Prostate Cancer Conference Report
Session 2: Primary Prevention

In this session, participants discussed primary prevention of prostate cancer in the United States. To avoid confusion, they agreed on the following definitions of terms.

Public health—Includes activities of state public health agencies, CDC and other government institutions, voluntary organizations, and the partnerships of these organizations.

Surveillance—The collection and presentation of data to describe trends and patterns of disease, behaviors, the environment, programs, policies, and the use of services.

Research—An analytic process that focuses on relationships between disease occurrence, disease characteristics, and risk factors for the disease.

Communication—Strategies to raise awareness, key messages, the intent of the message, and how the message should be delivered.

Programs and services—Specific services, policies, or environmental characteristics.

Primary prevention—Measures intended to reduce the incidence of cases of prostate cancer among individuals before the disease is initiated.

Secondary prevention—Detection and treatment of existing disease.

Several participants pointed out that primary prevention of prostate cancer is not possible because the modifiable risk factors for the disease are not known. Thus, determining the cause or causes of prostate cancer and understanding the etiology of the disease is absolutely necessary. This need was reiterated throughout the session.

The participants raised a number of issues regarding primary prevention of prostate cancer:

• How and when to convey information to the public.
• Disseminating information about studies that are underway to dispel beliefs that hypotheses are fact and that results of single studies are fact.
• Communicating the lack of knowledge about the primary prevention of prostate cancer.
• Measuring the success of primary prevention.
• Identifying populations at high risk for prostate cancer.
• Considering possible preventive measures such as diet change not just for prostate cancer, but for other chronic conditions.
• Integrating potential prostate cancer preventive measures into prevention activities for men's health in general.
• Assessing the fragmentation of the public health effort.
• Identifying environmental agents, chemopreventive agents, and dietary factors that affect risk.
• Evaluating self-medication with dietary supplements, such as saw palmetto.
• Identifying risk factors.

The group unanimously agreed that administering the PSA test is not primary prevention.

Surveillance and Monitoring

In their discussion of surveillance and monitoring, the participants developed a number of suggestions. First, the public health community should monitor potential modifiable risk factors for prostate cancer. Because the purpose of primary prevention is to lower the risk of new disease, it is essential that risk factors for prostate cancer be identified. To accomplish this goal, epidemiologists should collect data to correlate diet, environment, behavior, and other potentially modifiable risk factors with the onset of prostate cancer. Monitoring all potential modifiable risk factors is unreasonable, so the participants suggested that public health organizations begin to monitor four specific factors—sexually transmitted diseases, eating red meat, consuming dairy products, and low consumption of fruits and vegetables. Some research indicates that these may be risk factors.

Second, to identify risk factors for prostate cancer, the public health community should develop clear consensus on the data to be collected and the monitoring systems to be used. Consensus is needed in coding the stage and grade of prostate cancer. To conduct meaningful trend studies, uniform definitions and coding for stage and grade need to be applied to data from previous years. A committee of experts should be assembled to accomplish this goal. Because several cancer data collection systems are already in place—SEER, NPCR, the Behavioral Risk Factor Surveillance System (BRFSS), and state registries—public health organizations do not have to generate a new system. Rather, the existing systems should be refined, coordinated, and integrated.

The participants pointed out the importance of determining and monitoring the public's awareness of modifiable risk factors for prostate cancer, potential modifiable risk factors, and risk factors that cannot be modified. To gain an understanding of the public's awareness, public health professionals should collect data on what the general public knows about risk factors for prostate cancer and determine the degree to which they are misinformed. The public health community also needs to characterize various populations with respect to their awareness of prostate cancer and related issues. Knowledge of the public's awareness is necessary to learn what needs to be done to clarify some of these issues, particularly for populations at highest risk. More information is needed to know what channels are being used to obtain information about prostate cancer and what sources of information are the most influential.

The group identified several additional areas that require surveillance and monitoring. For example, data are needed to determine the relationship between premalignant stages and high risk conditions that lead to prostate cancer. To this end, data are needed to identify ways of classifying people in terms of risk. One pathologically identifiable condition the may be a precursor to prostate cancer is prostatic intraepithelial (or intraductal) neoplasia (PIN). Identifying a marker for PIN and developing an understanding of its natural progression is important for a clearer understanding of prostate cancer.

A system is needed to monitor cancer-related behaviors and the incidence and mortality of prostate cancer. This monitoring system should be in place to track behavior changes that men make to avoid prostate cancer. For example, surveys indicate that men are drinking tomato juice and green tea and taking saw palmetto. The participants pointed out the importance of identifying markers of sexually transmitted diseases and including this information in the monitoring systems because these diseases may be risk factors for prostate cancer.

Research

The participants defined applied research in prostate cancer as any research, including epidemiology but not etiology. Applied research in prostate cancer might include improved surveillance methods and use of health services.

The group discussed research to find the causes of prostate cancer. The agreed that, if primary prevention is the goal, the only useful research is to identify the causes of the disease. Although basic research was not the purview of this session, the group stressed the importance of preparing for the day when solid information is available about the causes of prostate cancer. To develop criteria for primary prevention research, the participants suggested several research projects. Three are summarized here:

• The public health community should set up mechanisms to generate hypotheses on the cause(s) of prostate cancer. Epidemiologists should conduct systematic reviews of the prostate cancer literature and perform metaanalyses. These reviews should have a global perspective and should highlight hypotheses concerning risk factors. The goal of the reviews and analyses should be to identify known and potential risk factors and to determine whether the research in other countries is applicable to prostate cancer in the United States. Combining information on human activities with survival or outcome data would be an ongoing mechanism to generate hypotheses. (Although some participants regarded this as a very important research topic, others argued that excellent reviews have already been published in such journals as Epidemiologic Reviews.)



• Public health professionals should conduct a historic review of incidence and trends of prostate cancer and correlate these data with events such as PSA testing or changes in diet. This type of analysis might reveal some cause-and-effect relationships.



• Public health professionals should sponsor research on the psychosocial aspects of effective communication. The chief aims of this research should be to learn the public's opinion on risk, what the public knows, how best to communicate the current state of knowledge on prostate cancer risk factors to the public, and how and why individuals change behaviors and lifestyles. The group agreed that determining the factors that motivate behavioral changes would help in efforts to affect change rapidly and effectively, once concrete information is available about actual risk factors for primary prevention.

The participants recommended the following additional research options for primary prevention:

• The public health community might consider enlisting the participation of members of the saw palmetto sales industry to query men who have used this product to determine their prostate health outcomes.



• Public health professionals might encourage investigators to undertake basic research in the following areas: collecting biological samples; conducting research to improve surveillance; investigating the effectiveness of educational methods for different populations; identifying how different populations, particularly ethnic groups, respond to different types of education; and identifying biomarkers.



• Conduct research that includes African American men, Hispanic men, and men from other ethnic minority populations.



• Include men from ethnic minority groups in clinical trials.

Programs and Services

The participants addressed the role of the public health community in providing programs and services for primary prevention. They discussed the overlap between programs and services and communication because communication programs are both a program and a service.

The group suggested that the public health community explore the feasibility of programs to reduce the cost of healthy behaviors. Diets high in fresh fruits and vegetables may be more expensive than diets high in fat. One participant had told an audience of native Hawaiians that their traditional diet, which was heavily based on fresh seafood and vegetables, may have protected against cancer. Members of that audience quickly replied that traditional Hawaiian foods, such as taro and fresh fish, are very expensive in grocery markets. Still other participants noted that it might not be prudent to spend money on promoting traditional foods when it is not known whether dietary factors are risk factors for prostate cancer.

The participants highlighted the need to determine the best ways to deliver programs and services to priority populations, including determining the most effective formats for target populations and the best methods to disseminate information widely. They suggested that public health organizations sponsor a white paper to review international programs and services, with an emphasis on examining the programs and services already in place in other countries. It was noted that some countries, such as Canada and Germany, have very effective and worthwhile programs.

The group members suggested that the public health community also explore the feasibility of partnering with food producers to provide consumers with low-fat whole foods as an alternative to altered foods with reduced fat that have recently entered the marketplace in response to recommendations from the public health community. They pointed out that food producers are focused on making money and have an agenda different from that of the public health community.

To provide consumers with information about healthful foods and diet, the participants offered several suggestions:

• Work with restaurants to encourage them to decrease portion sizes. Many restaurants serve meals that are 1,900 calories or more.



• Partner with grocery stores to post signs about beneficial foods and advertise their benefits. Current research, however, indicates that supermarket interventions have been unsuccessful, probably because supermarkets are saturated environments where added visual stimulation is not noticed by shoppers.



• Organize meetings that bring together scientists, policy makers, patient advocates, government representatives, and food industry representatives, including chief executive officers.



• Craft messages, using the research from a white paper, to let the public know that no solid information exists about what can be done to reduce the risk of developing prostate cancer. A statement clarifying the lack of information would be a service to those who might otherwise spend time and money on products of uncertain value, such as alternative medicine products. However, men are already aware that scientists do not know the causes of prostate cancer. Thus they take herbal products, such as saw palmetto.



• Develop programs that include men from racial and ethnic minority groups in research studies and in clinical trials.

Health Communications

The group made three suggestions about actions the public health community should take to communicate information about primary prevention of prostate cancer. First, educate health care providers, particularly primary care physicians, about the current state of knowledge regarding primary prevention for prostate cancer. Educational efforts should encourage physicians to spend about five minutes with each male patient talking about the disease and primary prevention issues.

The public health community should form partnerships and coalitions for communication with support groups and other organizations. For example, public health organizations should partner with consumer support groups, such as the American Association of Retired Persons, which regularly communicates with a population at risk for prostate cancer, and Us TOO International, which has a direct path to target audiences. Us TOO International has published booklets about prostate cancer. Developing partnerships with the National Cancer Institute (NCI) will also be important, because NCI funds a system of well-funded centers for cancer communication around the country.

The public health community should develop communication strategies that are effective in conveying information to all target populations. Communicating information about primary prevention requires reactive models in addition to proactive models. Communication should be a two-way street. A mechanism is needed for the public health community to learn what patients want to know. Interactive Web sites in which viewers ask questions are a good example, but other ways exist to provide the public with an opportunity to frame questions in ways that are meaningful to them. Studies indicate that an effective way to communicate with many men is through their spouses. The public health community should establish mechanisms to communicate with spouses. In many traditional U.S. homes, especially those with older men, the women buy the groceries, prepare the meals, and have a significant impact on men's diets and lifestyles.

To communicate information about prostate cancer, the participants highlighted the importance of tailoring educational materials to different learning styles and belief systems. They agreed that public health organizations should select the best spokespersons for each target audience. For some communities, the spokesperson might be a celebrity, but for others, the person might be a religious figure, a local politician, or a scientist who is a reliable, authoritative source.

The participants also suggested that a mechanism is needed for public health practitioners to quickly obtain information about the biology of prostate cancer from scientists at the National Institutes of Health (NIH) and from other organizations. Public health organizations should communicate information about primary prevention to the public in a standard way to lessen the impact of information communicated through nonstandard sources.

The group suggested that to communicate information and messages to hard-to-reach populations, public health organizations should collaborate with the Advertising Council. Participants noted that flexibility is key to effective communication among target audiences. Because effective communications strategies are predicated on having something to say, the participants stressed the importance of basic research into the causes of prostate cancer.

Highlighted Suggestions

The participants highlighted the following recommendations to develop and clarify primary prevention of prostate cancer:

Surveillance and Monitoring

1. Formulate a clear consensus on the data to be collected.



2. Monitor modifiable risk factors, such as diet and environment.



3. Use NPCR and the SEER cancer registry to collect risk factor data and link these data to incidence and mortality data.



4. Conduct surveillance to provide a better understanding of the associations between premalignant changes, including biological markers, in the prostate and the risk of prostate cancer.

Research

1. Perform a systematic review of the literature on potential risk factors, including metaanalyses.



2. Perform a historic review of prostate cancer incidence, mortality, and survival; identify trends and correlate these trends with changes in potential risk factors, screening, diagnostic procedures, and treatments.



3. Conduct research on the psychosocial aspects of effective communication for target audiences.

Programs and Services

1. Develop a white paper to document what is known about primary prevention issues.



2. Determine ways to best deliver programs and services to priority populations.



3. Explore the feasibility of a program to reduce the cost of healthy behaviors, e.g. healthful diet, and of living a healthy lifestyle.

Health Communications

1. Educate appropriate health care professionals about the current state of knowledge on primary prevention; encourage primary care physicians to discuss health issues related to the prostate and prostate cancer.



2. Develop coalitions and partnerships with organizations, such as the American Association of Retired Persons and Us TOO International, and links with NCI communication centers.



3. Develop communication strategies (two-way communications between patients and the public health community), involve spouses, and identify the best spokespersons to reach target populations.

Session Participants

Carol Moody Becker, U.S. Conference of Mayors
Donald K. Blackman, Centers for Disease Control and Prevention
Cynthia Boddie-Willis, Massachusetts Department of Public Health
Rosalind Breslow, Centers for Disease Control and Prevention
Ross C. Brownson, Saint Louis University
John Carpten, National Human Genome Research Institute
June Chan, University of California, San Francisco, Medical School
Paul A. Godley, University of North Carolina, Chapel Hill
Jerianne Heimendinger, American Medical Center Cancer Research Center
Cynthia Jorgensen, Centers for Disease Control and Prevention
Laurence N. Kolonel, University of Hawaii
Alan R. Kristal, University of Washington and National Cancer Institute
James R. Marshall, University of Arizona Cancer Center
Linda C. Nebeling, National Cancer Institute
Henry Porterfield, Us TOO International
Juanita Salinas, Texas Department of Health
Benedict I. Truman, Centers for Disease Control and Prevention
Richard Williams, University of Iowa
Walter Young, Advanced Health Directions
Facilitator—Amy Harris
Writer and editor—Lorraine Lica
Reporter—John Carpten