Prostate Cancer Conference Report
Appendix A: Plenary Session

Dr. Nancy Lee, Director of the Division of Cancer Prevention and Control at the CDC, presented an overview of prostate cancer and an introduction to the CDC and the Division of Cancer Prevention and Disease Control.

She explained that prostate cancer is the most commonly diagnosed, nondermatologic cancer among U.S. men and is second only to lung cancer as a cause of cancer deaths in men. Unfortunately, effective measures to prevent prostate cancer have not been identified. Furthermore, there is substantial controversy surrounding prostate cancer screening because there is no good evidence that treatment of asymptomatic or early stage prostate cancer can reduce mortality from the disease. The CDC follows the U.S. Preventive Services Task Force recommendations, which do not promote widespread screening.

Public health agencies and other organizations are increasingly asked to play an active role in efforts to reduce the burden of prostate cancer. The CDC planned this conference to obtain advice on programmatic activities in prostate cancer. The CDC is seeking suggestions about what steps the broader public health community should take in prostate cancer surveillance, research programs, services, and communications.

The CDC is an agency within the U.S. Department of Health and Human Services, whose role is to monitor health and prevent disease. It accomplishes this role by:

• Conducting research to enhance disease prevention,
• Developing and advocating sound public health policies,
• Implementing prevention strategies,
• Promoting healthy behaviors,
• Promoting safe and healthful environments, and
• Providing leadership and training in public health.

The CDC fulfills its role by partnering with:

• State and local health departments,
• Academic institutions,
• Community organizations,
• Other U.S. governmental agencies,
• Philanthropic foundations,
• Schools,
• Churches,
• Industry, and
• Labor.

The Division of Cancer Prevention and Disease Control is part of CDC's National Center for Chronic Disease Prevention and Health Promotion. The role of this division is to conduct surveillance of cancer incidence, mortality, risk factors, and preventive behaviors. The division also conducts research and evaluation and develops educational campaigns. The division focuses primarily on breast, cervical, ovarian, skin, prostate, and colorectal cancers. Lung cancer is addressed by another division.

The division has a number of programs, including the NPCR, which has funded cancer registries in 45 states since 1994. The other five states are funded by the NCI's SEER system. For the NPCR, the CDC provides funds to state health departments or their designees to support population-based statewide cancer registries. The quality of data from these registries has improved since 1994. More than 50 percent of the U.S. population is now covered by high-quality registries, from which the CDC will begin receiving annual data in 2001.

The division has active programs in:

• Early detection of breast and cervical cancer,
• Colorectal cancer prevention and control,
• Ovarian cancer control, and
• Skin cancer prevention education.

Dr. Durado Brooks, Director of Prostate and Colorectal Cancer Programs at the American Cancer Society, discussed the role of the ACS in prostate cancer. The society develops guidelines and support programs for prostate cancer patients and survivors. He pointed out that prostate cancer screening and treatment remain challenging areas.

Dr. Richard Williams of the American Urological Association pointed out that the AUA's mission is to foster the highest standards of care by providing education to physicians and their patients and by serving as a health policy advocate. Combating prostate cancer will involve public health initiatives in prevention, early detection, treatment, and palliation. It also involves recognition that not all prostate cancer patients require active treatment.

The death rate from prostate cancer is declining. Some of the reasons may be:

• Earlier detection,
• Improved management,
• Changes in competing causes of death,
• Changes in reporting deaths, and
• Lead time bias.

Research into quality of life issues is needed to determine whether to screen and how to manage patients as individuals. For this, health care professionals, the public, and patients need to be better informed.

The AUA has partnered with the federal government to further the cause of basic research into prostate cancer and hopes to partner with the CDC on applied prostate cancer research. The role of public health professionals in surveillance, information management, and dissemination of information is essential to the success of those endeavoring to improve the management of prostate cancer. Patient advocacy groups can provide a reality check to determine whether doctors are providing patients with the information and services they need, expect, and deserve. As frontline providers of health care, physicians are pleased to be able to work with public health professionals.

Dick Johnson has been the Director of Health Programs for the U.S. Conference of Mayors since 1982. He explained that the Conference of Mayors is a membership and service organization of mayors of cities with populations over 30,000. With a membership of 1,100 mayors, this group is one of Washington's seven major public-interest lobbying groups.

The principal role of the Conference of Mayors is to:

• Aid in the development of effective urban policy,
• Strengthen relationships between the federal government and cities,
• Ensure that federal policy meets urban needs, and
• Provide mayors with leadership and management tools for their cities.

Concern about cancer prompted the Conference to establish the Mayors' Coalition for Prostate Cancer Awareness and Education. The Conference of Mayors is conducting an awareness and education campaign that it hopes will lead to informed decision making.

Dr. Ross Brownson, a professor of epidemiology at Saint Louis University, delivered the keynote address. He spoke about public health approaches to disease prevention and control and presented an overview of public health issues.

According to Dr. Brownson, public health can be defined as a societal interest in the variety of conditions that make people healthy. Roles exist for both government and the private sector in public health, with a focus on partnerships. Public health is multidisciplinary, with contributions from prevention science, research, epidemiology, and other fields.

The causes of death in the United States have changed dramatically over the past century. Although infectious diseases were at the top of the list at the turn of the 20th century, chronic diseases are now the number one cause of death. Over the past century, the average life span in the United States has increased by 30 years Basic public health measures such as immunizations, refrigeration, and cleaning the air and water, have contributed to this increase. The goal now is not necessarily to increase life span, but to increase health span—the amount of time that an individual remains healthy.

In 1994, state public health agencies spent five percent of their budgets on chronic disease prevention and control and this number is rising. About 70 percent of health care dollars are spent on chronic diseases that occur at the end of life.

The contributing factors to chronic disease and death include tobacco use, diet, physical activity, and alcohol use. Each of these factors is amenable to some type of prevention effort.

Research design in public health differs from clinical trials research. In public health research, randomizing is usually not possible, so public health investigators rely on surveillance data and study designs that are only quasi-experimental and not random, to analyze what is occurring in the real world to a real population. Public health surveillance is the collection and analysis of numbers and information. Public health researchers determine whether a trend has occurred as a result of an intervention. Part of public health is putting a program or policy in place and assessing whether it is effective. Public health researchers study surveillance, numbers, and other forms of data. Public health investigators use epidemiologic information to form causative associations.

Education is another important component of public health. Coalitions and partnerships are key to the success of public health.

Some future challenges for public health are:

• The rapid changes in the field of public health, as well as in the field of health care. For example, molecular biology and the human genome project will continue to effect change in the predictability of contracting certain types of cancer.
• The risk factors for prostate cancer are not well established and remain a challenge for the future.
• Improving surveillance, because good information forms the foundation for intelligent decision making.
• Primary prevention of prostate cancer.

Dr. Ralph Coates provided some examples of the variety of prostate cancer activities at CDC. Examples were included for each areas of discussion at the meeting: 4 different types of public health activities, including surveillance, research, health communication, and other programs and services, and 4 different types of issues in prostate cancer, including risk and disease burden, primary prevention, secondary prevention and treatment and quality of life. Examples from states participating in a CDC Cancer Control Program were also included.

CDC has a number of activities in public health surveillance. A major CDC activity is the National Program of Cancer Registries (NPCR), previously discussed by Dr. Lee. The NPCR has helped the states that are not participants in the National Cancer Institute SEER cancer registry program develop their registries to provide information on prostate cancer for populations not included in the SEER program. The National Center for Health Statistics at CDC, collects and publishes prostate cancer mortality information for the nation. In cooperation with state health departments, CDC supports a number of other surveillance systems, including the Behavioral Risk Factor Surveillance System, that can monitor risk factors and intervention programs for prostate cancer, as risk factors for prostate cancer are identified. CDC has worked with NCI to collect the first national data on PSA test use through the National Health Interview Survey. Additional data will be collected by state health departments and CDC through the BRFSS, providing state-level information. Several states and an Indian Health Board are conducting additional surveys of public and provider knowledge about prostate cancer and their prostate cancer screening practices. Surveillance is also being conducted on quality of life for men with prostate cancer using the BRFSS and NHIS.

In the area of public health research, CDC funds studies to evaluate how completely registries identify the prostate cancers diagnosed in their regions. Research on primary prevention of prostate cancer has not been a major activity at CDC, but studies based on the CDC's National Health Interview Surveys and National Health and Nutrition Examination Surveys have contributed important research findings. CDC evaluations of the 5-A-Day program to increase fruit and vegetable intakes and evaluations of STD prevention programs might be considered primary prevention research. CDC is doing a case-control study of the effectiveness of prostate cancer screening and is collaborating with the NCI on the Prostate, Lung, Colorectal and Ovarian Cancer Trial. CDC is doing research on the validity of self-reports of prostate cancer screening and in a study using NHANES will provide information on PSA levels in U.S. men. CDC has a number of studies of methods to improve the prostate cancer screening decision making process for men and their physicians. CDC also has studies examining reasons for racial differences in survival and on end-of-life care.

In communication, CDC Division has in development a video on decision making for screening and training materials for physicians to help them in the process of informed decision making. Many state health departments have prostate cancer education campaigns for the public and for providers. One has unique effort to increase awareness of clinical trials for prostate cancer.

Two types of CDC activities that might qualify as primary prevention efforts for prostate cancer are the 5-A-Day program to increase fruit and vegetable intakes and efforts to reduce risk of sexually transmitted diseases, but there is no scientific consensus on the effects these activities are on prostate cancer risks. CDC does not fund or conduct screening programs for prostate cancer. However, at least two state health departments have implemented screening programs, although one stopped.

Kevin Brady of the CDC's Office Of Program and Policy Information discussed the format of the breakout sessions. The CDC had recently used this type of invitation-only working conference to gain useful information about public health needs in the area of ovarian cancer. He explained that the CDC hopes to gain suggestions for future direction and action, rather than formal recommendations.

Meeting Process

The remainder of the meeting was in the form of eight breakout sessions:

1. Disease Burden
2. Primary Prevention
3. Secondary Prevention
4. Quality of Life
5. Public Health Surveillance
6. Public Health Research
7. Public Health Communications
8. Public Health Programs and Services

Each participant was assigned to two sessions. Each session had a facilitator, an expert reporter to summarize the group's findings and present them to the group on the final morning, and a writer and editor to produce a written summary of the session. Transcribers were present in each session to produce word-for-word transcripts. Participants were asked to provide suggestions in a number of areas in a brainstorming session, and then to prioritize the ideas in order to develop a list of suggestions for future action by the CDC. Because the sessions overlapped somewhat in the nature of the questions asked, there was some overlap and duplication in suggestions.