Mortality rates for cancer in the United
States have risen steadily over the past 50 years. This disease causes 1 of
every 5 deaths in our country. From 143 per 100,000 people in 1930, the age-adjusted
mortality rate rose to about 171 in 1989. According to 1993 rates, 1 out of every 3
Americans (about 85 million people) will eventually have cancer. More than 1 million new
cancer cases were expected to be diagnosed in the United States during 1993. In Texas,
63,000 Texans were diagnosed with cancer and 29,200 died from their disease during that
year [1].
Not all the news is bleak,
however. The impact of primary prevention is improving through the avoidance
of potential oncogenic exposures (tobacco use, sun exposure, and excess dietary fat) as more
Americans adopt healthy life-styles. Secondary prevention has made great
strides, particularly in breast and cervical cancers, through early detection and
treatment. Survival statistics are on the upswing: 52 percent of the patients diagnosed
with cancer today may expect to be alive after 5 years, compared with only 30 percent in
the 1960s [1].
Nevertheless, although
physicians, and especially those providing primary care, are ideal agents to promote
prevention and early detection, studies indicate that opportunities for
prevention and screening are greatly underused in physicians' offices
[2,3]. One survey
showed that physicians in family practice are reluctant to treat the behavioral risks of
cigarette smoking, obesity, and lack of exercise, that they overuse relatively ineffective
risk-education strategies, and that they underutilize potentially more effective
behavioral or psychological treatments, either in practice or via referrals
[2].
Surveys of
physicians have identified some common barriers that may explain the underutilization of
these powerful weapons in the fight against cancer. These barriers include
uncertainty about screening guidelines, inadequate training in counseling and educating
patients (particularly on strategies for life-style modification), difficulty obtaining
provider reimbursement, pessimism about cost-benefit and/or the scientific basis of
prevention and screening options, additional costs to patients, and logistical problems in
the office setting (i.e., time constraints, staff, or referral sources). Furthermore, many
doctors entertain pessimism regarding patients' abilities to change their health
life-styles. Some of this pessimism could stem from the physician's reliance on relatively
ineffective educational techniques [3,4].
Most of these
physicians routinely advise their patients to change their health-related behaviors, but
this is not enough. More than risk education and advice to change behavior
is needed. One estimate suggested that if all physicians in the United States offered
routinely even 5 minutes of emphatic quit-smoking advice with minimal self-help
instructions, our national annual quit rate might be doubled. Patients need access to
skills and guidance to make behavioral changes. How the physician can provide such
assistance is a topic seldom covered in medical school curricula [2].
The medical school
curriculum fails to adequately prepare future physicians to become effective agents for
cancer prevention and control. The acknowledged need to integrate concepts
of preventive medicine into professional education has led to several concerted efforts,
including the assessment and project that are the subject of this monograph [4].
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