Costs of promoting cancer screening: Evidence from CDC’s Colorectal Cancer Control Program (CRCCP)

The Colorectal Cancer Control Program (CRCCP) provided funding to 29 grantees to increase colorectal cancer screening. We describe the screening promotion costs of CRCCP grantees to evaluate the extent to which the program model resulted in the use of funding to support interventions recommended by the Guide to Community Preventive Services (Community Guide). We analyzed expenditures for screening promotion for the first three years of the CRCCP to assess cost per promotion strategy, and estimated the cost per person screened at the state level based on various projected increases in screening rates. All grantees engaged in small media activities and more than 90% used either client reminders, provider assessment and feedback, or patient navigation. Based on all expenditures, projected cost per eligible person screened for a 1%, 5%, and 10% increase in state-level screening proportions are $172, $34, and $17, respectively. CRCCP grantees expended the majority of their funding on Community Guide recommended screening promotion strategies but about a third was spent on other interventions. Based on this finding, future CRC programs should be provided with targeted education and information on evidence-based strategies, rather than broad based recommendations, to ensure that program funds are expended mainly on evidence-based interventions.     

Evaluating the effectiveness of the first breast cancer awareness campaign in the United Arab Emirates: Lessons learned and next steps

Following an innovative breast cancer awareness campaign in the United Arab Emirates, a dual language survey of 500 women and in-depth interviews were conducted. The study found television advertising to be the most optimal awareness communication method, particularly among Emirati and other Arab women respondents. The research also found strong support for a year-long awareness campaign.     

Tobacco—the importance of relevant information on risk

Summary. Although it has been widely accepted since the 1960s that smoking cigarettes carries a substantial health risk, worldwide mortality from tobacco-related diseases is increasing rapidly at the beginning of the 21st century. To provide the motivation to control this epidemic there is a continuing and pressing need for information on the risks of tobacco consumption that is accurate, up to date, locally relevant and imaginatively presented.     

An Adjustment Factor for Mode-of-Action Uncertainty with Dual-Mode Carcinogens: The Case of Naphthalene-Induced Nasal Tumors in Rats

The U.S. Environmental Protection Agency (USEPA) guidelines for cancer risk assessment recognize that some chemical carcinogens may have a site-specific mode of action (MOA) involving mutation and cell-killing-induced hyperplasia. The guidelines recommend that for such dual MOA (DMOA) carcinogens, judgment should be used to compare and assess results using separate "linear" (genotoxic) versus "nonlinear" (nongenotoxic) approaches to low-level risk extrapolation. Because the guidelines allow this only when evidence supports reliable risk extrapolation using a validated mechanistic model, they effectively prevent addressing MOA uncertainty when data do not fully validate such a model but otherwise clearly support a DMOA. An adjustment-factor approach is proposed to address this gap, analogous to reference-dose procedures used for classic toxicity endpoints. By this method, even when a "nonlinear" toxicokinetic model cannot be fully validated, the effect of DMOA uncertainty on low-dose risk can be addressed. Application of the proposed approach was illustrated for the case of risk extrapolation from bioassay data on rat nasal tumors induced by chronic lifetime exposure to naphthalene. Bioassay data, toxicokinetic data, and pharmacokinetic analyses were determined to indicate that naphthalene is almost certainly a DMOA carcinogen. Plausibility bounds on rat-tumor-type-specific DMOA-related uncertainty were obtained using a mechanistic two-stage cancer risk model adapted to reflect the empirical link between genotoxic and cytotoxic effects of the most potent identified genotoxic naphthalene metabolites, 1,2- and 1,4-naphthoquinone. Bound-specific adjustment factors were then used to reduce naphthalene risk estimated by linear extrapolation (under the default genotoxic MOA assumption), to account for the DMOA exhibited by this compound.     

Interstitial Lung Diseases in the U.S. Mining Industry: Using MSHA Data to Examine Trends and the Prevention Effects of Compliance with Health Regulations, 1996–2015

Given the recent increase in dust‐induced lung disease among U.S. coal miners and the respiratory hazards encountered across the U.S. mining industry, it is important to enhance an understanding of lung disease trends and the organizational contexts that precede these events. In addition to exploring overall trends reported to the Mine Safety and Health Administration (MSHA), the current study uses MSHA's enforcement database to examine whether or not compliance with health regulations resulted in fewer mine‐level counts of these diseases over time. The findings suggest that interstitial lung diseases were more prevalent in coal mines compared to other mining commodities, in Appalachian coal mines compared to the rest of the United States, and in underground compared to surface coal mines. Mines that followed a relevant subset of MSHA's health regulations were less likely to report a lung disease over time. The findings are discussed from a lung disease prevention strategy perspective.     

Effects of Risk and Time Preference and Expected Longevity on Demand for Medical Tests

Despite their conceptual importance, the effects of time preference, expected longevity, uncertainty, and risk aversion on behavior have not been analyzed empirically. We use data from the Health and Retirement Study (HRS) to assess the role of risk and time preference, expected longevity, and education on demand for three measures used for early detection of breast and cervical cancer—regular breast self-exams, mammograms, and Pap smears. We find that individuals with a higher life expectancy and lower time preference are more likely to undergo cancer screening. Less risk averse individuals tend to be more likely to undergo testing.     

Quantifying Potential Health Impacts of Cadmium in Cigarettes on Smoker Risk of Lung Cancer: A Portfolio-of-Mechanisms Approach

This article introduces an approach to estimating the uncertain potential effects on lung cancer risk of removing a particular constituent, cadmium (Cd), from cigarette smoke, given the useful but incomplete scientific information available about its modes of action. The approach considers normal cell proliferation; DNA repair inhibition in normal cells affected by initiating events; proliferation, promotion, and progression of initiated cells; and death or sparing of initiated and malignant cells as they are further transformed to become fully tumorigenic. Rather than estimating unmeasured model parameters by curve fitting to epidemiological or animal experimental tumor data, we attempt rough estimates of parameters based on their biological interpretations and comparison to corresponding genetic polymorphism data. The resulting parameter estimates are admittedly uncertain and approximate, but they suggest a portfolio approach to estimating impacts of removing Cd that gives usefully robust conclusions. This approach views Cd as creating a portfolio of uncertain health impacts that can be expressed as biologically independent relative risk factors having clear mechanistic interpretations. Because Cd can act through many distinct biological mechanisms, it appears likely (subjective probability greater than 40%) that removing Cd from cigarette smoke would reduce smoker risks of lung cancer by at least 10%, although it is possible (consistent with what is known) that the true effect could be much larger or smaller. Conservative estimates and assumptions made in this calculation suggest that the true impact could be greater for some smokers. This conclusion appears to be robust to many scientific uncertainties about Cd and smoking effects.     

Uncertainty and Sensitivity Analysis in Assessment of the Thyroid Cancer Risk Related to Chernobyl Fallout in Eastern France

The increase in the thyroid cancer incidence in France observed over the last 20 years has raised public concern about its association with the 1986 nuclear power plant accident at Chernobyl. At the request of French authorities, a first study sought to quantify the possible risk of thyroid cancer associated with the Chernobyl fallout in France. This study suffered from two limitations. The first involved the lack of knowledge of spontaneous thyroid cancer incidence rates (in the absence of exposure), which was especially necessary to take their trends into account for projections over time; the second was the failure to consider the uncertainties. The aim of this article is to enhance the initial thyroid cancer risk assessment for the period 1991-2007 in the area of France most exposed to the fallout (i.e., eastern France) and thereby mitigate these limitations. We consider the changes over time in the incidence of spontaneous thyroid cancer and conduct both uncertainty and sensitivity analyses. The number of spontaneous thyroid cancers was estimated from French cancer registries on the basis of two scenarios: one with a constant incidence, the other using the trend observed. Thyroid doses were estimated from all available data about contamination in France from Chernobyl fallout. Results from a 1995 pooled analysis published by Ron et al. were used to determine the dose-response relation. Depending on the scenario, the number of spontaneous thyroid cancer cases ranges from 894 (90% CI: 869-920) to 1,716 (90% CI: 1,691-1,741). The number of excess thyroid cancer cases predicted ranges from 5 (90% UI: 1-15) to 63 (90% UI: 12-180). All of the assumptions underlying the thyroid cancer risk assessment are discussed.     

The effect of information on health risk valuations

This article examines the effect of familiarity with chronic lung disease on people's willingness to pay to reduce their risk of contracting chronic bronchitis, and on their willingness to increase their risk of auto death to reduce chronic bronchitis risk. We find that persons who have a relative with chronic lung disease are willing to give up more income to reduce their risk of chronic bronchitis than persons with no first-hand knowledge of the disease; however, their willingness to increase their risk of auto death to reduce their risk of chronic bronchitis is no different, on average, than persons with no first-hand knowledge of lung disease. This suggests that responses to risk-risk tradeoffs may be more stable than responses to risk-income choices.This research was sponsored by Resources for the Future and by the U.S. Environmental Protection Agency, Office of Policy Planning and Evaluation, Alan Carlin and Joel Scheraga, project officers. We thank Robert Mitchell for his help in conducting focus groups, and Caroline Harnett and Sari Radin for research assistance. Stan Presser, Sue Dowden, and Tim Triplett of the University of Maryland's Survey Research Center administered the survey. We especially thank Stan Presser for his suggestion that we sample relatives of people with chronic lung disease. We also thank Kip Viscusi, Wes Magat, and Joel Huber for making available their computer programs and data, and Ajay Kalra for programming help. Paul Portney and John Mullahy provided useful comments on an earlier draff of the article, as did two referees.     

A Method for Estimating Lifetime Cancer Risks from Limited Epidemiologic Data

Partly because of the poor quality of exposure information on humans, most lifetime carcinogenic risk assessments have been based on animal data. There are, however, surrogate measures for exposure that have not been fully utilized. One of these is duration of exposure where data on mean exposure levels are available. A method is presented for the use of such data, and the method is illustrated by developing a risk assessment from the available epidemiologic literature on gasoline and kidney cancer. This risk assessment is fairly consistent across studies and close to a risk assessment based upon an experiment with rats. While there needs to be much improvement in the quality of environmental data available to epidemiologists, it is possible that a number of risk assessments can be made from existing epidemiologic data and efforts directed away from extrapolation from animal data.