Component plan. Cancer and cancer services : a component plan brought forward from the 1983 state health plan

COMPONENT PLAN:
CANCER and CANCER SERVICES
A Component Plan brought forward froa the 1983 State Health Plan April 1983
Georgia State Health Policy Council and the
Georgia State Health Planning Agency 4 Executive Park Drive, N.E. Suite 2100 Atlanta, Georgia 30329
Publication of this document has been supported in part by the Department of Health and Human Services, Grant and Policy Standards pertaining to Public Law 93-641 (Title XV, Section 1523) and amendments.

TABLE of CONTENTS

INTRODUCTION

PAGE
i

GOVERNOR's APPROVAL LETTER

ii

GOALS and OBJECTIVES

1

RADIATION THERAPY SERVICE STANDARDS

3

NARRATIVE:

Introduction

4

Overview

4

Causes of Cancer

6

Health Status

6

Crude Mortality Rates

6

Age Adjusted Mortality Rates

7

SEER Reports: Incidence and Morality Rates &

Georgia Data Relating to Cancer of

Trachea, Bronchus and Lung

9

The Health System's Response to Cancer

Introduction

10

Georgia's Cancer Control Program

12

School Health Education

15

Private Sector Cancer Services

15

The Social and Economic Costs of Cancer

17

SEER Program Survival Data

19

Trends in Diagnosis and Treatment

20

Radiation Therapy Services

20

SUMMARY of HEALTH SYSTEM PLANS and

OTHER STATE PLANS

21

STATE HEALTH POLICIES for CANCER CONTROL

25

LONG RANGE RECOMMENDED ACTIONS

and RESOURCE REQUIREMENTS

26

IMPLEMENTATION REPORT - JANUARY 1986

29

APPENDIX

31

REFERENCES

37

NOTE: Numbers in parentheses in the text indicate references.

INTRODUCTION
This, document is a section of the 1983 State Health Plan adopted by the Statewide Health Coordinating Council (recreated in September 1983 as the State Health Policy Council), and signed by the Governor on April 27, 1983. This section is being brought forward as an official component of the 1986 State Health Plan.
It sets forth goals and objectives for the improvement of the health status of Georgians, and recomaended actions and strategies for improvements in the health care systems related to those objectives.
Included in this document is an Implementation Report identifying the progress and improvement occurring berween the date of publication of the 1983 State Health Plan and January 1986.
For purposes of the adainistration and implementation of the Georgia Certificate of Need (CON) Progr. . and Capital Expenditure Review UDder Section 1122 of the Social Security Act, criteria and standards for review (as stated in the Rules, Chapters 272-1, 272-2 and 272-3) are derived from this Component Plan as appropriate. The Rules, which are published separately fra. the Plan, and which undergo a separate public review process, are an official interpretation of the appropriate parts of any official Componont Plan which the review function has the legal authority to implement. The Rules are reviewed by the State Health Policy Council (prior to their adoption) for their consistency with the Plan. The Rules, as a legal document, represent the final authority for review decisions.
Any questions or comments on this Component Plan should be directed to the Planning and Implementation Division of the State Health Planning Agency, 4 Executive Park Drive, N.E., Suite 2100, Atlanta, Georgia 30329; telephone: (404) 325-8939.
i

April 27, 1983
W. Dougla. Skelton, M.D. Chairman Statewide Health Coordinating Council 43A Executive Park But, N.E. Atlanta, Georgia 30329 Dear Dr. SkeltonI
III accordance with ~ur request aDd with the authority g-ranted _ in Section 1524 (c.> (2) (c) of the Rational Health Planning and Resource. Degelo~nt Act u . .nc!c, I have reviewed the revi.ed andapdated second edition of the Georgia State Health Plan and do hereby approve it. I lIOU1d like to <= Inc! the Statewide Health Coordinating Council and the State Baalth Planning and oevelos-ent Agency on the tiJIe and effort which ha. goae into the d..,.lo~nt of this coaprehensive plan.
I certainly concur with the plan'. .-pha.is on cost-effective mea.ure. to achi.,e mre efficient utilization of the state's health resources. All stated in the plan, a cooperative effort among all levels of gogernment and the pcivate sector i. neceary to ensure the availabili ty of needed health _"ices to all. Georgian.. I lo,k forward to working with ~u COward this goal.
With kindest rec)ud., I r . .in Sincerely,
0 - i-.'Joe Prank Harris
JJ'B:1Ilbp
11

~:

HEALTH STATUS GOALS AND OBJECTIVES
The crude mortality rate for Georqians for cancers of all sites reduced from 152 te 100 deaths per 100,000 popUlation.

OBJECTIVE:

By 1990, the crude mortality rate for Georqia for cancer of all sites reduced from 152 to 147 per 100,000 population.

~:

The aqe adjusted statewide cancer mortality rate in Georqia for cancer (127.6 deaths per 100,000 population) reduced to lowest &SA rate (119.2) in Geo~qia.

OBJEC'l'IVE 1:

By 1987, the aqe adjusted mortality rate for respiratory canctr reduce( from 35.2 to 33 death. per 100,000 population.

OBJEC'l'IVE 2:

By 1987, the aqe adjusted re.piratory cancer mortality rate in Georqia male. reduced from 64.5 deaths to 63.2 and the rate fer female. r~uced fre- 12.7 to U.7 per 100,000 population for the .....ite.

OBJEC'rIVE 3:

By 1990, the aqe adjusted brea.t cancer mortality rate in all Georqia &SA ars reduced to 10.6 de.tha, the current state rate per 100,000 population.

OBJEC'l'IVE 4:

By 1990, no &SA with a hiqher rate for colon
cancer mortality toan the State rate of 9. a
death. per 100,000 poPulati~n.

OBJECTIVE 5:

By 2000, the incid~nce rate for cancer* (all s~te.) should not be hiqher for Georqians (335.2)
than for other are~. of th. u.S. (331.5) per
100,000 population.

*!Q!!~ These data are reported by the SEER project for the Atlanta Metropolitan Area. The SEER project uses 1970 as the base year for aqe adjusted data.
1

HEALTH SYSTEM GOALS AND OBJECTIVES

~

Georgian. knowledgeable abou~ the disease. known a. canc.r, the preven~ion and d.~ee~ion of cancer, and communi~ re.ourc available to ais~ them in pr.vention, d.~eetion, and manag_n~ of the dis (s) should it/th.y occur.

OBJEC'rIV'B 1:

By 1987, school hlth' educa~ion proqrlllU in all Georgia school. with in.truc~ion on the di...... known a. canc.r, the known ri.Jc fac~or. and ri.Jc avoidanc. b.havio:.:s.

OBJEC'rIVE 2:

By 1987, a coordin.~ed cOllllllUl1i~y canc.r conttol prograa av.ilabl. in all coun~i.aI in Georgia.

OBJEC'rIVE 3:

By 1984, tho eoun~i in Georgia with ~.h. high~ canc.r incid.nc. with community
= diqned, cc.nmJ.1:y .uppor~ecl cancer h:Lth
educa~ion proqraa ~g.~ed the popUlation a~ high~ risJc.

22!&:

All hospital., tha~ m_~ the accredita~ion standard. fl"r participation a. cancer c.n~er., participatinq in the ;,Jroqram and r.portinq throuqh the reqistty.

OBJEC'rIVE :

By 1984, 33 hospi~als reportinq lOOt ot I:ases to the Georgia canc.r Reqi.tty. (Curren'. l.vel - 31 ho.pitals reportinq lOOt of c:.ses):

Note: 25' of ea s.erved elsewh.re, qo
unr.por~ed.

2

RADIATION THERAPY SERVICES S'!'1'.NDARDS
To be juatifed, any chanqe in the system or in the operation of meqavoltaqe radiation therapy services shall meet the followinq conditions:
1) Each existinq radiation therapy unit with1n one hour drivinq time shall perfoJ:'Dl more than 6000 treat:menta (patienta visits) per year and serve a minimum of 300 cancer cases a year.
2) The radiation therapy services shall be under direction of a board certified radiation therapist. (Radiation therapist: A physician who is either hoard certified or (1) is certified in General l:adioloqy, su!)section in Therapeutic Radioloqy by the _ricaD Board of RadioloqyJ (2) has spent l.t least half-time in radiation therapy since (~OIIIPletion of his/her trainiDqJ and, (3) now c~evotes all of his/her professional time to the practice of radiation therapy.)
3) "he institution and physicians responsible for ..his service shall have written policies that l)rohibit exc:luaion of the.. services to any ~J&tient on the basis of aqe, race, creed, uthnicity or Ability to pay.
4) ..'he service sJaould be consistent with the facility's .onq-ranq. institutional plan.
3

NADATlVE
I'n troduction
Overview N.arly a decade aqo it was stated by a World H.alth Orqanization CODIIIlitt , UIOnq other qroup. and individuals, that 75' or llICre of all human cancer. will prove to b. prev.ntable; and that th.ir prevention dep.na. on:
avoiclanc. of exposure to cau.ative aq.nts; protection aqun.t action of cau.ative aqents; rec:oqnition and treatment of pr.cancerou. con~itions;
and, public acc.ptanc. and application of this knowledq.. (1)
To avoid expo.ur. to causativ. aq.na, those aq.nts capabl. of produc:inq cancer would need to b. identified. Even thouqn the mecl1aniSDl
by which tl1ay caus. cancer remain. unJcnown. cancer, due to those
IIlaterial., could b. prevented by avoidinq contact dm thea. (1, 18)
With the c.....:micabl. di...... and poor .anitation ..'.mo.t eliJainated as caus.. of IIOrtalit:y, Public He.lth has turned i a attention to the chronic dis. . . . . aDd to cancer control a. tl1a hitlht priorities n.ticmally. Whil. dths froa cardiovasc:ular di....... hav. been declininq, there l1as been a slow but st.ady incr.a.. in the incid.nc. and IIOrtaUty frca cancer, llIC.t partic:ularly lunq canc.r. (2)
cancer is the second l.adinq caus. of death in the OHited State. and in Georq1a claiJaincJ over 1 IIIi.LUon live. in the 'J.S~, and 7,SOO liv in Georqia over a thr y...~ period 197-4-77. -::n Georqia 18' of all dths durinq the fiv. y.ar Period 1974 to H"'S were attributed to cancer. (3) Thirty-thr_ perc.nt of tho dths were to race. other than whit., d.spit. the fact that ~l.y 1Ilad. up only 2" of Georqia's population.
Based on data collected frca the Nationa.l Canc.r In.:itute, Canc.r Surveillanc., Epideaioloqy and End Re.ults (SEER) prl 'qraa 197 ~-1 ~7 8, the Allerican Cancer Soci.ty provid llICrtality e.tiDLte. for 1982 as follow.: 430,000 persons will die of the disease in the U.S., 1180 persona a day or one person every 73 sec:ona.; and fiJally, nationally, on. of ev.ry five d.ath. frCllll all caus.s is from caner. (2) In the O.S., in the thr_ year. 1979, 1980, 1981, the vital statistics report states, 405,000, 413,000 and 421,000, persons reftpectively died of cancer, a 1.2' rise in each of tho years. (4) If the 1982 projections prove accurate. there will b. a 2.22' increase from the prior year. and for the four year period the increase will be 6.7%_
4

Canc.r is not just a disease of old aqe. Althouqh sliqhtly more than 50' of Georqian. who died wit.~ cancer w.re over 65, cancer k~_~l. mor. children under 15 than any other disease. In Georqia, in 1979, 71 children in this aqe qroup died of cancer. (3)
Th. cancer Soci.ty reports timat. that there will be 835,000
new ca of cancer diaqno.ed in the o.s. in 1982, and cf this
number 1,700 will be Georqian (2) Nationally it is estimated that on. out of every four person. now livinq will die of some fona of cancer and th.t ov.r tiJDe two out of every three families will have a member who d.v.lop. some fona of cancer. (2)
Th. SDR report suqqts that the probal:tility of d.v.lo,inq cancer fr02 birth to aq. 73, bued on th.ir calculations is 31 (5) On a hopeful not., d.ta show that the surviv.l rat. has improv.d in the l u t s.veral decad , fra- 1 in 4 in the 1940., to 1 in 3 (approximat.ly 70,000 peopl.) in 1982. Further, 25 to 33' mor. people could b. s.ved with improved deuction measur.. and early U ;:ment. (5)
Por convenience sak., cancer i. spok.n of as a di...... In reality it is a larq. qroup of di , characterized by uncontrolled qrOW1:.b and spr.ad of abnormal c.ll., which beh.ve differ.ntly in
different sit , that call for differinq and varied interv.ntion
(6) Bec.us. of the n.ture of th dis , wid. variety of hula re.ourc i. required for their manaqement. Prevention suateqie. are not known for all forIU of cancer: howev.r, in those in.tance. where they are known and h.ve been proven eff.ctiv., they she. u l.d b. impl_ented to further reduce cancer incidence and mort:.\li1:y
B.ca~. of the complexity of the dis.a , planninq cancer program. to ~aprov. the h.alth status of Georqian. must consider current kno_ledq , curr.nt r.source. and projections for the future: and sin,.. each of t:b. various cancem (by site) po sp.cial problems in ILm.qement and control, a qreat dl of expert input will b. needed to a ure a well drawn plan. This section will attempt to analiza the scope of the health status problem in Georqia (speci-
ficzlly IeDA Codes 209-410), address those parts of the system
kn~n to be in place, and to pose directions for future populationb. . .d planninq. Whil. it is hoped that future plan editions, with input from experts in the field, will address the manaqement and control of cancer more comprehensively, this edition will focus on one site only - cancer of the trachea, bronchu., and lunq, which is on the increa.e and caused 6,082 deaths in Georqia in the 3 years beginninq in 1977. Finally, the section will also provide specific standards for review of meqavoltaqe radiation therapy equipment.
5

Causes of Cancer Presently, there is little data on specific causes of the various caneers. Rather there are demonstrated linkaqes between certain cancers and environment and lifestyle. (18) For example, both
farmers and sun worshippers are known to be at risk for skin
cancer due to over exposure to the sun I s ultraviolet rays. In the Jun. 10 issue of N-.sweek in an article on cancer, the author estimated that nearly 400,000 persons will have a diaqnosis of skin cancer this year (1982) and th. majority of the will be attributable to the overexposure of th.ir bodies to the ultra - violet rays of the sun. (10)
Further, it has been de1:U1!l1ned tha1: a number of recen1:ly identified carcinoqena have unvittinqly been in1:roduced in1:O the environments of many people in the workplac., at hOllIe, in .chool, in the wa1:er, and the air. N-. lcnowledqe h.. shown tha1: farmers, induatrial workers, hoWl-.iv aDd scheol chiltiren have b_n expo.ed to medical and d.nul x-ray. with frequency found to b. hazmtul, were qiven
cer1:ain druq., aDd were ezpc:sec1 to fer1:iliz.rs, dy , inaec:1:icid
and the hasards of UDcon1:rOlled tozic WU't:e di.po.al sit.~. (6) Increa.ed lcnowledqe aDou1: carc:inoqenic sub.Unc h. . qiven ri to warninq. on ciqar.tte pac:Jcaq , md other ma1:erial. with which humana and their food ccae in conUct, and to s1:andard. for the workplac.. (S_ the Oc:cupa1:ional Health S.cUon of this Plan updat.)
Future plan editions will at.tempt tQ id.ntify thOse popula1:ion. and ar. . . of the s1:at. in wt.i.ch increasincr cancer ra1:e. mav indicate such linJcaq... What is r.t..van1: ..r. i. that pr.v.ntion, where linkaq.1l are UDder.toed, aua earl~' 1e1:ection of ca.e. are mcs1: lik.ly to have the qr~A~e.1: impact in reducinq cancer mcr1:ality.
!!,!1th Stat~
As h.. b_n no1:ed, while cAlcer del'th. of persons under 45 have been dec:reasinq, there has I,_n an incr.... in mcr1:ality over all and eSPecially for cancer OJ' the 1\ nq.
crud. Mor1:ality Rate. The crude mcr1:ality ra1:e fo~ the 0 S. and Georqia were 181.9 and 152.8 d.aths per 100,000 re.pec1:i~ly. (3,4) Osinq crude rates to flaq counties with hiqh 1a1:es, the data show that Georqia had 37 counties with crud. mcr1:ality rates hiqher than both the state and nation and 19 counties with crude mortality rates over 200. Table I in the appendix shows these counties. The hiqhest rates were for Schley (2 A'2.9\ ~3J.fair (253.0); Quit:Jllan (246.3), Taliaf8%1'o(229.9), and Jasper (229.0). In a publication by the State in 1976, mortality for six common cancers were studied, cancers of the stomach, 1arqe intestine, rectum, trachea, bronchi
6

and lung, brea.t and cervix. It was noted that there was variance among area. of the state, with sex and age reflecting higher risks
for sam. type. of cancer.
Age-adjusted Mortali1:y Rate. for the O'.S., the State and the aSAs The 25 year trend in age adjusted cancer death rate. per 100, 000
populat1on by sas, aa4 site of invasion, between 1951-1953 and 1976-
1978 in the O.S. i. shown below. As may be seen the death rate for
male. increased 25' while that tor f-.le. declined 't. The jump
in the rate f= male. haa b. .n attrilluted primarily to deaths from lung cancer.

25-V Trends in At--Ad)ul1lld Cancer 0..... R... PI' 100.000 Population 195152 to 1976-78

,1.7.1...1.
7.2 3.1
Q.3
211.0
21.8 24,8

211.7 131.1
7.2 1
U 27.1
21.4 20.0

Stteay

"'....., due to I"", CInar.

51 d ..



32

ea.-t......

.'" +

sn fIuctuadoM: ownAl no en."

Slttftt RuctuecioM: ov.nII no en~

19 5Iltftt fluau.dons: noticleble dec:r_.

K~
,_ _,,-.r.1 K ~
Uv.Uwr

4..7 1.2

5." 1.5

" +

Some fluclu8tioM: stitht IncreaL

Sli t flue:tuatian.: ownIl no ctUlftfJe in f......

32.A1
1.7 7.1

...".7
2.2
4,8 3.1

+ 31 Stady -Itht incr-.
51 flUClUMions: CNenI. no en."

+

11
28 53

e.ty i

I_I~t. . off.

..... I'. SII9't...., 1

1_ 1..,.1". off.

Some flUe:tuadons. St88dY d..- In bo1h

LunI L"", . F1IMMr- Owrv

21.5 5.0 1.1. ,"

11.3 17.8
a-

+ 172
.'+2!I

Slady i~ in bo... sax_ due to cigarftW
WftOki
S1itht fl~_ _I no en....'" botIt
sax...

+ 'S' , Stitedy inc:riele.l... fwefing off

P.....
....ICI_

,LS

11.2 + 30 Steady i. . . . in bom . . . . tit. . lev.tint off.

5.5

7.1 +,. 29 A....,.,. untlnown.

Praaace
Skin Skin

21.0 3.1

22.1 3A

over.' + I, Fluctuations a" thr SI""t flUCftllltioM:

owiod: ovwaU no en
no c:h.... in bo1h

1.9

1.9

sax...

SCOIMCh Stam.

22.8 12.3

"9..33

51 Sta"" dea In both .x_: r.aIOn. unknown.

U....

20.0

L7

57

PWClftt ctt-.. not 1-" b _ the"I . . fIOC-"'IfuI.

SOURCE: Cancer Facts and Figures 1982. The American Cancer Society.

7

The table below provides the number of deaths and the age adjusted mortality rates for Georgia's BSA., the State and the O.S., for the three years 1977, 1978 and 1979.

AREA
BSA 1* BSA II BSA III BSA IV BSA V BSA VI BSA VII Stat. O.S.

N'OMBD 01' DEA'l'HS
439 2,609 9,0)5 2,546 3,370 2,197 2,835 23, Ul 1,187,158

AGE ADJUSTED RATES
119.0 119.7 128.3 136.6 124.8 122.6 136.1 127.3 134.1

*'l'hr Georgia counti - catoo.a, Dad. And Walker.

As may be noted Georqia' s aqt! adju.ted mortality rat. for all cancer i. lower thaD the ra1:l. for th. Datiol" however, t1lIO BSAs (BSA IV and BSA VII) havo mortality rate. that: exceed both the Stat. and the nation (136.6 anel 131 1 r pectively). BSA III haa a sliqhtly hiqh.r rat. thaD th.: Stat. at larq. (128.3 va 127.3). When cancer by site i. UUlir.ed, it may b. seen that males exceed. the national and .tate rat.. for s.veral .it... Thes. are di.cWlsed further in this section.

Tabl. II in the appeDdix p~ides both crud. and aqe adju.ted IIIOrtality rate., aDd the numter of d.aths by .ex for sp.cific
cancer site. for Geo:c'CJia &Ill: the seven BSAII. The data cover the
three year period b~riJminq ia 1971 and show variation. amonq BSAs in canc.r deaths cy sit.. DAa I, IV, VI and VII had a high.r IIIOr1:&li ty rat. for cancer of the trachea, bronc:bu. and 1unq ( 35.9 ) than the Stat. a. a whol.. r1 addition, a hiqh.r incidAnce of brea.t cancer i . noted in BS1 II (11.1), BSA III (ll.S) and HSA IV
(11.5) a. oppo.ed to lower rat.s in BS~ I (8.3) and VI (s.a).

SEER Reoorts: Incidence and .-!Ortality Rate. In the Introduction, an oven iew of the dis called cancer was given, and the data source. (iscued. Th. table below derived frOID the SEER report show. thl aqe adju.teti (1970 standard) incidence and IIIOrtality of cancer repor :.d frOID all of the SEER participants and cOlDpare. the Atlan1:& Area SEER data to that of all areas.

8

AGJ: ADJUSTED INCICENCE AND MORTALITY RATES FOR CANCER ALL SITES PER 100,000 POPULATION, FOR ALL AREAS AND ATLANTA, BY RACE AND SEX.

INCIDENCE

G ROO P

All Areas

Atlanta

All race., both sexes

331.5

335.2

All race., male.

379.3

408.1

All race., female. White, both sexes

304.1 325.72

299.5 327.4

White, male.

371.6

388.8

Whit:e , female.

301.2

301.3

I Ot:her than white, bot:h. slXe!95.4 3
Ot:her tban white, male. 454.3

343.44 464.2

Ot:her tban wb!te, femalej 288.7

270.1

MORTALITY

All Areas Atlanta

168.5

165.6

212.7

225.1

137.7

128.8

166.1

158.2

209.5

21~.3

136.9

125.8

217.4 292.1 160.6

196.t
284.8 139.0

SOtmCE:

SED Report, 1973-1977, National Cancer In.titute.
1. All are. . included except Puerto Rico 2. Whi1:8 include. ADqlo and Hi.panic 3. Include. Black, Chin , Hawaiian, Philipino, American
Indian 4. Ot:her tban Whit. population for Atlanta Black predom-
inantly

As may be seen, ot:her tban white male. for all Area. aDel Atlanta have a hiqhc rat. of incidence and deat:h fraa canc.r tban any ot:her qroup. In addition, the rat for Atlanta mal exc.ed tho for all ar in all ca.... Frca the data it would Seell that t:he tarq.t qroup for priority interv.ntion in Atlanta would b. non-white mal... Th. SEB1l r.port also provid data by race, sex and site of canc.r. Th. data may be found in Tabl. III in the appendix.

Georgia Data Relating to Cancer of the Trach.a, Bronchus and Lung All ehe data in Appendix Tabl. II show the hiqh risk for cancer for male.. When cancer of eh. trach.a, bronchus and lunq are examined, mal.. J.n SSAa IV and VII and sp.cifically white mal.. wieh mortali 1:Y rate. of 70.5 and 75.0 resp.ctively are shown to be at hiqhest risk wit:h black mal.. in &SA III and IV (65 .3 and 67. 8) close behind. When eh. SEER data are examined, they showed Atlanta area male. at hiqher risk than eh. nation for this cancer, with black male. at hiqhest.ri.k. The data would support the SEER data: however, when ehe rest of eh. state is included (by BSA) it is clear ehat white male. in BSA VII have the hiqhe.t mortality rate of all qroups in the State for ehis cancer site. Since incidence data for the State are not available at ehis time, it is not possible to go furt:her wieh the analysis. Future editions of the plan will attempt to sacure such data as well as survival data from the 11 cancer centers.

9

The Health System's Response to Cancer
Introduction
The National cancer Act of 1971 lent impetus to new discoveries
in the field of cancer research. Increases in funding frOJll 230 million dollars in 1971 to 1 billion dollars in 1980 supported much of this activity. (18) Twenty cancer centers acro the nation enhance coordination and dis .-ination of new knowledges in diaqnosis and. treatment, and tbrouqh education and training proqrUlS and public infomation, support clinicians in the field. (18) Treatment. advances have been qreat over time. The Board Chairman of the National cancer Adv:isory COIIIRi tt.. stated that "tile. C4Il now ~ llIOb.t ;JCLtLe.ntA
~ 40. . .tqpu 06 CAlIeeJL aNi 4QItC pa;t;ien.t.s IAJi.th. 1IlO4.t .tJjpU 06 caAC.eJL." (18)
There i. still much. to be done in re.earch, education and treatlllent, especially identifying carcinoqens in the environment and those lifestyle habits that cause cancer. (18).
MUch of what is lcnowD aDout cancer COllIeS not froa the laboratory, but frca the study of pt'ople, and. how they live. As early as the 1770., scientists ob.erved the relation.hip between occupation and the enviroaaent aDd cancer. (18) There i. now a growing suspicion among epidea1010qists that . .81: of the disease. called cam:er may be related to the way we live, what we e.t, whether we smoke, where we work, whether we live in the city or country, if married or single, when we c~.e to have ow: ch11d:en and wbat we do in our sPare time. (18) The World aealth Orqa.u.zation International Re.earch on cancer, in studying different {<puation. in different countrie., observed that there were occurrence. of different type. of cam:er in different countrie., and tha: death rate. a1ght vary one hundred fold for specific cancers frcm country to country (18). These studies qave rise 1.;0 ~"e rea.cmiz:g that environment and culture might account for these difference.. (la) Public education coupled with in~ensive st~ of! the work 8r.'vironments and hoae environments of! tarqet populations should be unci_ r taken in Georgia. A qoal, objective and action relating to such t&1~eting is stated elsewhere.
Identifying carcinOCjtns in the environment is an es.ential prelude to preventive measure.. (18) By the 1950., the World aealth Orqanization rec01llllleftded testing (hemicals prior to marketing. According to the International Aqenc:- for Research on Cancer. there are 18 chemicals known to cause cancer in man. Included in this list are five che=ical processes in which the specific chemical has not been identified. (18) The National Institute for OCcupational aealth and Safety lists 2700 chemicals as cited in the literature as carcinogenic, with only 400 of these having been reviewed. One representative "quesses" that there are "between 700 and 800 chemicals for which there is reasonable evidence of carcinogenicity, and another four hundred for which evidence
10

is borderline.- (18) Georgia's Environmental Pro~ection Agency in
the Department ot Natural Resources toqether with the Occupational
Health Section ot the Department ot Human Resources should be assured ot .~pport tor their activities in protectinq Georqians from environ-
mental hazard. wherever they occur, but e.pecially should cancer-
causinq material. be strictly monitored for human hazard, and exposure
miniJlli.zed or eliIDinated.
Federal Proqrauu
The National Cancer In.titute: The National Cancer Institute (NCI) was creatid by the National Cancer Act of 1937 (as a part of the 0.5. Public Health Service) as the Federal Government' s principle aqency for research on cancer prevention, diaqno.is, treatment and rehabilitation, and for the dis.emination of inlormation for cancer control. The National Cancer _\C1: of 1971 directed the'Institute to plan and develop an expanded, coordinated cancer proqraa inclwiinq related proqrauu of other federal and non-federal re.earch in.titute. and proqrauu7 and to c~icate with the public and the medical cOllllllW1ity the latest advance. in cancer prevention and manaqament. The Act also directed the e.tabli.hment of a network of Coaprehen.ive Cancer Center. around the country, with a wide ranqe of activitie.. Additionally, the Act tablished a National Cancer Mvi.m:y Board of 23 ~r
The National cancer Act AIaeIl~U of 1974 u1:ended the
proqr.. for 3 year. and provided for additional cancer Cen1:er.. Gran1:. and contracts awarded by SCI allow for official aqencie. and the voluntary .ec1:or and profe.sional. and profeional orqaniza1:iona to becaDa involved in cancer control, re.earch, education, and ~ity proqrau for diaqno.is, treatmen1:, and rehabilitation. (13 , 15 , 16).
The In.titu1:e also participate. in in~lrnational activitie. such a. the World Heal1:h Orqaniza...ion, the International Union Aqain.1: Cancer, the Int~l&1:ional Aqency for Re.earch and Cancer, and The European Organization for Re.earch on Treatment of Cancer. one oU1:grovth of the.e activities i. an international data b41Uc, and an exchange in proqre in re.earch and eancer ca, managament. (14) Such sharing of re.earch ~nd its applic:ations are telt to enhance the poten1:ial for eventually f5.ndinq the cau.e. and cure. for the ?&rioua cancers.
The Office of Cancer COIIIIIlW1ica1:ion pra-ide. communications between NCI and the public by pr,)ducing and di.seainating educational material. and r J.ponding to public inquirie.. Throughtbe Cancer Informat.on Servi~. 411 area. of the U. S. have direct. acce.. tt.) cancer information fraa trained .taff, using toll frH numbers either to one of the 22 reqional Cancer Centers (where one exist.) or a national toll fr_ hot 11!le: 1-800-638-6694. (15)
The SEER Proqraa: The Surveillance, Ef,idemioloqy and End Results Proqraa (SEER) is a continuing proqraa of the
Nat.ional Cancer Institute, and is an out.growth ot two
earlier NCI proqrauu bequn in 1973. Eight goals are stat.ed for the prograa:
-1) Det.ermine periodically incidence of cancer in select.ed geoqraphic areas of the United States with respect t~ d~~~~aphic and social charac-
teristics ot the population.
11

2) Estimate cancer incidence for the United States on an annual basis.
3) Monitor trends in incidence of specific forms of cancer with respect to geographic area and demographic and social charact.ristics of the population.
4) Determin. periodically survival exp.rienc. for cancer patients diagno.ed among r.sid.nts of s.lected geographic ar of the Onited St.t.s.
5) Monit')r tr.nds in cancer p.tient surviv.l with respect to fozm of cancer, extent of di , therapy and demcqI'aphic, .ocioeconaaic, and oth.r param.t.rs of prognostic importanc
6) Identify cancer etioloqic factors by conducting sp.cial studi.. which disclos. group. of the popul.tion at high
or low C&DCer risks. Th.s. group. may be d.fined by soc; tal,
occupational, environmental, dietary, or oth.r characteristics, and ;,y drug histo~.
7) Identify f.ctor. r.l.ted to patient surviv.l through special studies of r.ferral p.tterns, diagno.tic procedures, treat:naent method., and other .spects of meclical car
8) PrClllO":. specialty traininq in .pidea101oqy, bio.tatistics, aDd tUllOr requ~ _t:hodoloqy, oper.tion, and management.' (5)
The p=qr_ contr.cts with in.titutiolW on the baai. of their ability to operate and maintain. population ba.ed cancer reporting
sy.1:_ and tor unique population subqroup. tha1: .ach of them ofter.
AlDanq thes. inuti1:UtiOIW is J!:DK)~ university which includes in its tarq.1: arn fOJ~ canc.r surveil:lanc. 1/3 of Georqia I s population.
Georqia 's Canc.!r Cont:=l Proqraa In 1937, the Gt orqi. Department of Public ae.lth implemented the Cancer State-A.'.d Proqr_ digned to male. tr.atment available to medically indig.n1: persons who had canc.r. This proqraa still p=vid diaq ""stic and trntmell1: servic.. in 21 Georgia cODDuni t::t hospitals. .J,"t. ho.pitals provide clinic: space and ho.pital care
tor which they are r.imbursed by the procp:'aa at the app...,ved Med.icue
rat (9) Phylician servic are provided by memb&~s of the medical staf. of th.s. ho.pitals. Participatinq physiciana. are reimbursed
only tor s.rvic.s to Medicaid or Medicare eligible patients at the rat.s usual &DC, customazy tor tho. . s.rvices. They receive no
compensation frr the servic they prOVide to medically indigent person. who arl' in.liqibl. for Yoedicar. or ~GClicaid. (9) Th. map in the appendix show. the location of these hospital clinicl.
With the pa.s~. of state 189islation in 1977, a locus for increas~ effort in cancer control was id.ntified in the Department of Human Resourc (Phy.ical aealth Division). Th. Stat. leqislation establi~hes an advisory cOlllBi ttee of 15 members appointed by the Governor, representing medical schools, hospitals, the'Georgia Division of the Ame:ican Cancer Society, the Cancer Manaqement Network, and three members from the ereneral public. (11) With the advice of this clJlIIII&ittee, the lesiglation directs the Cancer Control Officer (required to be a physician) to determine patient eligibility criteria, standards for
12

equippinq and staffinq cancer clinics with a maximal travel time to
a clinic of 75 mile.,* and to utilize federal and other funds in
behalf of the proqram of cancer control. The leqislation includes extendinq financial aid to person. in need, developinq proqrams for prev.ntion, early d.tection, a statewide cancer reqistry, and public information.
Sine. the proqraa focu prtmar11y on indiq.nt car., additional fund. will be required to expand the proqram to fulfill the leqal mandat.. Prev.ntinq pauperization of functional familie. is also id.ntified in the leqi.lation a. co.t effective in dollars and human terma and should b. reit.rated with each fundinq request.
To fulfill the leqal mandat., the canc.r control proqram has set forth the followinq purpo aDd obj.ctiv.:
~raa Purpo :
TOClec:r lIIOrbidity and III(Irtality re.ultinq from canc.r, which affec:ta about 21,500 persons in GeOrqi
Objectiv : To ensure that .11 persons vith abnomal scrninq results rec.ive further diaqno.i. and tr.at:ment.
To provide financial support for medical diaqnosi. and treatment to ensure that 50' of the medically indiq.nt canc.r pati.nts improve or r ....in at status quo.
To rec.ive cancer lIIOrbiditv and mortality data frOll at least 95' of the qualified canc.r tr.atment c.nt.rs. (9)
To accoapli.h th objectiv.s the proqraa recClGlMnda that the Department of Buaan Re.ourc in cooperation with a variety of other human service entities (ho8Pital., Vi.itinq Nurs.s Associations, the ccaaunity hlth center., medical soci.ti and voluntary aqencies) undertake a vari.ty of activiti inclucUnq education of cOllllllunity and profional PeOP1., screeninq, diaqno.is/treatment, follow-up and data collection. It is proj.cted that the end result of these activiti would be reduction of cancer risk where risk factors are known, and decr.a.edlllOrtality throuqh early diaqnosis, treatment and appropriate follow-up within the budq.tary limitations of the proqraa and medical capacity to effect cure or r_is.ion. (9) Accordinq to the Coordinator of the canc.rcontrol activities, the consequence. of not fundinq these activities may include any or all of the follovinq:
-Mortality and lIIOrbidity rates for cancer will continue to increas Co.t for hospitalization and nursinq homes will continue to increas Preventable disability and sufferinq will continue unabated.- (9)
*NOTE: The Statewide Health Coordinatinq Council has accepted a travel time of 60 minutes as the maximum for patients requirinq radiation therapy treatment for cancer.
13

ever the years, a number of categorical programs have been added to the State-supported effort including the Georgia Cancer Registry in 1966, the Georgia cancer Management Network in 1974, and the Cervical cancer Screening Prograa in 1975. These are described below.

The Georqia Cancer Riiis~ry: In 1966 the Georgia Regional
MeiHcal Proqraa IiiIt atid a Cancer Registry. The Department
of H~ Resources assumed responsibility for this program and it is opeJ:ate4 under contract with the Medical Association
of. Georgia. The purpose of the registry is to record and evaluate the nature and extent of the cancer probleJD in Georgia, to de~er.mine the effectivene o~ treatment, and to as.ure adequate pa~ien~ follaw-up.

Each of the hospitala participating in the a1:)ove cited
9roqram has a cancer registry, and is expected to se.ld
iDstracU of their cancer p.tien~st recorda ~o the c.part-lI8D~ of HUII&ft Resourc"s supported central registry, where <ia~a is entered in~o a coaaputer and anal:/zed. Registry repo~ are sen~ to particip.ting hospitals and DD. ADy special a1:Udies on specific types of cancer 1U.y be
d"ne on request (within budget constraints). currently the 31 ~icipatinq hospit.ls are reporting 100' of their cases. Incre.sing the number of p~icip.ting hospitals to 33 by 1984 is one of the qoals of the A.dult H....lth UDit.*

T:.1e Geo"ia cancer Mar:-i-nt Ne~;,rork: This organiz.tion,

W:lICli was &lVileped

974 w.s phisid out in 1980. It had

a board of directors representative of health aqencies

t.1rouqhou~ the st.te and was funded by the N.tional Cancer

~lstitu~e. Twelve hospi~ala participa~e4 in the Network

~~eas~ cancer study and service proqraa which served 2000

W>JDen with br__~ cancer. Oncolo'n nurses in the pa.rticipating

h )apitala collected data, condue:t'Sd cancer edueatior.. programa

...ld g.ve support and counsel to the participants. IncOllle

criteria were not applied to clia~ts in this proqr~., so

~)th private and medically indige~~ p&~ients were served. (5)

'r.le Cervical cancer Screening Prmam: Fundtld by the National
Cmcer InatJ.tute in 1964, a cervCiI cancer Ilcr. .ning program
f,r high risk older women who were indigent and/or ineligible
'1' otbar proqr. . . was bequD. This proqraa was added to the c mcer screeninq services provided to family planning partiei-
p mts originally begun by the High Risk Maternal Service. a ld Faaily Planning units of the Department of Hwaan Resources
in 1974. 'l'his proqrua is currently operated by the Adult tealth Section as part of its overall cancer control efforts, and is
funded by en. State of Georgia. (9)

I :cordinq to the earlier referenced document, over 75' of the f~ds allocated to the cancer control program -is needed and lSeel for treac.ent.- (9) The balance prOVides for prevention . nd diaqnosis, public and professional education and rehabilita-
. ion. (9) The efforts of the Department of Hwaan Resources ~ rogram are directed primarily to meeting the needs of indigent
1=stients.

~OTE:. Approximately 25' of cancer cases are treated in other facilities across the state and these cases are often unreported.
14

School Health Education:
School children should be provided an introduction to the diseases ~~WI1 as cancer, the known risk factors, and risk avoidance behaviors. Because Georgia has such a high school dropout rate, these knowledg.s should be provided to children by the time they have compl.ted the 7th grade. Emphasis on pr.vention and d.tection a. well a. comaunity re.ourc... for cancer d.t.ction and management should also be a part of the cancer prevention health education proqram, with empha.is for girls to includ. br.a.t s.lf examination and pap smear., and for boy. tho tho.e sit. specific cancers lIIO.t pr.val.nt for male.. Both sexes should understand the dang.rs of overexpo.ure to the sun's rays, and smoking a. th.y r.late to the incidence of cancer in Georgia. Th.y should become familiar with known and frequently u.ed sUl).tanc.. which have been det.rmined to be carcinogenic, and how be.t to avoid r.pe.ted expo.ure to them.
This edition of the Stat. a.alth Plan h a s.ction on School alth Educ.tion. One of the units which should be included in the five y.ar School a_lth Educ.tion Enhanc_nt Plan, covered in the section, should be cancer risk .voidanc.. In .ddition, two smakinq c tion model. are currently b.inq demon.trated by the a lth Mark.tinq Program in the Department of auaan Resourc.s. Thes. JDOdels should becalM available stat..,ide should the ev.luation show th.t they are succful.
Priv.t. S.ctor cancer Servic Phy.ician Servic : Except for the p.tient's recognition oCts. s.v.n diiig.r siqn.ls, the physician is the first lin. of att.ck on canc.r and its early d.tection. Given the opportunity to examin. his/her p.tients on a reqular basis, .arly detection of l ion. in s.veral sites (oral, brst, cervix, skin and rectum) is pos.U-l.. Th. physician in priv.t. practic. is the sourc. of the majority of ca diaqno.ed nation.lly and in Georgia. (18) Th. d.ath rat.
for men froa cancer exn. .d.d that tor WOIIKln in Georgia and
the n.tion. Incrsed awarene of the need for m.dical s.rvic.s to pr.vent illn.ss or for early diaqno.is may chang. that ratio.
In Georgia in 1980, the physicians renewing th.ir licenses who identified th. . . .lv a. sp.cialists in the category Neopla.tic or Oncoloqy SPeCialist totaled 69. Th. table below id.ntifi.s practic. status for these and for the 46 nuclear medicine specialists.
15

PHYSICIAN SPECIALISTS PRIMARILY SERVING CANCER PATIENTS BY PRACTICE
SITE 1980

Private SDecialtv Practice

Neoplutic

47

or Oncolocn

Nuclear

~4

Medicine

HOSDital 5
17

Practice Status

Federal

in

bolovee TraininQ' Facultv

1

6

9

1

~

"

I
Public: Health Total

1

69

-

46

No attempt will be made at this time tD explore the adequacy of the supply of these physicians in Georqia no: their distribution. It is a.sWlled, that because of the technoloqy required tor these physicians to s~ their pa~ients, includinq laboratory and. other equipment and. support ~ ersonnel, that they would locate in an area with ready access ~o a medical center.
Further, since these are not the only physicians who work with cancer patients, an in-depth study of manpower in the Ueld of cancer services in Georqia would be needed to attempt turther analysis of physician supply. At such time as support tor manpower plazminq is evidenced in Georqia, this area will be pursued further. What should be noted, however, is that the number of physicians specializinq in medical oncoloqy practicinq
in the O.S. baa qrOWll traa t..-r than 100 in 1960 to ~800 in 1980,
with 1800 of th. .e certified u specialists. {lSi
Dental Services: Oral cancers are often detectea as a part of the exaa:i.nati.on of the dental patient. However, since tewer than 50' of Georqians visit their dentists annually (see Dental Health Section of the Plan), ~ oral cancers wt.;.icn could be detected early and treated succe.sfully are left undiaqnosed in early staq... HlItJ:e, too, iner_oed emphuis on l.ppropriate use
of health servic. . is needed tor those populations who do not
visit their dentists.
volun9i Aqencies: The AllleJ:ican Cancer Society (ACS), and' its Georq1.a Chapter, place major empl'asis on public and professional
education. Public "dueation batt' tor prevention and early detec-
tion are carried out by all Chapf ers, notaDle the PACE project
which tocu,e.. on tour of the six sites where tXe IDOst lives can
be saved (lunq, oolon, breast,u.d uterus). (~) The national orqanization reports that ACS pw,lic education proqr&ma reached 10 million adults and over ~o mi' lion youths, an increase of 3 million over the previous year (~) Throuqh national conference., clinical meetinqs, profess~,nals are reached by the Society'S education proqr..... The Society also supports research. In Georqia, throuqh its 21 otUce units and 177 volunteer units aeross the state, nWllerous smokinq cessation classes were held, thousands of volunteers distributed literature, and participated in the Society's education and t".nd raisinq campaiqn. (~4) OVer 400,000 persons nationally have "Ieen assisted in ACS rehabilitation and service proqr.....
While not specifically dedicated to cancer prevention, the activities of the Georqia Lunq Association play a stronq role in cancer prevention throuqh smokinq cessation proqrams, and research. In Georqia the Association holds numerous smokinq cessation classes annually.

16

Th. Social and Economic Costs of Canc.r In March of 1981 the O.S. D.partment of a.alth and auman Services published a report .ntitl.d ~ocial and Economic Implications ot Cancer in the O.S. Th. r.port cl.arly states th.t .stimation ot social co.t. is impr.cis. and th.t new information .nd m.thods are raqui%ed to id.ntify, -truly, th co.t.. E.timate., usinq shaclov price. .ttempt to attach quantitative value to such concerns tamily instability, family income 10 and other non medic.l costs, w.ll the impact of illn on p.&sonal w.ll b.inq. Rehabilitation co.ts, and fin.lly death co.t. mu.t also b. aed. (8)

T1sinq shadow pricinq, in limited t hion the minimum annu.l costs l)f cancer in 1975 were timated at 2.5 billion doll;l%'s, excludinq dth, and if the co.ts of dyinq .nd de.th are includ.d, the cost then ro to 138 billion dollar (8) Th co.ts have undoubtedly ri.en sine. the timate and the rearch on which it was ba.ed was COIDPleted.

Direct econaaic co.ts are thoociated with prev.ntion,-diaqno.is and treat:ment in wh.tever s.ttinq they occur. Th.y lI&y also include the co.t. of pzoovider traininq, tacility collStruction, medic.l r arch and public educ.tion. Direct .co.ts are the value of r ource. th.t
could b. u.eful tor other purpo in the ab.enc. of dis
InciiJ:ect co.ts are the value of idle resourc.s and 10.lt output. Th. table that tollows provid.. the dir.ct co.ts for maliqnant n.lOplasa in 1975 and .stimated incr in 1980. O.inq th d.t., and the rate of incr of the lIIO.t .ppropri.t. co.t of livinq
lIUur tor hospi.t.l, physician co.ts .nd applyinq the r.te of
iIfl.tton to druq and other profes.ion.l service costs, the followinq di.ta are derived. (8)

T'tal co.t. of canc.r a).pital care P'lysician Ccs~. D,-uq , Other P~otes.ional costs
'rursinq Heme Oller

1975
$5.3 billion 4.1 billion 671 million S3 million
202 million 270 million

1980
9.2 billion 7.3 billion 1.1 oillion
75 million
318 million 430 million

*The ho.pital co.ts estim.te. are bd on room rate incre.ses oflly and therefor. are low.r than ov.rall actual costs.

*NOTE: Sh.dow pric.s are accountinq prices attached to goods and s.rvices for which there are no m.rket prices. Shadow prices are the costs to obtain items in question.
17

While the above data are based on estimates only, and may be severely underestimated, it may be seen that the direct cost for cancer services are high indeed, and have increased markedly over time.

Another cost estimate, wbich takes lifetime earnings into account adjusted for an annual average increase of 2\ in productivity, derived frca work exper:l.ence rates of the Bureau of LaDor Statistics, are provided. for the year 1975. Table IV i.n the appendix depicts the nUllber and percent distribution of perBons by death, person years lost, sex, and cost and percent distribution by discount rate (6 and 10\) and sex according to age for 1975.

No attempt will be ~l here to explore iT\ detail the economic costs of cancer by site. Because there is variance in treatment 1IICI4. . , survival rates and tezainal care, it IIlUSt be noted ',~at thes. costa aay vary greatly frca site to site as well as t.he staqe at wbich diaqnosis is made, as the next table relatinq to site and direct costs in 1977 for the nation s~. (8)

EstiJlated AlM)unt in Millions, and Percent Distribution of Expenditures

by Site for Bospital and Physician Services for Neoplasms, Onited

State., 1977.

'

Site

I , ::inert:::itay

I Hospital Distri-

. care

buti"n

Physician S.rvice

,
Distribution

I

All neepl....

$5,768.10 100.0

$1,560.70 100.0

Dige.tive organa Respiratory organs

956.00 632.80

16.6
11.u

143.00

9.2

97.70

6.3

Skin

I

125.50

2.2

57.80

3.7

Breast

:

479.60

8.3

Female GeD!tal Organ ! 412.70

7.2

105.60

6.8

92.60

5.9

Male Ge!'lital Organ

256.80

4.5

64.20

4.1

Leuk..-ia

I 164.20

I All other neopl....

. 1,591.20

Beniqn and Non Maliqnant

Neapla..

I 1,149.40

2.8 27.6
19.9

29.90 324.70
645.20

1.9 20.8
41.3

!

Osinq national data, it ~s estimated that 2\ of all of the cancer deaths in the O.S. in 19'~8 oc:c:urred in GeoJ:'(Jia. (3,4) Even thouqh livinq costs and waqes are lower in Georqia than in some states, on averaqinq all costs in all states, it may be assumed that Georqia's direct and indirect costs approximated 2' of the costs of the nation. This sum recurs and has been shown to nearly double over a five year period (197~-tq~O). Increased prevention and detection efforts in an attempt to reduce the incidence and mortality rates of cancer in Georqia would be a most cost effective approach. A goal and

18

objective relating to prevention and detection is stated elsewhere.

SEER Program Survival Data

~t of the data collected by four of the participants in the SEER

project fraa 1950 to 1973, the Biometry Branch of the NeI published

its 5th survival report in 1976. While promise of an update in

1982 has been made, it has not yet been distributed. There is

good rea.on to a.sume improved survival rate. for certain cancers

fraa preliminary data released by the Biometry Branch and published

by the Georgia Chapter of the American Cancer Society. As may be

seen fraa the figures in the table, the ca... with the be.t survival

rate. are tho.e which are localized. Wha~ also may be seen is that

for all cancers and irre.pective of stage, survival for white persons

i. higher than for black per.ons except for ~tiple myeloma and
localized cancer of the ovary whiCh i. the s~ for both race

Whether this is because IIIOre black people lack infoma1:ion about

symp~, lack the resources to seek care, or b.cause of long

standing nutritional deficits and inability to a.cure medications

once discharged frOll in.titutional care i. not known. It may well

the.. b. a caabination of all the.e factors and others not id.ntified.

What i. .ugge.ted by

data is 1:hat target populatio.-r should

be identified for any c~ity effort 1:0 educate, ca.e find, and/or

treat aDd rehabilitate, to illlprove this picture.

'rRDDS IN SURVIVAL BY SID OF CANCZ1\, BY RACE
ca Diagno.ed in 1960-63 Compared to Tho Diagnosed in 1970-73

!.!.!!

WHIT E

1~O-fl3 1970-73

RELATIVE RELATIVE

5-YEAR 5-YEAR

SUeRnVIVAL

SURVIVAL (,)

I
,
IN-
~

8 LAC K
19&('-03 1970-73 RELATIVE RELATIVE 5YLAR 5-YEAR S"'V IVAL SURVIVAL
-UL (,)

,
IN-
CREASE

Prostate

50

Kidney

37

Uterine Corpus

73

Bladder

53

Colon/RectUJll

41

Uterine Cervix

58

Brea.t

63

OVary

32

Brain and Central

Nervous

18

Lung and Bronchus

8

-1 StOlUCh

11

Esophagus

4

Hodgkin's Dise.se

40

L=~tiC ,......

4

Lymphocytic Leuk_ia

Chronic

35

Non-Hodgkin's Lymph 31

Larynx

53

Tongue

28

Melanoma of Skin

60

Pharynx

24

Thy.roid

83

Mouth

44

63

13

46

9

U

8

61

8

48

7

64

6

68

5

36

4

20

2

10

2

13

2

4

0

67

27

28

24

51

16

41

10

62

9

37

9

68

l!

~1S

4

I 86

3

44

0

3!'

55

3t

44

31

44

. 2~
3"

34 ,35

4"

61

4,'

51

3"

32

1~..

19 7

'I

13

4

20 6
13 10
4
14
5
0
0
2 5 3
I
I
I

Source: BiometrY Branch, National Cancer Institute (Taken from Cancer

Facts and Figures - 1982 - The American Cancer Society) .

19

Trends in Diaqnosis and Treatment Cancer manaqement today is becominq increasinqly individualized with r~~pect to both diaqnostic procedure. and treatment. Early detection is followed by precis. staqinq of the dise.s. and use of a combination of therapi.s. New cancer druqs includinq the wellknown chemotherapies, th. new bioloqic response modifiers includinq exp.rimental interferon, thymesen and IIOnochlonal antibccUe., may hold incr.asinq promise when used in combination. ~ diaqnostic t.chniqu.s includinq simple and inexpensive blood tests hve incr.ased promi in d.t.ctinq several cancer.. Ther. are at l ....t 50 druq. th.t have been found to be .ffective aq.inst certain cancer. and oth.rs are b.inq te.tea. New surqical t.chnique. and new t.chnoloqy includinq bon. replacements and las.rs are chanqinq surqical ou1:Ce-a... The us. of ultra sound ~. 10catil1Cj tUlllOr. aDd. t.heir tr.atlUllt l1IOr. precise. Byperthumia. the raisinq of Dody temperature, i. used to incr.ase effectivene of radio aDd ch.-otherapy. (18) 'l'hose diucoverie. and t.chnique., coupled with ;.ncrsed en-lirODlMlltal awarene.s and the prevention of exposure to hazards in the env1ronJllClt cannot f.il to impact on incidence aDd. survival rat.s for cancer. (18)
Bospice care which rec:oqn;i.ze. the benefits of care when cure . . . .ur. . are no lonqer thouqht to be appzopri.t. for the patient is an innovation which hall ail i 1:8 qoal enhancil1CJ the qual!ty of life for the cancer patient/f.ily. reducinq the costs of care durinq the teDlinAl illne , and red'JCinq the social aDd. economic costs attendant upon bereav. .ent. SOspic" service. are covered in another section of this Plan.
Radi.tion Therapy Service. The first edition of the State Bealth Plan provided an extensive analysis of radiation therapy servic in Georqia, their cllltriDution, utiliz.tion and r~r. . .n1:8. This analysis will not be updated in this Plan edition, however, service specifi~ standards for this t.chnical, specialized s.rvice are included to emphasize
the continued need to IIOni tor its d.velopment. (see paqe 16
for the stanciar4a).
20

SUMMARY OF REALTH SYS'I'EMS PLANS AND OTHER STATE PLANS
During the several years of planning, each of the HSAs has addressed cancermcreality as a priority pro~lem and advocated increased hlth education as preventive str.tegy. A sUIIIIII4rY of the goals and o~jectivesd.v.lopedby the HSAs follows in chart form. Th. St.t. h.s, to dat., no comprehensive canc.r management and control plan. Th. Adult Hlth S.ction of the Department of Human Resourc.s has reque.ted funds to in':r.... its servic.. and to enhance the potenti.l for coordin.ted ce-unity proqr.... Th. pro~l_. identified by the Adult a.alth Secti',n ancl the *dical As.oci.tion of Georgia which contr.cts to r= th. Cancer Regi.try have alre.dy been addr.ssed.
21

SELECTED IIIlICATORS AlID GOAlS fROI TIlE LATEST EDITIONS Of TilE GEORG IA liSPs AND TIlE SlIP

GOAL/OBJECTIVE LEVELS BY AREA

.PROBl~HlIHDICATOR

STATE

liSA I

liSA 2

liSA 1

liSA 4

liSA 5

liSA .6

liSA 1

Age adjusted mortality rate, Goal a

100,000 popUlation by selec
ted sites and by total (ICDA Code 140-209, 151,

119.2/ 100,000

None

Reduced age None adjusted
cancer
IDOrtality

!~fofafliz speciH::

Discussed 111.2/100,

Goa1z A cancer mor-

ates will 000 popula- tality rate

flOt exceed tion.

in USA VII

153, 154, 162, 114, 180)*

rates for

[;eorgia

that is

all countiel

ates.

less than

with rate.

10\ above

excatoding

the state

Crude cancer mortality rate; Goalz

Goalz 138

- fl Goall111.l/ state rate.

~8C

000
481

None

100,000 popUlation by age, l1J07I00,000 per 100,000 Re uce the

Discussed 136.8/

[;oalz r68"overall

Discussed

rate.
Plan included spe-

race, sex.

population. rate to

100,000 ::ancer 1Il0r-

cHic objec

Objz By

141.1 per

population ality rate

tives by

N N

1990, in/ 100,000

Objectivez 100,000 By 1986, population 155/100,000 by 1982.

will not ~xceed 144 leaths/lOO,

site: tung - rate ess than

population.

lOO popula-

20\ above

ion.

state rate.

Digestive

rate below

state rate.

Breast -

rate for

females 100

*objectives by site stated

below state

in plan section.

rate.

Cervix -

rate below

state rate.

I
._ _ _ _ _ ~._.___ . . .0- _0. ____ .... ___. _ ....- - - - - - - - - . - - - - - - - - -

SELECTED 1IIlICATDRS AlID GOAlS FROJI THE LATEST EDITIONS OF TIlE GEORGIA liSPs AI.D TIlE SlIP

GOAl/OBJECTIVE LEVELS BY AREA

PROBLEt'INDICATOR

STATE

HSA

lISA 2

lISA :I

lISA 4

liSA 5

liSA 6

Cancer incidence rates/year, state, USA, county.

168/100,000 160.3/100, per 5 year 000 in reaverage in gion disregion dis- cussed.
~. . . . . .et

P~blic Education Programs Available.

objectives I
By 1981, school hlth educatJon to include the disease known as cancer in all schools

N W
----_.- .'--"-"

By 1987 ,a coordinated cOllllllunity cancer control progra in all Ga"s counties.
By 1984, hose C.:.. ~ounties w/ highest in- I cidences . with a clllty designed, clllty supported chrch. hlth ed. prg. targeted to pop. at high-
_ . .-. -- --... .._. est risk. -- _..--------- -

None

None

None

None

~~o~alnlaAivcea.-

Objective I
By 19u, an

Objective I
By 1984,

public educa- education 100' of the

ion and ~etection

program for households specific will

~rograa con- counties have infor-

I:erning can- concerning mation avail

I:er should the dsks able on the

~e ava nable of cancer causes,

o all high of the laJljE treatment,

isk popula- intestine importance

ion groups. due to Ufe c.t preven-

style, en- tion, diag-

vironaent, nosis and

and inher- early treat

ited factor ..ent of

cancer.

By 1983, an

eQlAcatio ObjeCi:.A...,e6:

prograa for By 1982,

specific pubUc eduCll

counties tion plans

concerning should exili

the risks for at leas

of cancer 50' of the

of the

counties

trachea, that do not

,

bronchus, presently

and l'l"Ig due to lit

havE'! a..........

USA 1
Nor-e
"

PROBLEHVIHDICATOR
N,
.J:-

STATE

SELECTED IIID.ICATORS A1ID GOAlS fRlIl TIlE LATEST EDITIONS Of THE GEORGIA liSPs AND TIlE SlIP

GOAl/OBJECTIVE LEVELS BY AREA

liSA I

lISA Z

liSA J

lISA 4
style and environ..ental factors.
By 1982, educate the felUle popu lation of specific counties concerning the importance of periodic breast exam in early detection of cancer

liSA 5

.

lISA 6

liSA 1 ,
.

I

_ - - - - - - - - --------_. -_._-" .. "-'-'" ....................

-

STATI REALTH POLICIES FQR CANal CON1JOL IN GEORGIA
Seat. leqi.laeion mandaee. service. to the citizen. ot Georqia to prevene di.ea.e and to a i.e person. with a diaqno~is of cancer to receive care. The leqi.l~eive policy seipulaee. thae families should not be pauperized because ot the co.e. ot cancer. Litele n~ to be added to the policies see ~orth in the leqislation. Since the.e policies do need to be reintorced and aceualized, the tollowinq policies are recommended. 1. A coordinaeed cancer conuol p:oqrma should be available to
.111 Georqia cieizena whether they live in an urban or rural area. 2. All practicinq Georqia h_lth provider. should have the op~ortuni1;y
to requ!arly upqrade their Icnowlee.qe. in relaeion to uea1:lLene proeocols and diaqnostic proced.ur.u for cancer. 3. Sutficient funds should be available to hospieal. ,md physicians cont:.ractinq with the .eaee to provide indiqent care so that all o~ the population can be s~. 4 ~ Provbion should be lUde so ehat MBdicaid reimbur. . . .nt ~cou. available to individuals/familie. who have exhau.eed their fund. for cancer care, and are unable to purcha.e .ervice. required eithu for ereat:1lleDe or palliative care. S. The Seate ot GeOqia should illlpl-.nt a st:.ronq cancer education
and scr. .ninq proqraa aimed at earrJet population. mown to be
ae ri.k in are. . of the hiqh. .t ineidence. 6. Qualit:y hospice suvice. with adequaee mechani for s.rvic~
reimburs~t should be developed for all Georqian. in need. (S. . Bo.pice section of the Plan).
25

LONG RANGE RECOMMENDED AC'l'IONS" AND RESOURCE REQUIREMENTS

OBJECTTVE:
o.

By 1987, school health education program. in all Georgia schools with instruction on the diseases knewn a. cancer, the known risk factors, and risk avoidance bebaviors.

In the heal~ education section of this Plan a five y.ar plan for capacity enhancement is proposed to assist teachers to provide health education in the classroaR. That plan id.ntifies a mechaniua for providinq a taped IIICldel ef instruction and a t.acher work bC'ok for he.lth units. It is re<:CGlllended that cancer, the risk factors, and ri.k avoidance behaviors be ene such unit.

RESOURCZ UQOI~: bsource requirements arlt identified in the ae.lth Educ.tion Section of this Plan.

OBJEC'rIVZ: By 1987, a coordin.ted ccaaaunity cancer control proqr_ availAble in all counties ill Georgia.

Currently, there i. no univer.ally accepted IIICldel on which h.alth depar1:ment personnel lllAy bue cancer detection .U1d pr.vention proqr.... While all faaily planninq clienU an.l pJ:enatal clients are provided a PAP . .ar, it i. not standard practice statewide th.t WIC IIIClt:'1ers or other women are off.red thi;1 service, or are tauqh1: bre. .t self exi nation, or ccouraqed to attend smoking c. . . .tion clinic

The cancer control proqr_ recea-end. that at lea.t one SIIIClking ction clinic anually should be held in .ach health d.partment. The he.lth depar1:ments, accordinq to the background discUssion in the Cancer Control Proqrua fundin':i reque.ts, have r.ached th.ir proqr. . service capacity in their cancer screening programs, and, they state, follow-up care for clinic service patients is hind.red by liP~~~ staff. Further there is limited coordination between he.lth depar1:Jllent and t1DDOr clinic proqruas. To rectify this,. their reque.t for funds includes minimal staffinq and supplies for a ccaaunity control proqr. . in sev.ral aealth Districts.

RESOURCE UgUIREKENTS: Th. resources requested are for improvemAnt
for three districts and units in three other districts. These costs
would provide personnel and their support to:
conduct at lea.t one prof.s.ional or public cancer education program a month
facilitate quality care fer 1050 cancer patients.
annually expand cancer screening by 20' in each of these areas (nearly 3000 additional screenings)

26

and, through a contract with the Medical Association of Georgia, upgrade the Cancer Registry.

Th. reque.t was for a total of $238,400 to be contracted.

Di.trict 1 (Rural) Di.trict 3 Onit 3 (Orban) Di.trict 5 Unit 2 (Rural) Di.trict 6 (Orban/Rural) Di.trict 8 Unit 2 (Rural) Di.trict 10 (Rural)

$37,000 26,800 37,000 63,600 27,000 27,000

OBJECTIVE:

By 1987, tho counti in Georgia with the highe.t cancer incidence with a cOllDUDity digned, cODllllUnity supported canc.r health education program targeted to the population at highe.t ri.k.

Th. social and economic costs of canc.r are increa.inq with the incr.... of cancer incidence and lDOrtality in the St;\t.. Ther. is little disaqr. . .nt that early intervention and improved pr.v.ntion .trateqi could mak. a po.itive diff.renc. in reducinq th rate What i. at i ue is fundinq, and .pecifically what .trateqi might prove 110.1: effectiv

cooperation betwe.n the publiC: and private .ector. in Georgia's 21 cancer clinics. the Georgia Cancer Reqi.try, and the Georgia Caneer N.twork have already b.en demon.trated. Th. State Cancer AdVisory Cc.aitt.. has re<:allDeDded iU1 incr.a.. in funding for ~ty cancer control coordination. Thi. Plan support. their lonq ranqa 9Oal.

Thi. ?lan also recam.ends that a c~ity canc.r control research project be und.r'taken, that is jointly planned, executed. and also funded froa the application of public and private re.ource.. Th. project shoUld b. aimed at one urban and one rural area which have the highest incidence and lDOrtality rate for a cancer that has the best potential for control. where coaaunity awareness, control and
lUDaq_nt resourc are cCllllll8itted to the task. oro diqn the project
a. well as the evaluation schema and to id.ntify funding sources, the SEC should request the Georgia canc.r Advisory Board to convene a task fore. made up of publia and private sector repre.entatives, includinq Georgia's two medical school~currently involved with cancer services. The project would focus on community coordination and ways to develop health, industry, education. and consumer participation in those activities designed to improve the health status of the residents. wh.ther in lifestyle changes. health practices. the use of the system, or medical management. The proje<:t would require that formative evaluation be built into the plan, as well as technical assistance over a five year period. Hopefully from this exercise

27

the followinq benefits would accrue: answers to questions that relate to cancer awareness, cancer risk identification, motivation
tor chanqe of risk-frouqht behaviors and life styles, motivation tor' and knowledqe about the use of the health care system, optimal
canC8% manaquent, and the costs and cost benetits of such a coordinated proqram. Given adequate planninq time, a tarqet population with priority for action, and the application of the expertise availabJ.e in Georq14, the potential for developinq a workable, affordable community model may result.

lU:SOORCE REQOI~: No additional resources are needed

OBJEC'rIVE:

By 1984, 33 ho.pitals report tnq 100' of their cancer ca.e. to the Georqia Cancer Reqistry. (Current level - 31 ho.pi~ls)

<:urrent.1.y 31 hospital. participate in the Georqia cancer Reqistry. An incr.... of 2 ho.pitals was the stated objective of t.l. Cancer Control proqraa and the Medical A. .ociation of Georqia which operate. the reqistry. Becau both the quality of care and the basis for planniDq for cancer care are c".erivativ.s of this -effort, increased fundinq i. supported h~ein.

RESOUBCE RZQtJIREMD'rS: Inereased consultation staff and data proce.sinq co.ts require an additionAl ~20,OOO.

28

There were four objectives specified in this plan component that related to the State's cancer control and cancer management programs. and four standards for megavoltage radiation therapy services.
Objectiv~-!: By 1987, school health programs in all Georgia schools with instruction on the diseases known as cancer, the known risk factors, and risk avoidance behaviors.
Health education in Georgia public schools is a requirement at certain stated grade levels. The primary thrust in school health for cancer prevention activities is related to heart health, i.e.; the hazzards of smoking. In certain areas of the state, more comprehensive instruction has been undertaken in pilot projects (Bulloch County, Muscogee County and Ware County as well as Chatham County). The Cancer Society Chapters, the Heart Association and the Lung Association have all carried their programs into the schools where these organizations have active chapters. This is not a coordinated effort and LS uneven across the state.
In January 1986, a planning meeting LS scheduled with representatives of the National Cancer Institute, the Georgia Department of Education, DRR and other groups to develop a cancer education thrust for Georgia schools. With this special impetus, and hopefully matched by increased program support (funds), this objective has the possibility of being approached within the specified time frame.
Objective 2; By 1987, a coordinated community cancer control program available in all Georgia counties.
Since no funding improvement has been granted to the cancer control program gains that have been made across the state have not been as rapid as projected. However. the DHR plan relating to cancer prevention and treatment programs projections for fiscal '86 through fiscal '90 speaks to reduction of cervical, breast, colorectal cancers and the increase of smoking cessation clinics in the district health departments. Increased activity with WIC, family planning and prenatal clients and older adults is also included. Finally, the increase of
29

medically indigent persons accepted into the cancer care program is addressed, and a three million dollar improvement package is indicated as a requirement to increase and enhance this latter activity.
Objective 3: By 1984, 33 hospitals reporting 100 percent of their cancer cases to the Georgia Registry (an increase from current level of 31 hospitals).
This objective was accomplished and additional resources are being sought to secure an ~ncrease in the number of hospitals participating in the Registry.
Ob~ctive 4, which is to be completed in 1987 and is related to targeting of counties with highest incidence, has activities in progress by DRR cancer control staff. Their progress may be enhanced by
the receipt of funds under a contract with Ncr for this purpose
if such an award is granted to Georgia. This Agen~y has supplied data to the ORR Family Realth Division/Cancer Control Unit, and will work with their staff as requested, and will maintain liaison on an ongoing basis.
30