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Update Healthy New Jersey 2000
Second Update and Review

Priority Area 4
Prevent, Detect And Control Cancer

Introduction

Statewide incidence rates for most cancers diagnosed among New Jersey residents declined from 1992 through 1996. For the major preventable/treatable forms of cancer - breast and cervical, colorectal, prostate and lung - New Jersey has made great progress and appears to be on track to meet most of the year 2000 objectives. Nevertheless, cancer remains second only to heart disease as the leading cause of death in New Jersey. Furthermore, the persistence of tobacco usage among adolescents and the increased incidence of malignant melanoma, a skin cancer strongly linked to sun exposure, are causes for concern. The outlook for achieving all of New Jersey's year 2000 cancer-related objectives is mixed.

Outlook For Reaching Specific Objectives:

Achieve target: Likely Unlikely Uncertain
4A. Reduction in the female breast cancer death rate for:




the total population
X




females, 50-65
X




females, 65 and over
X


4B. Increase in clinical breast exams and mammograms
X


4C. Reduction in the lung cancer death rate for:




the total population
X




minority males
X


4D. Reduction in cigarette smoking for:




persons 20 and older
X



high school students
X

4E. Reduction in the colorectal cancer death rate
X


4F. Increase in the average daily servings of fruits and vegetables
X

4G. Reduction in the cervical cancer death rate for:




total females

X


minority females
X




females, 65 and over
X

4H. Increase in Pap tests for:




total females
X



minority females
X



females, 65 and over
X

Data Update

4A. Reduce breast cancer deaths per 100,000 females to:

22.7 for total female population (age-adjusted)
72.5 for females aged 50-64 years
130.2 for females aged 65 and over

Achieve target:LikelyUnlikelyUncertain
all females
X
females, 50-64
X
females, 65 and over
X

Death Rates From Breast Cancer
Year Total, Age-Adjusted 50-64 Years 65 And Over
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
28.2
26.4
25.6
25.8
27.1
25.5
27.2
25.4
23.6
24.1
23.3
21.9
93.8
85.3
82.8
83.2
84.4
78.5
83.5
77.9
77.8
68.7
65.1
67.6
153.6
150.7
149.7
147.2
161.5
154.1
168.2
158.2
156.2
155.8
152.7
146.9

New Jersey reached its year 2000 objective for the age-adjusted breast cancer death rate in the total population of females in 1996.

The age group that is responsible for the decreasing trend in the overall breast cancer death rate is females 50 through 64 years of age. The death rate in this group reached the year 2000 objective in 1994 and may by the year 2000 go even lower.

Women aged 65 and over, who are at higher risk of breast cancer, now seem likely to achieve the year 2000 target. The death rate in this group is more than twice the rate in the preceding age group and had been fairly stable from 1985 to 1994. Since 1994, however, the rate has declined, perhaps reflecting greater use by older women of breast cancer screening opportunities.

4B. Increase the percentage of women aged 40 and over who received a clinical breast
examination and a mammogram within the past year to:

60.0 percent

Achieve target:LikelyUnlikelyUncertain
X

Women Receiving Breast Exams And Mammograms
Year Percent
1991
1992
1993
1994
1995
1996
1997
42.4
42.2
42.5
40.6
42.1
46.1
50.6

Estimates of the percentage of women who have received a clinical breast examination and a mammogram within the year previous to being interviewed are obtained from the Behavioral Risk Factor Surveillance System. Questions addressing these topics have been included in the survey annually since 1991. The resulting estimates indicate an increase in prevalence of mammograms and clinical breast exams in women aged 40 and over in recent years. In view of this most recent trend, it appears that this objective may be met by the year 2000.

4C. Reduce deaths due to lung cancer per 100,000 population to:

41.7 for the total population (age-adjusted)
68.9 for minority males (age-adjusted)

Achieve target:LikelyUnlikelyUncertain
the total population
X
minority males
X

Age-Adjusted Death Rates
Year Total Minority Males
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
38.2
38.6
38.6
37.7
39.1
39.5
38.8
37.7
38.8
37.3
37.3
36.7
78.8
75.0
71.4
68.3
73.9
71.5
72.2
64.3
69.8
63.3
57.9
55.0

The target death rates for lung cancer among the total population and minority males were designed to avoid increases in the baseline death rates. While these targets might look too low in comparison to those for other types of cancer, they reflect the fact that there is currently no means of early detection and treatment for lung cancer. Improvements in the lung cancer death rate are achieved primarily through prevention measures, such as reductions in smoking. The effects of prevention on death rates take longer to be realized. For the population as a whole, the lung cancer death rate has remained relatively unchanged since 1985, and the year 2000 objective is likely to be met. For minority males the target was achieved in 1992, and the trend since then has been dramatic further improvement. However, the lung cancer death rate for minority males continues to be substantially higher than for the total population.

4D. Reduce the prevalence of cigarette smoking to:

15.0% in persons aged 20 and over
20.0% in high school students

Achieve target:LikelyUnlikelyUncertain
persons 20 and older
X
high school students
X

Percent Currently Smoking
Year Persons 20 And Over Year High School Students
1991
1992
1993
1994
1995
1996
1997
22.2
20.5
19.0
23.0
20.0
22.7
21.0
1980
1983
1986
1989
1992
1995
39.6
41.5
41.2
32.9
33.0
39.8

The percentage of persons aged 20 and over who report that they currently smoke can be estimated based on survey data from the Behavioral Risk Factor Surveillance System. According to this survey, the trend since 1991 has been stable, and it is not likely that the year 2000 objective for adults will be met.

The estimates of smoking prevalence among high school students are obtained from surveys conducted every three years by the New Jersey Department of Law and Public Safety. The percentages include students who report smoking "on occasion" as well as those who say they smoke from "less than" to "more than" half a pack of cigarettes per day. Results from these surveys have fluctuated over the recent past, but have shown no indication of a decline in the percentage of students who currently smoke. Moreover, the prevalence of smoking among students is almost twice as high as among adults (taking into account that the data came from two different sources). The data on student smoking do not reflect the potential impact of more recent interventions to reduce youth smoking. However, since the 1995 prevalence of student smoking was about twice the year 2000 target level, it is unlikely the objective will be met.

4E. Reduce colorectal cancer deaths per 100,000 population to:

13.2 for the total population (age-adjusted)

Achieve target:LikelyUnlikelyUncertain
X

Colorectal Cander Death Rate
Year Age-Adjusted Rate
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
18.6
16.7
17.5
17.1
16.7
15.9
15.8
15.4
15.3
15.6
15.0
14.3

The death rate from colorectal cancer has declined for more than a decade. The original year 2000 target was met early in the decade, after which it was revised downward, in order to promote further progress. The most recent data suggest this revised target will also be achieved.

4F. Increase the average daily servings of fruits and vegetables (including legumes)
in the population aged 18 and over to:

5.0 or more

Achieve target:LikelyUnlikelyUncertain

X

Daily Servings Of Fruits And Vegetables
Year Average
1991
1992
1993
1994
1995
1996
1997
3.8
3.9
N/A
4.2
4.1
4.1
3.9

There has not been any meaningful change in the average number of daily servings of fruit and vegetables consumed by New Jersey adults since 1991, when the Behavioral Risk Factor Surveillance System first began gathering data on this behavior. This objective was included to focus attention on the importance of a healthy diet, since there is recent scientific evidence suggesting that diet can play an important role in reducing the risk of some cancers.

New Jerseyans have consistently reported consuming on average about four fruits and/or vegetables per day. The target of five per day for the year 2000 is unlikely to be met.

4G. Reduce cervical cancer deaths per 100,000 females to:

1.3 for total females (age-adjusted)
2.6 for minority females (age-adjusted)
3.2 for females aged 65 and over

Achieve target:LikelyUnlikelyUncertain
total females

X
minority females
X
females 65 and over
X

Cervical Cancer Death Rate Per 100,000
Year Total Females
Age-Adjusted
Minority Females
Age-Adjusted
Females 65
& Over
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
2.8
2.9
2.8
2.7
3.1
2.9
2.6
2.5
2.5
2.9
2.7
2.5
5.1
5.6
7.0
5.7
7.6
5.6
6.1
4.3
5.7
5.1
4.7
4.0
11.0
9.0
10.7
6.4
11.1
9.2
9.1
9.0
8.6
8.8
10.6
8.4

The availability of the Pap test for early detection of cervical cancer led to dramatic decreases in both the national and New Jersey death rates from this type of cancer in the 1970s and into the 1980s. For the total population of females, there has been only minimal decline in these rates since the mid-1980s. Achievement of the objective is uncertain.

Age-adjusted death rates from cervical cancer remain almost twice as high in minority women as in the total population of females. The rate of decrease has been sharper for minority women, however, making achievement of the year 2000 objective more likely.

Given current trends, it is unlikely that the cervical cancer death rate objective for women 65 and over will be met by the year 2000.

4H. Increase the percentage of women (with uterine cervix) who had a Pap smear in the past two years to:

85.0% among total females
85.0% among minority females
70.0% among females 65 years and over

Achieve target:LikelyUnlikelyUncertain
total females
X
minority females
X
females 65 and over
X

Percent Of Women With Pap Smear
Year Total Females Minority Females Females 65 & Over
1991
1992
1993
1994
1995
1996
1997
78.5
74.4
77.3
75.6
77.3
76.2
78.2
77.6
73.7
70.2
76.4
77.1
69.9
76.6
60.8
49.4
63.2
61.3
62.4
47.6
62.5

According to survey data from the Behavioral Risk Factor Surveillance System, there has been no change since 1991 in the percentage of women with an intact uterus who had a Pap test in the two years prior to being interviewed. These findings are consistent with the lack of substantial further decline in the death rate for cervical cancer. Of particular concern is the relatively low rate of Pap tests reported by elderly women. It is unlikely that the year 2000 objectives will be met.

Discussion

Cancer is not one disease, but a group of diseases characterized by uncontrolled cell growth. Each type of cancer has different risk factors as well as different intervention strategies. With the exception of malignant melanoma, incidence rates in New Jersey for the major preventable/treatable cancers have declined in recent years. In the case of melanoma, the incidence rate, although low, has been increasing.

Strategies to reduce cancer morbidity and mortality have tended to be disease-specific. While this is generally appropriate, the Department recognized the need for better coordination of efforts across types of cancer, among all involved groups. A key first step in taking a more comprehensive approach to cancer was the convening of all key stakeholders in a Breast Cancer Summit in 1995. A comprehensive set of recommendations resulting from the summit was published in that year. In November, 1997, a similar Prostate Cancer Summit was convened. The report of the Summit's findings was published in September, 1998. This was particularly timely, given the growing recognition of the need to more vigorously promote prostate cancer awareness, early detection and treatment, particularly among minority males. Building on these earlier efforts to convene the full range of stakeholders engaged in various types of cancer, the Department formed in 1998 the New Jersey Coalition to Promote Cancer Prevention, Early Detection and Treatment. The Coalition is developing an initial plan for comprehensive cancer control in the state, and will be working to refine and implement this plan. The plan is designed to focus available resources efficiently and appropriately, through better coordination of Coalition members' efforts and systematic use of epidemiological data.

The plan recognizes, however, that disease-specific intervention strategies will continue to be necessary. For breast, cervical, lung, colorectal, prostate and skin cancer, the key strategies for reducing death rates concentrate on prevention and/or screening, early detection and treatment. In addressing these six types of cancer, the Coalition is taking a broader approach than Healthy New Jersey 2000, which has objectives related to breast, lung, colorectal and cervical cancer.

The Department's prevention efforts are focused largely on lung cancer. For lung cancer, unlike many other cancers, early detection and treatment have not yet proven effective in reducing deaths from this disease. The most effective interventions are those that focus on reducing exposure to environmental risks, primarily tobacco. Because tobacco is addictive, prevention efforts are focused on adolescents. Research shows that most adult smokers began experimenting with tobacco during their teen years. The most recent data are not encouraging in terms of the prevalence of smoking among teens. However, these data do not reflect more recent major initiatives undertaken by the Department to address teen smoking. These are discussed at greater length in Priority Areas 3 and 11. Funds from the tobacco settlement, which should be available starting in 2000, will be used for a comprehensive program designed not only to discourage youth from taking up smoking, but also to assist smokers of all ages in their efforts to quit.

One trend that is very encouraging is the reduction in the age-adjusted lung cancer death rate among minority males, a decrease that is attributable to the progress made in the previous decade in reducing the prevalence of smoking among this population. With a comprehensive tobacco control program, New Jersey should be able to make much more progress in reducing deaths from lung cancer.

For breast and cervical cancer, early detection and treatment are effective in reducing the death rate. Minority and elderly women lag behind the total population in their use of screening tests, such as the Pap test, clinical breast examination and mammography. Since 1993, the New Jersey Breast and Cervical Cancer Control Initiative has provided intensive education, outreach and screening to ensure that all women, regardless of economic status, are aware of the screening guidelines and have access to quality screening services. In 1996, 3,700 women were screened under the auspices of this program. The Department is also conducting a pilot test of a comprehensive wellness program developed by the National Caucus and Center for the Black Aged. This pilot is focusing on low-income African-American females residing in senior housing in Mercer and Camden counties. The "wellness" components additionally include breast and cervical cancer, nutrition, physical activity, and injury prevention.

Since January, 1998, Medicare has covered the annual cost of mammography and Pap tests for women 65 and over. In order to assure that women in this age group take advantage of these newly covered services, the Department will be continuing its partnership with the Peer Review Organization of New Jersey (PRO) and other private and voluntary organizations involved in cancer control for education and outreach.

The continued reduction in the death rate from colorectal cancer is encouraging. Nevertheless, the lack of progress toward the year 2000 objective of average daily consumption of five servings of fruits and vegetables per day is a cause of great concern, as evidence continues to mount concerning the health benefits that derive from a balanced diet not only for colorectal and other cancers, but also for cardiovascular and other serious diseases. One concrete step the Department has taken to promote a better diet is its Senior Farmers Market initiative, a pilot program in four municipalities to provide 500 low-income seniors with vouchers to purchase fresh fruits and vegetables from farmers markets during the New Jersey growing season. The Department will continue to look for other opportunities to promote healthy eating behaviors among New Jerseyans. In terms of early detection for colorectal cancer, Medicare has also introduced coverage for colorectal cancer screening, and the Department is again working with the PRO to alert older adults to this benefit.

Healthy New Jersey 2000 does not contain goals for prostate cancer or malignant melanoma. Malignant melanoma incidence rates have been rising at a rate of 4 percent per year, even though this type of skin cancer is largely preventable through reducing sun exposure. Prostate cancer is the third leading cause of cancer death among men in New Jersey. These two types of cancer are being addressed in the state's comprehensive cancer control plan. Once again the focus is on prevention, in the case of melanoma, and education, early detection and treatment for both melanoma and prostate cancer. The Department will encourage men age 50 and over, and black men 40 and older, to complete the PSA test and digital rectal exam.

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