persons who have a
Almost one third of North Carolina’s BMI range from 25.0 to 29.9 are considered
children ages 10 to 17 are overweight overweight. A BMI of 30 or greater
or obese.18 High rates of overweight indicates that the person is obese.7
and obesity in the state and nation cause
decreases in life expectancy, productivity
Physical Activity
and quality of life.
and Healthy Eating
A healthy weight depends on a person’s Physical activity and healthy eating are risk
height so recommendations for a healthy factors for cancer independent of healthy
weight are often expressed in terms of body weight. The 2008 Physical Activity
mass index (BMI). BMI is a number that is Guidelines for Americans notes that
calculated using both weight and height. physically active people have a significant-
(See Appendix D for Body Mass Index Chart) ly lower risk of colon cancer than inactive
North Carolina Comprehensive Cancer Control Plan 2014-2020 13Core Behaviors to Reduce meats by baking, broiling or poaching Adult Physical Activity Guidelines
Overweight and Obesity25 rather than by frying or chargrilling. • Adults should do at least 2½
Cooking meats at high temperatures can hours (150 minutes) of
Increase Physical Activity cause the formation of toxins that have moderate-intensity or 1¼
A pattern of regular physical been shown to cause cancer in animals. hours (75 minutes) of
activity beginning in childhood or vigorous-intensity aerobic
adolescence is critical for lifelong Drink Less Sugar-Sweetened Beverages physical activity per week.
weight management. Physical Reduce the number of sugar-sweetened • Adults should also do
activity burns calories both during beverages, including soda, sweet tea, muscle-strengthening activities
and after activity. Physical activity energy drinks and sports drinks. These that are moderate or high
should consist of not only aerobic beverages provide calories with little intensity and involve all major
activities that get the heart or no nutritional value. muscle groups on 2 or more
pumping, such as walking
days a week.
or bicycling, but also activity that
Decrease Television Viewing
strengthens muscles and bones Note: U.S. Department of Health and
and Screen Time
and increases flexibility. Human Services, 2008 Physical Activity
Reduce television and screen time so there Guidelines for Americans
Eat More Fruit and Vegetables is more time for physical activity. This also
reduces exposure to advertisements
Fresh fruits and vegetables are low for foods that are high in fat and sugar. Encourage Breastfeeding
in calories and high in vitamins,
minerals, fiber and antioxidants. Promote breastfeeding to increase healthy
Eat Less Energy-Dense Foods nutrition for infants, and decrease the risk
A diet with lots of fruits and
vegetables is higher in volume and Reduce the number of calorie-rich foods of childhood obesity. Some studies
fiber while being lower in calories. such as packaged snack foods; frosted suggest that breastfeeding may slightly
cakes, cookies and candies; cheeseburgers; lower breast cancer risk in mothers.
Eat Less Red and Processed fried chicken; French fries and doughnuts. (For additional North Carolina information see
Meats Foods that are energy-dense contain a large North Carolina’s Plan to Address Obesity: Healthy
number of calories, mostly from fat and Weight and Healthy Communities 2013-2020
High intake of processed meats sugar. Decreasing the portion sizes of these at http://www.eatsmartmovemorenc.com/
such as bacon, sausage, lunchmeats foods reduces calories. ESMMPlan/ESMMPlan.html)
and hot dogs are linked to an
increase in colorectal cancer
incidence and mortality. Prepare
14 North Carolina Department of Health and Human Services | North Carolina Public Health | North Carolina Cancer Prevention and Control BranchCancer Risk Associated with Tobacco use increases cancer because of exposure to secondhand
risk for:8 smoke. There is no risk-free level of
Tobacco Use and Exposure exposure to secondhand smoke.
to Secondhand Smoke lung stomach Thus, for every one person who
Tobacco use is the number one preventable colon/rectum liver dies from smoking, 20 more suffer
cause of premature death and disease breast head/neck at least one serious tobacco-related
in North Carolina and the nation. Annual illness.26
prostate pancreas
North Carolina medical costs incurred from
bladder kidney Protection from Tobacco
smoking are $3.8 billion.1
skin ovarian Exposure
In the United States, tobacco use is cervix uterus Protect and promote the health of
responsible for: acute myeloid leukemia everyone by reducing tobacco use
• nearly 20 percent of all deaths, and exposure to secondhand smoke.
This will reduce cancer incidence
• at least 30 percent of all cancer
and prevalence, as well as help
deaths and 17 percent, a rate that has barely changed
North Carolinians live longer, be
• 87 percent of lung cancer deaths. 8 for more than 20 years.8 In North Carolina,
more productive and have happier
the five-year observed survival rate for lung
lives.
cancer is 20 percent.1
Smoking
In North Carolina, more than 12,200 people Other tobacco products
Key Strategies
die each year due to smoking. Lung Protect people from tobacco
cancer is the leading cause of cancer death Smokeless tobacco users have an increased
smoke
in North Carolina and the United States risk of developing cancer of the oral cavity.
There is no known safe form of tobacco Create more smoke-free/tobacco-
for both men and women.1
use including e-cigarettes, snuff, chewing free spaces where people live,
tobacco, cigars and hookahs. work, play and learn.
Survival rates
Maintain a statewide
Survival rates for lung cancer are among Secondhand smoke smoke-free law for all North
the lowest of all cancers despite medical
Nonsmokers die from lung cancer and Carolina restaurants and
developments in its diagnosis and
heart disease and hundreds of thousands bars.
treatment. The national five-year survival
rate for lung cancer in 2003-2009 was of children suffer from respiratory infections
North Carolina Comprehensive Cancer Control Plan 2014-2020 15 Build support for the Educate about the need for
adoption of a comprehensive recurring state funding for a
smoke-free law that protects statewide media campaign
all workers from exposure to educate North Carolinians,
to secondhand smoke. particularly youth, about the
harmful effects of tobacco use.
Promote smoke-free and
tobacco-free local
regulations. Enforce bans on tobacco advertising,
promotion and sponsorship
Promote tobacco-free
colleges and community Maintain compliance with the NC
colleges. Youth Access to Tobacco law so
Promote QuitlineNC (1-800- that North Carolina meets federal
Maintain North Carolina’s requirements to keep youth tobacco
QuitNow or 1-800-784-8669) and
tobacco-free schools and sales rates below 10 percent.
www.QuitlineNC.com for all N.C.
hospitals.
tobacco users who want to quit. Maintain activity under contract
Promote smoke-free with the FDA to enforce the North
Educate about the need for
multi-unit housing in North Carolina’s requirements of the
increased funding for QuitlineNC,
Carolina. Family Smoking Prevention and
so that evidence-based nicotine
replacement therapy will be Tobacco Control Act.
Offer help to quit tobacco use available for all QuitlineNC users
Encourage people who use any type who want to quit tobacco. Raise the price of tobacco products
of tobacco products to quit. through increased taxes on cigarettes
Warn people about the dangers and other forms of tobacco
Increase the number of
healthcare systems that of tobacco use Educate and inform the public and
adopt clinical practice Promote evidence-based media decision-makers of the health and
guidelines for treating campaigns and local interventions economic benefits of tobacco price
tobacco use dependence, that educate about the harms and increases to prevent young people
and make it a systematic addictiveness of tobacco use, the from becoming addicted and to help
part of clinical assessment, dangers of secondhand smoke and tobacco users who want to quit.
much like a vital sign. the best practices to reduce tobacco
use.
16 North Carolina Department of Health and Human Services | North Carolina Public Health | North Carolina Cancer Prevention and Control Branch Work with partners to educate Cancer Risk Associated with tasteless and odorless when it
about the specific benefits of an leaches into groundwater.
increase in tobacco excise tax and
Environmental Exposures Long-term exposures to high levels
a comparable increase for other According to NCI, researchers have of arsenic have been linked with
tobacco products. estimated that as many as 67 percent non-melanoma skin cancers, lung
of cancer cases are linked to some type cancer and other types of cancer.
Sustain tobacco prevention and control of environmental factor such as exposures
infrastructure and policies to radiation, infectious agents and Pesticides are chemicals used
substances in the air, water and soil.4 Some to reduce or eliminate unwanted
Educate and inform the public and
workers may be exposed to cancer-causing pests or weeds. Exposure to
decision-makers about the return
chemicals and other substances in their pesticides may occur through
on investment of comprehensive
workplaces. inhalation, skin contact and
tobacco control programs
ingestion. Exposure to pesticides
in coordination with state and
Certain types of exposures are linked has been linked with prostate,
national programs.
to specific cancers; for instance, radon breast, bladder, colon and other
Incrementally increase North exposure is linked to lung cancer. types of cancer.
Carolina’s investment in tobacco
prevention and control in order Radon is a radioactive gas that cannot be Low-level medical radiation is
to meet the 2014 CDC Best Practices seen, smelled or tasted. It is considered commonly used for x-rays to
annual investment recommendation the primary cause of lung cancer for diagnose broken bones and dental
by 2020. non-smokers. When released naturally cavities. The risk of cancer from
from soil and rocks, it can accumulate such radiation is considered
Educate about the benefits
and reach harmful levels when trapped very small since they are used
of recurring state appropriations
in enclosed spaces such as homes, schools infrequently and at very low doses.
for evidence-based youth tobacco
or other buildings. If detected, building
prevention and cessation programs
modifications can be made to prevent the High-level medical radiation is
to develop and sustain strong
accumulation of high levels of radon. The used to diagnose and treat certain
tobacco use preventive
N.C. Department of Health and Human types of cancer; it can increase
interventions at the community
Services Radon Program (ncradon.org) cancer risk later in life.
and state level in North Carolina.
offers monitoring and mitigation guidance.
(For more information see North Carolina Tobacco
Prevention and Control Branch Web site at http:// Arsenic is a naturally-occurring element
www.tobaccopreventionandcontrol.ncdhhs.gov.)
found in natural rock formations. It is
North Carolina Comprehensive Cancer Control Plan 2014-2020 17Protection from Wear protective clothing, gloves Key Strategies
Environmental Exposures and eye protection when working
Protect the skin with sunscreen
with pesticides or other chemicals.
Minimize environmental exposures Work outside or in a well-ventilated Use a generous amount of sunscreen with a
to radiation, chemicals and other area. sun protection factor (SPF) of at least 30.
toxic substances at home, schools,
offices and the worksite. Wash hands and clothes thoroughly
after working with pesticides or Avoid long periods of exposure
other chemicals. Remove shoes to the sun
Key Strategies
outside the home. Especially avoid the sun between 10 a.m.
Check homes, buildings, and and 4 p.m. when it is the strongest.
Wash fruits and vegetables
schools for high levels of radon
thoroughly before eating. Select
Test and monitor for elevated levels organic when possible. Wear protective clothing and
of radon. A radon reduction system sunglasses with UV protection
may be installed to remove the Reduce exposure to diagnostic X-rays Protective clothing includes wide brimmed
radon trapped under the building hats and tightly woven long sleeve shirts
and vent it to the atmosphere at a Speak with your doctor about alternative
diagnostic methods. or clothing with sun protection embedded
safe distance from the building. in it.8
Test well water for arsenic Cancer Risk Associated
Educate about the importance of a
levels exceeding state and with Ultraviolet Radiation state law to protect minors from UV
federal limits Exposure exposure at indoor tanning beds
Test according to North Carolina UV radiation comes from the sun, sunlamps Several measures have shown to decrease
Well Water and Health schedule. If and tanning beds. It causes early aging of the use of tanning salons by adolescents:
levels are elevated, seek assistance the skin and skin damage that can lead to
to treat water or use alternative imposing an age limit or requiring
skin cancer. parental permission,
source of safe drinking water.
Protection from UV Exposure mandating salons to post the
Minimize or avoid use of warning signs of tanning bed use
pesticides and other chemicals Avoid exposure to ultraviolet radiation from and
the sun and other sources such as tanning
Research and use alternative limiting advertisement.
beds.
methods of pest control.
18 North Carolina Department of Health and Human Services | North Carolina Public Health | North Carolina Cancer Prevention and Control BranchCancer Risk Associated Schedule regular Pap test screenings mouth cancers is especially high
according to recommended guidelines because alcohol and tobacco both
with Viral Exposure to detect cancer early come in direct contact with those
Human papillomaviruses (HPVs) infection areas.
(See Appendix B – Cancer Information Resources
is the main cause of cervical cancer. for cancer screening information)
Tobacco use, long use of birth control pills Protection from Alcohol
and having given birth to three or more
Cancer Risk Associated Abuse
children are also risk factors for cervical
cancer. HPV infection also may be a risk with Alcohol Use According to the American Institute
factor for other types of cancer such as oral Drinking too much alcohol can increase the of Cancer Research, studies show
cancers. chance of developing cancers of the mouth, an association between alcohol
throat, esophagus, larynx, liver, breast, drinking and several types of
Protection from Viral Exposures colon and rectum. Cancer risk increases cancer. Reduce the risk by reducing
with the amount of alcohol a person drinks. or eliminating alcohol use. People
Since HPV is a major contributor to cervical who drink alcohol should limit their
cancer, there is a focus on the prevention alcohol intake to two drinks per day
and treatment of HPV. The HPV vaccine is Smoking alone is a known risk factor
for some cancers. Smoking and drinking for men and one drink per day
proven effective in the prevention of many for women.20
forms of HPV and can prevent cervical together intensifies the cancer-causing
cancer as well as anal cancer, mouth and properties of each substance and poses
throat cancers, cancer of the penis in men an even greater risk. The risk of throat and
and esophageal cancers in gay men.
A standard alcoholic drink in the United States contains 14.0 grams
Regular Pap tests can prevent cervical (0.6 ounces) of pure alcohol.
cancer by detecting cancer at an early
stage, so successful treatment can begin Generally, this amount of pure alcohol is found in
early.
• 12 ounces of beer (3 - 7 percent alcohol)
• 8 ounces of malt liquor beer (3 - 7 percent alcohol)
Key Strategies
• 5 ounces of wine (9 - 15 percent alcohol)
Protect children with HPV vaccines
• 1.5 ounces or a “shot” of 80-proof liquor (usually 35 - 40 percent
HPV vaccines are recommended for boys alcohol), but can be higher.
and girls starting around 11 to 12 years old
until age 26, if appropriate.
North Carolina Comprehensive Cancer Control Plan 2014-2020 19Cancer Prevention and
Control Action Plan
In order to decrease the cancer risk
and increase cancer protective
factors, the Cancer Plan has five
overarching goals. They are:
Prevent new cancers.
Detect cancer at its earliest
stages.
Treat all cancer patients
with the most appropriate
and effective therapy.
Enhance the quality of life
for every person affected
by cancer.
Reduce cancer-related
disparities in North Carolina.
The Cancer Plan focuses on four
areas: prevention, early detection,
care and treatment and survivorship
including palliative care.
20 North Carolina Department of Health and Human Services | North Carolina Public Health | North Carolina Cancer Prevention and Control BranchCancer Prevention Strategies
Cancer Prevention Education and promotion of healthy behaviors
Focus Provide education on evidence-based practices, policies, systems and
environmental change approaches that focus on: health disparities, tobacco use
Change behaviors, policies, prevention and control, cancer screening, physical activity and healthy eating.21,25
environments or other Develop and use strategic, effective and tailored messaging and media campaigns
systems to reduce North in combination with other strategies to support healthy behaviors and reduce risk
Carolinians’ cancer risk. factors.
Continue the N.C. Department of Public Instruction Standard Course of Study
for K-12 students that promotes healthy behaviors.
Promote radon testing/mitigation in homes, schools, workplaces and other
Most cancers can be prevented by taking
community settings.
steps to reduce risk factors such as:
Promote HPV vaccination for girls and boys starting at age 11 or 12 years until age
• avoiding tobacco use and 26, if appropriate.
secondhand smoke,
Promote cancer-screening tests that may prevent future breast, colorectal, cervical
• limiting exposure to environmental and skin cancers.
toxins,
• limiting alcohol use, Promotion of public policy
• limiting exposure to ultraviolet rays Support the development and enforcement of state and local policies to prevent
from the sun and tanning beds, and minimize tobacco use, eliminate secondhand smoke and promote quitting.
Support the development of state and local policies to encourage colorectal cancer
• eating a variety of fruits and
screening for preventive purposes in people between the ages of 50 and 75.
vegetables,
Support education and policy approaches in worksites and communities that can
• maintaining a healthy weight, reduce occupational and environmental exposures to carcinogens.
• being physically active and • Promote education and policy approaches that limit unprotected exposure
to ultraviolet light.
• having recommended check-ups.
• Promote radon testing, radon resistant construction and mitigation of radon
(See Appendix B – Scientific Information in schools, daycare centers, workplaces and homes.
Resources)
Support health education and health promotion policies, processes and
interventions that increase the awareness of cancer screenings.
North Carolina Comprehensive Cancer Control Plan 2014-2020 21Early Cancer
Detection Focus
Promote the adoption “Never give up and early detection
of recommended saves lives.”
cancer screening
– Patricia, cervical cancer survivor since 1992
and early detection
methods and referral
procedures.
Screening means checking the
body for cancer before a person has
symptoms. Appropriate screening (See Appendix B – Scientific Information Resources for information on cancer screenings)
and early detection methods can
have a significant impact on the
incidence and mortality from Early Cancer Detection Strategies
certain cancers. Education and promotion of healthy behaviors
Recommended screening varies Encourage healthcare providers to recommend and deliver cancer screenings
depending on the type of cancer. based on the latest screening recommendations. (See Appendix B – Scientific
Regular screening tests may find Information Resources for information on cancer screenings)
breast, cervical, colorectal and skin Partner with public and private healthcare providers and community leaders to:
cancers early when treatment might • increase cancer awareness,
be most successful.
• improve opportunities for cancer screening with emphasis on people with high
Research on effective cancer risk of developing cancer and
screening is an ongoing process • improve opportunities for cancer screening with emphasis on people with
with new methods being tested and limited access to screenings.
released while approved older Promote research for early detection that will lead to improved outcomes, cancer
methods are reevaluated. Check care and quality of life. (See Appendix B – Scientific Information Resources
sources for up-to-date information for information on clinical trials and research)
on recommended cancer screening.
22 North Carolina Department of Health and Human Services | North Carolina Public Health | North Carolina Cancer Prevention and Control BranchCancer Care Continuum • transportation which makes it
difficult or impossible to get
The cancer care continuum begins with to treatment or other care,
cancer screening or diagnosis, goes
through treatment, continues throughout • lack of health insurance,
survivorship and includes end-of-life care. • fear of the unknown and/or
Survivorship covers the physical, • distrust of the medical system.
psychosocial and economic issues of
disease, beyond the diagnosis and Patient navigators often work with a patient
treatment phases. It may include issues starting with diagnosis and continuing
related to: through all phases of the cancer
experience. These navigators offer help
• accessibility of healthcare and to patients, families and caregivers
follow-up treatment, by working with the healthcare system
• continued effects of treatment, to ensure they receive needed care.
• reoccurring and/or additional
cancers and
Quality Care
According to the National Institute of
• quality of life.
Medicine (IOM), patients should receive
cancer care that:
Palliative care involves taking care of
symptoms and providing relief from pain • is given by qualified medical
and stress of an illness. providers, “...we can live with hope
Patient navigation involves helping
• is decided by both the patient and
the medical team (called shared
because we are not alone
patients, families and caregivers work
through issues that arise during the cancer
decision making), in this journey.”
journey. All cancer patients, especially • considers age, sex, race, ethnic
background, customs, social – Lidia and Ana Maria,
low-income patients, can have problems
background and religion, breast cancer survivors
getting cancer care. Some of these since 2006 and 2010
problems might be: • is given in a safe and helpful way
and
North Carolina Comprehensive Cancer Control Plan 2014-2020 23• is done in a way that saves The continuum provides patients, their
money and time. loved ones and/or caregivers with the
knowledge, resources and tools to support
There are other issues involved them through their cancer experience.
in providing cancer care. They are
the need for:
• a well-trained and reliable
work force in which
evidence-based practice
guidelines are used,
• continuous monitoring of
the quality of care across the
state to be sure everyone is
working together and
following guidelines,
• patient navigation to help
patients, families and
caregivers work with the The daffodil –
healthcare system to receive
needed care and the flower
• health information of cancer
technology (HIT) and
electronic health records survivorship
(EHRs) to keep track of
referrals made, evidence-
based care given and
guidelines followed.
24 North Carolina Department of Health and Human Services | North Carolina Public Health | North Carolina Cancer Prevention and Control BranchCancer Care Strategies
Cancer Care Focus Access to Care and Care Coordination
Work with professional associations and other groups to:
Improve access to care,
enhance care coordination • promote a statewide patient navigation model with increased training and
networking of patient navigators,
and assure quality treatment.
• increase the number of patient navigators available to help patients overcome
both structural and psychosocial barriers to care across the cancer continuum,
• promote increased access to clinical trials for cancer care that will lead to improved
Cancer care includes: outcomes and quality of life, especially for medically underserved populations and
• promote adherence to national guidelines for cancer diagnosis and treatment.
• taking care of symptoms and relief
from pain beginning at diagnosis,
Quality Treatment
• focusing on the whole person,
Offer educational opportunities and support to non-Commission on Cancer (CoC)
• watching to see if the cancer returns accredited cancer centers, general physicians, other healthcare workers and local
(recurrence) or if an additional new agencies so they can:
cancer develops and
• follow national guidelines for cancer diagnosis and treatment,
• supporting the patient, the • offer evidence-based, value-based and patient-centered care and communications,
patient’s family, other loved ones
• engage the patient in the care and treatment plan, including informed decision
and caregivers throughout
making,
survivorship.
• use electronic health records,
Care and treatment should be based • provide age-sensitive and age-appropriate cancer treatment for pediatric,
on the age of the patient. The very young adolescent, young adult (AYA) and geriatric cancer patients,
and very old need care and treatment • utilize a team approach to patient care that uses appropriate specialist and
by healthcare professionals who specialize non-specialist professionals,
in cancer care for their population groups. • achieve and adhere to CoC quality guidelines for accreditation and
Adolescent and young adult (AYA) cancer • provide educational opportunities for healthcare professionals that enhance
patients are another group who require or increase their knowledge and skills in:
special attention. comprehensive, team-based cancer care,
palliative care and
end-of-life services.
North Carolina Comprehensive Cancer Control Plan 2014-2020 25You can also read
