California Cancer Research Program
Completed Projects
The following Principal
Investigators have completed their research as funded by CRP. Where applicable,
publications resulting from CRP funding are also included.
CYCLE I FINAL LAY
ABSTRACTS
Prevention
Wendy Max, Ph.D.: The Costs of Gender-Specific Cancers in California
Cheryl L. Rock, Ph.D., R.D.: Measuring
Dietary Change and Its Effect on Hormone Levels
Tammy O. Tengs, Sc.D.: Cost-Effectiveness of Cancer Prevention and Control
Paul T. Williams, Ph.D.: Internet Survey and Resource for Studying Diet and
Activity
Pilot and Feasibility
Study Awards
Nancy K. Amy, Ph.D.: Ovarian Cancer in Large Women: Reducing Barriers
to Care
William J. Aronson, M.D.: Soy Protein and Low Fat Diet for Prostate
Cancer Treatment
Leonard F. Bjeldanes, Ph.D., B.Ch.:
Control of Prostate Tumor Cell
Growth by Dietary Indoles
Joel D. Killen, Ph.D.: Environmental Influences on Children's Food Intake
Ofelia V. Dirige, Dr.P.H., R.D.: Cancer Prevention for San Diego Filipino
Americans
Eloise Jenks, M.Ed., R.D.: Dietary Quality
and Food Security Among WIC
Participants
Robert J. Melton, M.D., M.P.H.: IMPACTO II: The Monterey County
Hispanic B.R.F.S. Study
Regino Chavez, M.A.: What Will I Fix to Eat: Exploring Meal Planning and
Food Choices
Christopher Gardner, Ph.D.: Center for
Advanced Studies in Nutrition and
Social Marketing
Esther P. Hill, Ph.D.: Restaurant Nutrition Program: Implementation and
Evaluation
University of California,
Berkeley
Pilot and Feasibility
Study Award, $218,398.00 / 24 mos.
(Ovarian Cancer)
Large women frequently delay seeking health care and cancer screening. Large women were surveyed to determine to what extent and for what reasons they avoid or delay seeking care, and what are effective strategies in overcoming barriers. Health care providers were surveyed to determine how provider attitudes or clinical practices related to weight influence large womenÕs access to care, and what key best practices could improve clinical effectiveness. We surveyed 498 large women, white and African-American. The BMIÕs were divided into ranges of 25 to 35, 35 to 45, 45 to 55, and 55+. BMI is weight (in kg) divided height squared (in in). More than 95% of the women had health insurance and there were no significant differences between education or employment among the size groups. The data show that as weight increased, the percentage of women who delayed seeking health care increased, and the barriers to seeking health care and cancer screening increased. Over 20% of the women with BMIÕs in the 25-35 range reported delay of seeking care and that weight was a barrier, whereas more than 80% of the women with BMIÕs of 55+ reported that weight was a barrier. The women reported barriers in three areas: a) medical equipment, tables, gowns and chairs that are too small; b) negative attitudes of providers, disrespectful treatment and unsolicited advice to lose weight, and c) embarrassment being weighed. The health care providers reported having little or no special training in examining and caring for large patients or in providing weight-related advice for this population. The majority finds examining large patients more difficult than other patients and that supplies are not always readily accessible to accommodate their largest patients. Regardless of practice setting, the providers are dissatisfied with resources and referrals for their large patients.
Soy Protein and Low Fat
Diet for Prostate Cancer Treatment
University of California,
Los Angeles
Pilot and Feasibility
Study Award, $145,200.00 / 24 mos.
(Prostate Cancer)
A significant body of
evidence suggests that nutrition may play an important role in the prevention
and treatment of prostate cancer. Over the past 3 years, our project funded by
the California Research Program project has focused on the role of a low-fat
diet in preventing the development and growth of prostate cancer using mouse
models, and human clinical trials. We have made significant progress in this
regard. Our mouse studies have conclusively shown that human prostate tumors
grown in immunocompromised mice have a reduced growth rate when the mice are
fed low-fat diets as compared to high-fat diets. Serum and tumor studies in the
mice suggest that the diets may be impacting on the growth of prostate cancer by
affecting the insulin-like growth factor pathway which is a pathway known to be
related to the development of prostate cancer. Further studies on the serum and
tumors of these mice will give us more important information on the effect of
diet on the insulin-like growth factor pathway.
Based on our work in the mice
as described above, we also performed studies on men (without prostate cancer)
undergoing a low-fat, high fiber diet intervention to evaluate if there are
changes in serum factors that may impact on the development and growth of
prostate cancer. We studied fasting serum from men that participated in a 2
week low-fat, high fiber program and found that after the intervention, their
serum had reduced levels of insulin-like growth factor-1 and increased levels
of insulin-like growth factor binding protein-1 which would be expected to
impact favorably on the development or growth of prostate cancer. We also found that the
post-intervention serum from these men reduced the growth of human prostate cancer
cell lines in tissue culture when compared to the preintervention serum. These
discoveries have now led us to propose a prospective randomized trial in men
with prostate cancer to hopefully give us important information on specific
low-fat diet regimens that men in California may use to possibly prevent the
development or progression of prostate cancer.
1. Tymchuk CN, Barnard JR, Heber D, Aronson WJ.
"Evidence for an Inhibitory Effect of Diet and Exercise on Prostate Cancer
Cell Growth." J Urol. 2001 Sep;166(3):1185-9.
2. Tymchuk CN, Barnard RJ, Ngo TH, Aronson WJ. Role of
testosterone, estradiol, and insulin in diet- and exercise-induced reductions
in serum-stimulated prostate cancer cell growth in vitro. Nutr Cancer.
2002;42(1):112-6.
3. Ngo TH, Barnard RJ, Tymchuk CN, Cohen P, Aronson
WJ. Effect of diet and exercise on serum insulin, IGF-I, and IGFBP-1 levels and
growth of LNCaP cells in vitro (United States). Cancer Causes Control. 2002
Dec;13(10):929-35.
Control of Prostate Tumor
Cell Growth by Dietary Indoles
Leonard F. Bjeldanes, Ph.D., B.Ch.
University of California,
Berkeley
Pilot and Feasibility
Study Award, $191,118.00 / 24 mos.
(Prostate Cancer)
Indole-3-carbinol (I3C) is a naturally occurring component of dietary vegetables of the Brassica genus, which includes broccoli, Brussels sprouts, kale, and cauliflower. I3C and its major digestive derivative, 3,3Õ-diindolylmethane (DIM), are well established as cancer protective agents in several in vitro and in vivo assays and are promising cancer preventive agents. These indoles have been shown to markedly reduce the incidence of spontaneous and carcinogen-induced mammary tumors in rodents. Because of these well-documented cancer preventive effects of I3C and DIM, especially the effects on hormone-mediated cancers, we are currently investigating the effects of the two indoles on prostate cancer cells. In preliminary studies, we have discovered that I3C and DIM act as potent extracellular growth suppression signals by inducing a G1 cell cycle arrest of cultured androgen-responsive human prostate cancer cells. Thus, it seems likely that I3C and DIM can potentially control the emergence and proliferation of prostate cancer cells by regulating G1 cell cycle components in prostate cancer epithelial cells. Furthermore, we observed that the protein and RNA level of prostate specific antigen (PSA) and one of the cyclin dependent kinases, CDK6, decreased upon I3C or DIM treatment. Therefore, we plan to examine the mode of action of the indoles on the expression of genes involved in aspects of tumor growth and progression and to establish the role of these genes in the cancer protective effects of the indoles. To establish the mechanism of action and to pursue the cancer preventive properties of I3C and DIM, we plan to: 1) characterize the individual and combinatorial cell cycle and functional effects of I3C and DIM on prostate cancer cells, 2) examine I3C and DIM regulation of androgen responsiveness and prostate cancer cell-specific gene expression, 3) establish the anti-proliferative role of indole-regulated cell cycle components in cultured cells and in cells transplanted into athymic mice.
1. Le HT, Firestone GL, Bjeldanes LF.
3,3'-Diindolylmethane (DIM) Acts as a Potential Antiandrogen in LNCaP Human
Prostate Cancer Cells. Journal of
Nutrition. 2001;131(1S):192S.
Regino Chavez
Diet and Behavior Change
RFA, $55,000 / 18 mos.
(General Cancer)
This
study explored meal planning, meal preparation and food choices as these
related to fruit and vegetable consumption among a limited-income segment of
Los Angeles Latinas. The study incorporated face-to-face interviews and
observations of grocery shopping experiences of a sub-sample of the women. The
study was funded by a grant from the California Cancer Research Section.
It
was found that a number of factors come into play when women consider meal
planning, meal preparation and food choices. Among them are the economic
situation that they are in, their familyÕs taste and food preferences and the
particular roles they play in that context. The findings here point out that
the women consider a larger network context rather than an individualistic one
in accounting for health, food beliefs and food purchases. These considerations
are extended to purchases and consumption of fruits and vegetables as well.
The
findings also illustrated how these very real factors take shape for the Latina
respondents in this study. Other
major findings included that male partners are playing a large role in shopping
for groceries and that childrenÕs tastes and food preferences greatly influence
what food choices are made and how the food is prepared.
In terms of fruit and
vegetable consumption, women were found to use these in their daily diet
although they did not believe that they eat nor could eat five servings daily.
Although they recognize the important health benefits of consuming fruits and
vegetables, they were found to interpret consumption within a larger framework
of health that included the family and how they would negotiate among this
expanded notion of health and the interplay of family food preferences, their
mission of providing a nutrition meal and their economic situation.
Ofelia V. Dirige, Dr.P.H., R.D.
Kalusugan Community
Services
Cheryl L. Rock, Ph.D.,
R.D.
University of California,
San Diego
Community-Initiated
Research Collaboration Award, $96,800.00 / 12 mos.
(General Cancer)
A cancer crisis grips the
Asian American and Pacific Islanders (AAPI) including Filipino Americans
(Fil-Ams). While cancer is the leading cause of death in the nation, it has
become the major killer of AAPI women. Cancer incidence and death rates have more
than doubled in the population.
Medical authorities urge scientists studying cancer to focus on regional
and ethnic groups to determine why minorities are more prone to develop cancer
and less likely to survive. Fil-Ams are the second largest ethnic group in
California and the biggest in San Diego (SD). Reports show that new cancer
cases are higher among Fil-Ams than whites in the following sites: cervix uteri
for women, liver and intrahepatic bile duct for men and women, nasopharynx for
men and thyroid for Filipino men and women. It is estimated that 30% of all
cancer deaths are due to what people eat and 5% to an inactive lifestyle. By
following the proper diet, becoming physically active and maintaining an ideal
body weight, the likelihood of getting cancer may be reduced by 30-40%. Among
all foods, diets high in vegetables and fruits have been associated with
decreased risk of many cancers and lower overall cancer rates. It is
recommended that eating a minimum
of 5 servings a day can prevent a wide range of chronic diseases.
Kalusugan Community Services
(KCS), an organization dedicated to improving the health of Fil-Ams, teamed up
with the University of SD's Cancer Prevention and Control Program and SD State
University to address the above issue. The coalition is implementing the
Siglang Buhay Project to increase Fil-Ams intake of fruits and vegetables and
levels of physical activity (PA). The program was based on the results obtained
from a one-year assessment showing that cancer is a big and important problem
in the community. Only 16% of the 458 respondents consistently eat 5 servings
of fruits and vegetables each day and 35% does moderate exercise for 30 minutes
five times a week or vigorous exercise for 20 minutes three times a week.
Residents stated that the best way to reach Fil-Ams with the health message is
through their community organizations.
Eighteen Fil-Am community
organizations were recruited to participate through letters, ads in the media
and personal contact. Each organization recruited two individuals to coordinate
the program. Based on the organization profile, they were assigned to the
comparison or intervention group. The estimated sample size was 480 but a total
of 661 members were recruited to allow for attrition. Five organizations
dropped out during the second year leaving thirteen organizations to continue,
i.e., 5 in the comparison group and 8 in the intervention group. The comparison
groupa are the Association for the Advancement of Fil-Ams, Ceboley USA,
Filipino Association of St. Rose of Lima, Guagua Batulabalani Club of SD and
Iriguenos of Southern California. The intervention groups are Baguio City Association, Bicol Club of SD, Fil-Am
of East County, Olongapo City Association, Salinas Association, SD Majestic
Lions Club, South Bay Terrace Fil-Am Senior Citizens and United Fil-Am Senior
Citizens of SD.
Staff conducted a 12 week training for the coordinators with emphasis on "Cancer Screening" for the comparison group and "Nutrition and Physical Activity" for the intervention group. A monthly meeting of coordinators were held for follow-up and update. Coordinators were expected to share knowledge gained with their members. Periodic workshops were held throughout the year so members can interact with each other. The comparison groups attended workshops on "healthy living" and sponsored a health fair. The intervention groups participated in nutrition/PA workshops and activities such as picnic/basketball tournaments, supermarket tours, recipe contests and food demonstrations, walkathon, gardening, and line and ballroom dancing competition. Questionnaires were given after one year of intervention for evaluation and they are currently being analyzed.
Formerly funded to Mary N.
Haan, Dr.P.H., M.P.H.
University of California,
Davis
Diet and Behavior Change
RFA, $1,400,000 / 36 mos.
(General Cancer)
The University of California at Davis, Center for Advanced Studies in Nutrition and Social MarketingÕs mission is to advance social marketing practice, methods, and evaluation regarding diet and physical activity for the primary prevention of cancer and other chronic diseases in California. The Center had two specific aims for this funding period: 1) To conduct research to increase the effectivness of nutrition and physical activity projects. 2) To provide resources and education for community practitioners to strenthen nutrition and physical activity social marketing campaigns.
To meet these aims Center activities focused on: funding, as well as conducting research, compiling a collection of evalaution tools, and providing technical assistance.
The Center sponsored an invitation only social marketing conference in which key researchers and practitioners explored the challenges and identified opportunities to use social marketing in reducing the risks for chronic disease. The conference proceedings are to be published in a special issue of the "Social Marketing Quarterly" and are available on the CenterÕs website as well.
Two evaluation projects funded through the CenterÕs small grants program were completed: 1) "Farmers' Market: A Channel for Nutrition and Physical Activity Education," evaluating the effects of the 5 A Day Power Play! Campaign Farmers' Market Outreach Program on the fruit and vegetable consumption of children aged 9 - 11 and their parents in San Diego County, and 2) "Evaluation of the Effectiveness of the Salad Bar Program in the Los Angeles Unified School District," evaluating a program which offers a salad bar as a school lunch option to increase fruit and vegetable consumption of children in grades 2 to 5. Manuscripts were submitted for publication for both projects.
Two Center funded research projects were also completed. A paper was accepted in the "Journal of American Dietetic Association" for one of the projects, an ethnographic survey of Mexican-American women that aimed to understand factors related to fruit and vegetable consumption in Mexican-American women living in Sacramento. The second project, which investigated the effectiveness of using goal setting in adolescents to change dietary and physical activity behaviors, produced a curriculum and CD-ROM for use by teachers.
Technical assistance was provided through a variety of modes. The monthly lecture series, which provides a forum in which experts present current and emerging issues in nutrition, physical activity, social marketing, media advocacy, agricultural economics, and policy. Video taped lectures are loaned through the CenterÕs video lending library. And, over a hundred hours of training in social marketing and evalaution was provided to California Nutrition Network local grantees by Center staff.
Four grant proposals were submitted to the Cancer Research
Program and one grant proposal was submitted to the Allen Foundation
Ju‡rez & Associates,
Inc., and Accents on Health, Inc.
Diet and Behavior Change
RFA, $1,313,000.00 / 36 mos.
(General Cancer)
As a pilot study, Ju‡rez
& Associates and Accents On Health conducted a social marketing campaign in
San Diego entitled ŅTrEAT Yourself Well,Ó to encourage the selection of
healthier restaurant meals. For the campaign, a ŅhealthyÓ entrˇe was defined as
including 2 or more servings of fruits and/or vegetables and containing under
30% of calories from fat or under 20 grams fat. Improving the nutritional value of restaurant meals is
important because research shows that the frequency of dining out is increasing
(now averaging four to five meals per week) and most restaurant meals contain
insufficient quantities of fruits and vegetables and are high in fat.
The goals of this program
were: (1) To provide target consumers with information to create awareness of
healthy menu choices in restaurant settings, (2) To position healthy menu entrˇes
as positive choices among the target consumers, and (3) To increase the
percentage of restaurant sales and positive consumer attitudes toward healthy
menu selections.
Six restaurant chains
(primarily family style and quick service) agreed to promote the healthier menu
choices during the 15-month period between 1 March 2000 and 31 May 2001. Within each chain, customer attitude
surveys and monthly sales data were collected in two San Diego locations
(experimental restaurants subject to the social marketing promotions) and one
or two control locations outside the San Diego promotion region. Also within each chain, the menus
designated the healthy menu items identically in experimental and control
locations.
Promotions implemented for
the experimental sites in San Diego included paid advertising (KFMB Channel 8
TV ad spots and full page color ads in San Diego Magazine) and brochure distribution for all the participating
restaurants. Other in-restaurant
and neighborhood promotions varied among restaurants, but included waitstaff incentives and contests, a
custom newspaper insert, restaurant database mailings, food sampling, and
promotion to and through health providers in the community.
Data from four restaurant
chains were analyzed to measure change in customer behavior and attitude during
the program, and to ascertain which marketing techniques were most closely
correlated with increasing sales of the healthier choices. Focus group and survey data showed that
most diners look for taste and value in restaurant meals and have only mild to
moderate interest in the nutrition aspects. Nevertheless the customer survey data showed significantly more
diners reported awareness of the campaign, positive attitudes toward and
purchase of the ŅhealthyÓ meals by the end of the campaign in the experimental
restaurant locations. Sales data
showed a significant increase in sales of the healthy menu items. Multiple regression analysis showed the
paid media to be largely ineffective in increasing sales during the measurement
period. The promotions most effective in increasing sales of the targeted
dishes were (1) paying waitstaff to promote the healthy items, (2) mailing
coupons to restaurant database customers, and (3) offering restaurant gift
certificates to health providers to raise their awareness of the campaign and
encourage them to distribute materials to clients or patients.
Public Health Foundation
Enterprises WIC
Gail G. Harrison, Ph.D.,
R.D.
University of California,
Los Angeles
Community-Initiated
Research Collaboration Award, $71,790.00 / 12 mos.
(General Cancer)
Introduction: The overall objective of this study is
to determine the contribution of the WIC program to food security and to
understand the mechanisms, which influence the intake of fruits and vegetables
(FVs) for individuals and families.
Pregnant women, who are first-time WIC participants, are the focus of
this study. The specific aims are
based on data that were obtained at three separate interviews, (first prenatal
WIC visit, during the last trimester, and 3-6 months postpartum) and include:
1) determining the occurrence of household food insecurity and hunger,; 2)
examining the relationship between food insecurity and a number of cultural and
family-related characteristics; 3) exploring the relationship of food
insecurity and hunger with dietary quality, in particular fruit and vegetable
intake; and 4) developing plans to enhance WIC nutrition program education
components and community linkages to distribute fruits and vegetables at low or
no cost to participants.
Research Methods: We followed 313 pregnant, first-time
WIC participants for a period of one year to track their progress. We used measurement tools developed by
the USDA to assess food security and to determine standard portion sizes for fruits
and vegetables. Questions on
knowledge, attitudes and behaviors about fruit and vegetable intake were taken
from the California Dietary Practices Survey.
Results: Food insecurity decreased 15.6% among
families participating in the WIC program approximately six months following
their enrollment. There was a
slight increase in food insecurity after women delivered their infants, but
overall a decrease of 12.7% in food insecurity was achieved when compared to
status at enrollment.
Average fruit and vegetable
intake was 7.06 servings at recruitment into the study [standard deviation (sd)
=5.07] and 6.37 servings (sd=6.50) six months after recruitment. Intake decreased slightly from
recruitment to the second interview for the group overall and for each of the
ethnic groups. There was a statistically
significant difference in the consumption patterns for Hispanics and
African-Americans with Hispanics eating more FVs. No differences were found for comparisons across age groups,
levels of education or income. No
association was found thus far between fruit and vegetable intake and food
security status for the survey time points individually. More advanced analyses will be
conducted to take into account changes across time. The primary reasons participants gave for eating FVs were
Ņto set an example for their families" and "to have more
energy". Participants with an
education less than high school and Hispanic women were more likely to give
these responses than those with more education and African-Americans. Some women also reported that eating
FVs was "the right thing to do". Common barriers to eating FVs were cited as finding it Ņtoo
difficult to get (FVs) at restaurantsÓ, Ņtoo difficult to get (FVs) at workÓ ,
the participants' "family not liking FVs", being Ņunsure about the quality of FVsÓ, and "not
knowing how to fix FVs". The proportion of women reporting the
last two barriers decreased from the first to the last interview.
Summary: Food insecurity appears to have
decreased as a result of these women's participation in the WIC program. Fruit and vegetable intake dropped
slightly six months after the participants began the study, but this may be due
to the timing of the interview in the last month of pregnancy. We were not able to show a relationship
between food insecurity and fruit and vegetable intake possibly because of the
eating customs of the large number of recent immigrants in our study, who have
not yet adopted American habits.
Analyses examining changes over time will determine if this relationship
truly does not exist. Participants
experienced improvements in some of the barriers they had to eating FVs. This may have been a result of the
nutrition education modules at WIC, which teach women how to shop, prepare and
cook food.
Stanford University
Pilot and Feasibility
Study Award, $204,599.00 / 24 mos.
(General Cancer)
Food insecurity defined as
limited or uncertain availability of nutritionally adequate and safe foods or
limited or uncertain ability to acquire acceptable foods in socially acceptable
ways, is a critical variable for understanding the nutritional status of
low-income populations. However,
there are no reports that examine the association between living in food
insecure households with school-age childrenÕs nutritional status. Therefore, the objective of our
research was to examine the relationships between household food insecurity,
household food supplies, childrenÕs dietary intake and childrenÕs weight. As
part of a school based obesity prevention program we sampled a group of 124,
predominantly Hispanic, 5th grade children and their mothers. ChildrenÕs weight, height and
three 24 hour dietary recalls were collected. Mothers provided reports of household food insecurity and
household food supplies. Food insecurity was negatively associated with
childrenÕs Body Mass Index (BMI) and household food supplies, but not with
childrenÕs food intake. However, children from the most food insecure
households had more precipitous drops in energy intake and meat consumption
compared to children from food secure households. This research is the first to
report a significant association between food insecurity and childrenÕs
nutritional status. Food insecure childrenÕs age and sex adjusted
weights-for-height were lower than food secure childrenÕs, but still within the
normal range. Lower
weights-for-height in food insecure children may be due to short-term, yet
periodic food restrictions that result as household food supplies diminish prior
to payday. Future research is
needed to assess the physiological and psychological effects of periodic food
restriction on childrenÕs health.
1. Matheson, DM, Varady, J, Varady, A, Killen, JD.
Household Food Security and Nutritional Status of Fifth Grade Hispanic
Children. Am J Clin Nutr (accepted for publication) July, 2001
2.
Matheson DM,
Killen JD, Wang Y, Varady A, Robinson TN. ChildrenÕs food consumption during
television viewing. American Journal of Clinical Nutrition, Vol. 79, No. 6,
1088-1094, June 2004
University of California,
San Francisco
Investigator-Initiated
Award, $478,590.00 / 24 mos.
(Gender-Specific Cancer)
This study focuses on the
costs of four gender-specific cancers that are among the leading causes of
cancer death and incidence in California -- prostate, ovarian, uterine, and
cervical cancer. Costs estimated include diagnostic procedures,
hospitalizations, outpatient care, other medical care costs, and the value of
lives lost. Both annual and
lifetime costs are being estimated.
The study has three specific aims:
1.Annual Cost. To estimate the annual cost of
gender-specific cancers in California, including direct medical care costs and the value of lives lost. The role of cancer as a comorbidity is
also being analyzed.
2.Lifetime Cost. To estimate the lifetime cost of
gender-specific cancers in California
3.Cost-Effectiveness of
Alternative Treatment Modalities.
To estimate the cost of treating each of the cancers under alternative
treatment modalities and use these estimates to compare the cost-effectiveness
of alternative treatments for a given diagnosis.
In 1998 in California there
were 9,043 hospital discharges with a primary diagnosis of prostate
cancer. Most were older - 60% were
over age 65 - and the total cost amounted to $64 million. The three female cancers studied were
most common among relatively younger women, with those under age 65 accounting
for 84%, 60%, and 49% of discharges for cervical, ovarian, and uterine cancer.
Cervical cancer resulted in 2,170 hospital discharges at a total cost of nearly
$19 million. Ovarian cancer
discharges numbered 2,463 at a cost of $34 million and there were 3,608
discharges with uterine cancer at a total cost of $27 million.
Cancer is commonly listed as
a secondary diagnosis for a hospitalization. To estimate the resulting costs, the cost of those with no
secondary diagnoses were compared to those with a secondary diagnosis of one of
the four cancers under study. The
cost attributed to secondary cancer diagnoses was estimated at $43 million for
prostate cancer, $8 million for cervical cancer, $16 million for ovarian
cancer, and $6 million for uterine cancer.
In addition to
hospitalizations, annual costs were estimated for physician care, ED visits,
outpatient and office-based visits, medications, home health care, and nursing
home care. These costs were
substantial. The resulting total
direct costs for hospitalizations and other direct costs in 1998 were $180
million for prostate cancer, $47 million for cervical cancer, $91 million for
ovarian cancer, and $62 million for uterine cancer.
Cancer led to a number of
deaths of Californians in 1998 – 2978 from prostate cancer, 460 from
cervical cancer, 1397 from ovarian cancer, and 605 from uterine cancer. These lost lives represent considerable
lost productivity in the workplace and in the household, which amounted to a
present value over the expected remaining lifetime of $182 million, $162
million, $204 million, and $65 million for prostate, cervical, ovarian, and
uterine cancer respectively.
Lifetime costs of cancer were
estimated for Medicare recipients.
First a survival model was developed that includes the probability of a
person surviving, estimated separately by type of cancer, stage of the disease,
and age at diagnosis. Per person
lifetime costs ranged from $18.000 for prostate cancer to $45,000 for ovarian
cancer. Costs were lower for those
diagnosed with localized cancer, but the pattern of cost by stage and age at
diagnosis followed different patterns for each cancer. Lifetime costs are being estimated for
different treatment modalities.
1. Max W, Rice DP, Sung HY, Michel M, Breuer W, Zhang
X. The economic burden of prostate
cancer, California, 1998. Cancer. 2002 Jun 1;94(11):2906-13.
2. Max W, Rice DP, Sung HY, Michel M, Breuer W, Zhang X.
The economic burden of gynecologic cancers in California, 1998. Gynecol Oncol.
2003 Feb;88(2):96-103.
IMPACTO II: The Monterey
County Hispanic B.R.F.S. Study
Robert J. Melton, M.D., M.P.H.
Monterey County Health
Department
Marilyn A. Winkleby, Ph.D.
Stanford University
Community-Initiated
Research Collaboration Award, $96,800.00 / 12 mos.
(Cervical/Colorectal
Cancer)
Abstract not available
from final report.
University of California,
San Diego
Investigator-Initiated
Award, $763,445.00 / 36 mos.
(Gender-Specific Cancer)
There is considerable
evidence that what people eat may have a major impact on their chances of
avoiding and surviving cancer. The
focus of this study is on the relationships between diet, blood lipids, and
hormonal factors relevant to hormone-related cancers (particularly ovarian,
breast and endometrial), and how these relationships are best studied in a
human population. Dietary factors
are believed to contribute to risk for these cancers, and much remains to be
learned about the usefulness of dietary assessments and the lipid and hormonal
responses to diet modification. As
an efficient approach to addressing these research questions, we are focusing
on participants in an ongoing National Cancer Institute-funded study that is
examining the effect of a diet high in vegetables, fruit and fiber, and low in
fat, on cancer recurrence and overall survival. This approach allows us to address the research questions
(which are all highly relevant to studies of diet and all of the
hormone-related cancers) at much lower cost than would be incurred by developing
and implementing a new clinical trial, because we are using data and biological
samples that have already been collected.
The research questions addressed by this study are: (1) How do two
common methods of collecting dietary data (repeated 24-hour recalls and food
frequency questionnaire [FFQ]) compare with biological measures in
responsiveness to dietary change in important nutrients that may influence
cancer?; and (2) What is the effect of adopting a plant-based diet on
circulating lipid fractions? Is
there evidence that change in self-reported dietary intake or in a biomarker of
vegetable and fruit intake (circulating carotenoids) are associated with
changes in a possible mechanism for increased cancer risk (hormonal
factors)? During the final year of
the project, we demonstrated that the FFQ instrument reliability was very good,
with a mean correlation coefficient of 0.63 in the comparison group study
arm. We also found significant
correlations between changes in intakes in the intervention group (from
baseline to year 1) of energy-adjusted nutrients measured using the two dietary
assessment methods for most nutrients.
In a comparison of responsiveness of the FFQ and recall approaches for
key intervention target nutrients (such as fat and fiber intake), the
approaches were comparable. This
is useful information for conducting research studies because the FFQ is easier
and imposes much less burden for people.
However, the two approaches to measuring dietary intake contributed
independently to the ability to predict the biological measures in the blood,
so there is some value in being able to use both methods. Regarding the hormonal factors under
study, we verified that a plant-based (high fiber) diet prescription promotes
lower blood levels of estrogens, which are known to promote progression of the
hormone-related cancers in women.
Finally, we demonstrated that a decrease in fat intake from 28% to 21%
of energy, concurrent with an increase in carbohydrate intake from 56% to 64%
of energy, does not increase blood levels of insulin or insulin-like growth
factors. These factors have been
suggested to increase risk for cancer progression, and the possibility that
increased carbohydrate intake could adversely affect these factors has raised
some concern about the long-term benefit of this dietary pattern. Results from this study show that the
hormonal effects of a lower fat, higher carbohydrate intake (lower estrogen
levels) are beneficial with regard to increasing the likelihood of survival
after the diagnosis of a hormone-related cancer. Also, we found that insulin and insulin-like growth factors
are mainly influenced by a personÕs degree of overweight, and that the levels
of fat and carbohydrate in the diet that are recommended as prudent goals for
cancer prevention do not adversely affect these hormonal factors in humans.
1.
Rock CL, Demark-Wahnefried W. Nutrition and survival after the
diagnosis of breast cancer: a review of the evidence. Journal of Clinical
Oncology 20:3302-3316, 2002.
2.
Thomson CA,
Giuliano A, Rock CL, Ritenbaugh CK, Flatt SW, Faerber S, Newman V, Caan B,
Graver E, Hartz V, Whitacre R, Parker F, Pierce JP, Marshall JR. Measuring
dietary change in a diet intervention trial: comparing food frequency
questionnaire and dietary recalls. Am J Epidemiol. 2003 Apr 15;157(8):754-62.
University of California,
Irvine
Investigator-Initiated
Award, $918,053.00 / 36 mos.
(Gender-Specific/General
Cancer)
Some cancer prevention and
control activities yield large health gains at low cost while others yield
small health gains at high cost.
Because resources are limited, policy makers want to invest those
limited resources wisely – maximizing public health gains given the resources
expended. The goal of this project
is to provide decision-makers with information on the relative
cost-effectiveness of different interventions aimed at cancer prevention and
control.
Data was obtained from
published cost-effectiveness analyses.
To date we have identified 353 analyses that met our inclusion
criteria. From these analyses we
extracted cost-effectiveness information for more than 1400 forms of cancer
prevention, screening, and treatment.
In addition, we recorded the quality of each analysis.
Information on
cost-effectiveness was gathered by two or more research assistants who read
each article and coded approximately 200 pieces of information into a
database. Some of the items
coded included the nature of the intervention, e.g., annual pap smears, target
population, e.g., all women age 18+, cost per year of life saved, cost per
quality-adjusted year of life saved, "perspective" from which the
analysis was conducted, e.g., societal (which includes all costs regardless of
who bears them), discount rate, etc.
After coding these items into a database, the research assistants then
met and came to consensus on their work.
The principal investigator then checked their coding, occasionally
requesting revision.
After collecting information
on cost-effectiveness, research assistants then coded the quality of each
analysis. They referred to the
recommendations of the US Panel on Cost-Effectiveness in Health and Medicine
and for each recommendation coded whether it was completely, partially, or not
met. We developed a scoring system
and gave each article 1-5 gold stars based on the quality of the analysis.
The "working"
database is now complete and contains cost-effectiveness information for about
1400 interventions along with the quality of each analysis. We also began the process of developing
a web-based database so as to make our data publicly available on the
Internet. The design and functionality
of this "web" database is about 90% complete and it contains about
one-third of the data in our "working" database.
Results indicate that the cost-effectiveness of preventive interventions varies from those that save money to those costing upwards of $2 billion for each year of life saved. Similar variation can be found for cancer screening and treatment. This highlights the importance of understanding the cost-effectiveness of specific interventions - data that is available in our database. We are now in the process of preparing several manuscripts describing the relative economic efficiency of various cancer prevention and control opportunities.
1. Tengs TO. Cost-effectiveness versus cost-utility
analysis of interventions for cancer: does adjusting for health-related quality
of life really matter? Value Health. 2004 Jan-Feb;7(1):70-8.
Internet Survey and
Resource for Studying Diet and Activity
Lawrence Berkeley National
Laboratory
Investigator-Initiated
Award, $1,218,746.00 / 36 mos.
(Prostate/Colorectal Cancer)
Lawrence Berkeley National
Laboratory (LBNL) currently uses the internet for promoting collaborative
research in biology, materials science and physics. Drawing upon the
laboratoryÕs expertise in software development and studies on nutrition and
physical activity, LBNL researchers plan to develop the next generation of
research tools for studying the effects of lifestyle on cancer risk.
LBNL scientists propose to
develop the "Epinet"- an internet based survey that provides any
internet-user an on-the-spot analysis of their diet and physical activity, and
a comparison of their lifestyle to public health recommendations. Users can choose to join an LBNL
national study on how diet, dietary supplements, physical activity, and
prescription medications affect cancer risks. The 3-year study hopes to enroll
80,000 participants (to complete ten one-day surveys), who will be recontacted
after five years to determine their health.
The study provides individual
users with a free analysis for their benefit. "Epinet" will also serve as a potentially valuable
resource to other researchers and to the health care community. Other researchers conducting separate
studies can direct their participants to "Epinet" to subscribe to the
survey. Each time they enter their diet, the analysis will be sent automatically
to the researchers by E-mail. As widely recognized, health care providers pay
little attention to life-style approaches for disease prevention.
During the last year,
significant progress has been made in three areas: the design of the web site,
the material delivered by the site to the user, and software. We have added
several features to the web site that were not originally envisioned. When
revisiting the site, participants will be able to determine which parts of the
survey they wish to receive each time they revisit the site, whether they wish
to be recognized automatically, and whether there are questions they wish to
track themselves. Foreign language translations of the survey will become
available to the participant based on the language used by their web browser
(i.e., whether the browserÕs preferences are set to English, Spanish, etc.). A
monthly calendar will be available for the participant to display previously
entered results. During the last twelve months, the database of foods has been
refined with the help of two registered dieticians, whoÕs tasks have been to:
1) organize the foods for easy identification; 2) review the choice of portion
sizes; 3) create the lists of garveys, fats, oils, sauces, etc. that are
frequently added to foods. There
are currently 31,287 choices of foods and portion sizes, and 1,881 food
additions (toppings fats, etc. that can be added to foods). We have also included 5,694 brand name
foods to the existing database.
To entice participants to
visit the internet site frequently, we have created the TransAmerican exercise
log, which is a visual enticement for getting participants to record their
daily running, walking, and cycling mileage. A participantÕs reported number of miles ran, walked, or
cycled will represented by a virtual travel across the United States. Each time the participant enters their
activity a picture will be displayed showing an actual image of what they would
see if they were actually accumulating their mileage in a cross-country walk
across the US.
We have decided to deploy the
web site using the computer application ŅWebObjectsÓ running on Macintosh OS X servers. The new version of the internet site is expect to be
deployed by October 1, 2000.
Although recruitment will not formally begin until the new version of
the site becomes available, we nevertheless continue to receive approximately
100 new visitors to the site each week, and of these one in seven complete the
survey.
California Cancer Research Program
(916) 449-5550