Vol. 4, 429-433. June 1995 Cancer Epidemiology, Biomarkers & Prevention 429

Received 3/24/95; accepted 4/7/95.

Meeting Report

Nineteenth Annual Meeting of the American Society of

Preventive Oncology

Elizabeth T. H. Fontham

Department of Pathology. Louisiana State University Medical Center, New

Orleans, Louisiana 70112

Ellen Gnitz (The University of Texas M. D. Anderson Cancer

Center, Houston, TX) presided at the 19th annual meeting ofthe American Society of Preventive Oncology held March

8-12, 1995. Roger Winn (M. D. Anderson Cancer Center)served as Program Chair.

The Distinguished Achievement Award was presented toPelayo Cornea (Louisiana State University Medical Center,New Orleans, LA). His lecture, “From Pathology to Epidemi-obogy to Prevention” traced his career beginning as a pathobo-

gist in Colombia, his evolution and careen as an epidemiologist,and his current work in gastric cancer prevention.

The first symposium focused on cigarettes in the 21stcentury, chaired by Ellen Gnitz. Jack Henningfield (AddictionResearch Center, National Institute of Drug Abuse, Baltimore,MD) highlighted nicotine addiction facts that have to be neck-

oned with in regulation. In particular, nicotine exposure pro-duces tolerance and physical dependence and can activate brainreinforcement such that impaired functioning results duringwithdrawal from cigarettes. Cigarette withdrawal symptoms

may reduce occupational performance and ability to interactsocially. Nicotine dosage forms vary in toxicity and addictive-ness, and cigarettes are the most toxic and most addictive form.Cigarettes themselves are cheap, easy to obtain anywhere,anytime, by anyone, while nicotine-containing medications are

often more expensive pen day, require a prescription, and aresold in quantities that require a relatively large expenditure of

money upfront.Matthew Myers (Coalition on Smoking on Health, Wash-

ington, DC) followed with a discussion of policy and legislativeissues with emphasis on pediatric addiction. He noted a number

of effective strategies that need to be implemented in additionto school-based education: (a) increase taxes, the single mosteffective short-term tool; (b) eliminate the tools the tobaccoindustry uses to encourage underage smokers, namely adver-

tising and marketing; and (c) restrict youth access by eliminat-ing sale of single cigarettes, self-service displays and vendingmachines, licensing retailers, and disciplining offenders.

Myers also discussed the current legislative climate inwhich there is a strong move to cripple health and safetyregulation, and he urged the medical and scientific community

to become advocates against such a move.John Slade (University of Medicine and Dentistry of New

Jersey, Skillman, NJ) followed with an overview of the tobaccoindustry marketing and advertising techniques. In 1992, $5.2billion were spent on tobacco advertising with a large share

($1.5 billion) in promotional allowances and coupons, and

retail value added ($2.2 billion), much of it directed at the

underage markets. He suggested counter techniques which in-dude ridicule, removing tobacco from view, and a markedchange in warning labels, including their size, placement,

content, and inclusion of quit-line phone numbers.The second symposium was chaired by Michael E. Ste-

fanek (Johns Hopkins University School of Medicine, Balti-

more, MD) and provided a lively debated on the pros and cons

of prostate screening with Ian Thompson (Brooke Army Med-ical Center, San Antonio, TX) providing the rationale forscreening and Barnett Kramer (National Cancer Institute, Be-thesda, MD) the reasons for not implementing prostate cancer

screening at the present time. The rationale posited for screen-ing was: (a) it is the only reasonable option to this large publichealth problem; (b) tumors detected by screening are clinically

significant; (c) the natural history of untreated prostate cancer

in younger men is extremely poor; (d) the outcome of screeningand therapy is extremely good (70% cured at 10 years based on

negative PSA); (e) the cost-utility of screening is good (0.35-

3.0 quality life-years gained by screening and treatment; and (flif given the option and informed, 95% of patients choose to bescreened.

Dr. Kramer then discussed the many unresolved issues andthe enigma of prostate cancer: when cure is necessary, is it

possible; when cure is possible, is it necessary? He noted thatwhile prostate cancer meets some of the criteria for massscreening (e.g. , significant burden of disease and recognizablepreclinical stages), it has not been demonstrated that treatmentat an early stage improves outcome as measured by cause-specific mortality. This can only be demonstrated by a random-

ized trial such as the ongoing PLCO screening trial. The effi-cacy of early detection is inseparable from therapy which

includes substantial long-term complications (urinary inconti-nence, impotence, urinary blockage, etc.)

Two concurrent presented papers sessions followed.

Barbara Rimer (Duke Comprehensive Cancer Center,Duke University, Durham, NC) chaired the session on Behav-

ioral Science/Quality of Life. Robert A. Hiatt (Kaiser Perma-nente, Union City, CA) described the breast and cervical cancer

intervention study that is evaluating the effects of a multi-factorial program for underserved women in San Franciscoand Contra Costa County, California. The program includeswoman-to-woman education with the use of indigenous

outreach workers with emphasis on repeated screening;provides cross-cultural education; and provides case

management of women with abnormal mammograms orPapanicolaou smears. Evaluation has demonstrated that cul-

tivation of sustained cancer screening among this under-served population is complex, costly, and labor intensive.The institutions serving this population are limited in me-

sources and are not organized to provide ongoing outreacheducation. The effectiveness of the program is difficult to

demonstrate. One proposed solution is to institutionalize theuse of trained indigenous workers.

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430 Meeting Report

Generosa Grana (Fox Chase Cancer Center, Philadelphia,PA) presented data on psychological outcomes of participationin a genetic cancer risk program. The baseline assessment of

approximately 200 women to date with a family history ofbreast and/on ovarian cancer indicates significant worry andmood disturbance over risk of getting cancer and a significantperceived risk of cancer. One year after undergoing genetic riskassessment counseling and risk modulation by preventive mea-sures, measures of anxiety and mood disturbance improve butcoping styles affect improvement. Risk measures, therefore,need to be tailored to the coping styles of individuals.

Rima Couzi (Johns Hopkins University Medical Center)

next discussed findings of her work to determine the prevalenceof menopausal symptoms among breast cancer patients, theirbeliefs about estrogen, and attitudes toward ERT.2 A highprevalence of menopausal symptoms was found among 190postmenopausal respondents to a mail survey, with the most

common including hot flashes (65%), night sweats (44%),difficulty sleeping (44%), and feeling depressed (44%). While31% of these women were willing to consider taking ERT, 94%had at least one concern about taking ERT. Among thosefactors associated with willingness to take ERT were youngerage, current smoking, lower education, perception of a problemrelated to menopause, and being nonwhite.

Scott Cummings (M. D. Anderson Cancer Center) de-scnibed a randomized prospective field trial of a work siteintervention which included 1 14 work sites in 14 states. Pan-

ticipatomy strategies were used under the assumption that peopleare more likely to participate in an activity when they have been

involved in planning and implementing the program. Employeeadvisory boards were used to generate enthusiasm for theprogram and as a vehicle for sending and receiving information.Process evaluation and program monitoring have been used.Conclusions of evaluation at present are: data collection mustbe kept simple in such a dispersed project; the program must betailored to fit the needs of both the project and the participants;training is essential to successful implementation; and evabua-tion is equally important.

Kathryn M. Kash (Strang Cancer Prevention Center, NewYork, NY) presented the final paper in this session on devel-opment of an instrument to measure breast cancer anxiety. Theinstrument has been administered to 177 high risk and 60normal risk women, predominantly white and college educated.

The 21 item ranked (0-3) breast cancer anxiety measure sig-nificantly discriminated between high and low risk women onanxiety levels. Women at high risk were older, had greatenbreast cancer knowledge (as well as anxiety), had more intru-sive thoughts, and perceived both a higher risk and greatensusceptibility. They tend to overestimate risk but have lessfrequent clinical breast exam and are less likely to practicebreast self-examination, especially when breast cancer anxietyis high. Interventions that target these specific barriers to earlydetection behavior will be addressed.

The second concurrent presented paper session was

chained by Melissa Bondy (M. D. Anderson Cancer Center).Katherine McGlynn (Fox Chase Cancer Center) presented me-

sults of a case-control study of patients with colon cancer and

colon polyps. Subjects without colon pathology had lowerlevels of ferritin than patients with benign on malignant neo-plasia, indicating higher iron stones. Data on transferrin, an

2 The abbreviations used are: ERT, estrogen replacement therapy; CA, continuous

abstention; DFMO, ra-difluoromethylornithine; PSA, prostate specific antigen;

DRE, digital rectal examination; CBE, clinical breast examination.

indirect indicator of iron stores, were less consistent. Althoughthe pathogenic mechanisms involved in this phenomenon are

not known, the hypothesis that disruption of iron metabolismmay be linked to an increase in free radical release was

suggested.Loic La Manchand (Cancer Research Center of Hawaii,

Honolulu, HI) investigated family history of cancer in 7605first-degree relatives of cobonectal cancer patients and 7778relatives of controls. An overall increased relative risk of 2.6

was found for relatives of patients with cobonectal cancer,limited to the same cobonectal location. The elevated risk wasmore pronounced in Japanese than in Caucasians, in siblingsthan in parents, and in relatives of index patients <SO years old

at diagnosis. The data suggest interaction between susceptibil-ity genes and environmental exposures.

Roberd Bostick (Bowman Gray School of Medicine,Winston-Salem, NC) presented data on estrogen replacement

therapy and adenomatous polyps of the large bowel from acase-control study carried out by the Minnesota CPRU team,headed by John Potter. There were no differences between

female cancer patients and colonoscopy negative on communitycontrols with respect to parity on use of oral contraceptives.Estrogen replacement therapy reduced the risk of adenomatouspolyps. The protective effect was more marked in women witha high body mass index.

Marion Lee (University of California, San Francisco, SanFrancisco, CA) reported on a case-control study of malignantgliomas which addressed the hypothesis of N-nitroso corn-

pounds as carcinogens by means of dietary questionnaire anal-ysis. She reported higher weekly intakes of bacon, red meats,alcoholic drinks, and overall nitrate in cases than in controls.

The cases reported lower intake of poultry, fish, as well as�-canotene and vitamin C rich fruits and vegetables. Cases alsoreported less use of vitamin supplements.

Maria Elena Martinez (Harvard School of Public Health,Boston, MA) reported on a study of aspirin and anti-inflam-matony drugs in patients with cobonectal adenornas, carried outin collaboration with investigators from the M. D. AndersonHospital. The odds ratio was 0.77 for weekly users and 0.36 fordaily users. Inhibition of prostaglandin secretion, especially

PGE2, was considered as an etiopathogenic hypothesis.The first day ended with a poster session and reception.

The Best Poster Award was given to Deborah Bowen et a!.(Fred Hutchinson Cancer Research Center, Seattle, WA) for

“Predictors of Retention in a Chernoprevention Trial.” Honor-able Mentions were awarded to: Robert Burach et a!. (WayneState University, Detroit, MI), “The Effect of PhysiciansReminders Upon Mammography Use in an HMO ServingMinority Women in Detroit”; Anne McTiernan et a!. (FredHutchinson Cancer Research Center), “Occurrence of BreastCancer in Relation to Recreational Exercise in Post MenopausalWomen”; and Xifeng Wu et a!. (M. D. Anderson Cancer

Center), “Higher Lung Cancer Risk for Younger AfricanAmericans with the Pro/Pro p53 Genotype.”

Larry Kushi (University of Minnesota, Minneapolis, MN)and Margie Clapper (Fox Chase Cancer Center) co-chaired asymposium on the nutritional aspects of chemoprevention.

Michael Wargovich (M. D. Anderson Cancer Center) gave anoverview of cancer prevention by naturally occurring agents infruits and vegetables (citrus, brassica, alliums, and legumes) aswell as grains, tea, and spices. Although almost all fruits andvegetables contain carotenoids, vitamin C, folate and otherwell-studied substances, he focused on other compounds withpromise for human chemoprevention. Among the flavanoids,quercetin structurally interacts with planar carcinogens (e.g.,

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Cancer Epidemiology, Biomarkers & Prevention 431

hetemocyclic amines) and is antimutagenic and anticarcino-genie. It is found in high quantities in the outer rings of red and

yellow onions. Soy-based isoflavones, in particular, genistein,

act as a weak antiestrogen, are antiprolifemative in cell culture,and inhibit mammary tumors in rats. Protease inhibitors, also

found in soy, are powerful anticarcinogens in purified form butare extremely expensive at the present time. Monoterpenes incitrus, e.g. , d-limonene in lemon oil, can deactivate the ras

oncogene and inhibit mammary cancer in rats. Lirnonene pluspenillyl alcohol acts as an isoprenylation inhibitor and is cur-nently being tested in a Phase I clinical trial in the UnitedKingdom. This combination may be promising in the chemo-prevention of pancreatic cancer. Other substances reviewedincluded isothiocyanate (crucifemous vegetables), polypenols

found in tea, curcurnin (i.e. , the spice turnenic), and organosub-

fur compounds in garlic. These chemopreventive agents actthrough one on more of the following mechanisms: destroy theformation of carcinogens; modulate metabolism or detoxifica-

tion of carcinogens; bind directly and competitively to cancin-ogens; on suppress the initiated cell.

Joanne Lupton (Texas A & M University, College Station,TX) completed the session with a discussion of the science basesupporting the claim of dietary fiber as protective in coloncarcinogenesis and the consequences of such health claims. It is

clear from animal studies that not all fibers are protectiveagainst colon cancer. Of the two broad classes, fermentable andpoorly/nonfermentabbe, only the batter is protective. Ferment-able fiber produces short-chain fatty acids and gases as the fiber

ferments. As it disappears it no longer serves as a good bulkingagent that can dilute carcinogens in stool. The fatty acidsproduced stimulate cell division, which is likely to promote

rather than protect in colon carcinogenesis. In the current foodsupply, two-thirds of fiber available is nonfermentable andone-third fermentable. Dietary recommendations call for 30 gof fiber/day without specification as to type. The current aver-

age consumption of fiber in the United States is about 11grams/day. Increased intake may be advanced in the future byenrichment of fiber containing foods and new products withfiber added.

Following the annual business meeting, Ellen Gnitz pre-sented the Presidential Address. Her long-standing work with

tobacco cessation among head and neck cancer patients has

recently turned toward quality of life issues. One year after

diagnosis, a relatively high proportion of current smokers en-tered into her program are continuous abstainers (65%). Pre-dictoms of CA include: type of medical treatment with a lowerrate among patients receiving radiation only; readiness tochange at baseline; time to first cigarette, >30 mm yielding ahigh rate of CA; age and race, younger patients and nonwhiteshaving higher rates of CA. Continuous abstainems were morelikely to quit cold turkey and had lower levels of anxiety!tension and craving for cigarettes. The trigger for relapse washow the patient was feeling. Patients who survive cancer do notreturn to a state of normal health. They demonstrate a variety offunctional difficulties (physical, psychological, marital, andsexual) and in interactions with medical providers. She ernpha-sized the need to incorporate quality of life assessment as an

end point in clinical trials, to identify specific determinants ofquality of life in head and neck cancer patients, and to tailorinterventions with the use of a multidisciplinary approach tocomplex treatments.

Donald R. Shopland (National Cancer Institute, Bethesda,MD) received the Joseph Cullen Memorial Award. Hepresented an update on national efforts to control tobacco use.In his lecture he traced consumption trends, total and pen capita,

as well as prevalence trends in adults and adolescents, notingboth the successes (e.g. , decline in cigarette use and lung cancerin white males) and failures (e.g. , dramatic increase in moist

snuff use).Following this luncheon lecture a symposium on minority

issues in community outreach was co-chaired by Robert Hiattand Roshan Bastani (University of California at Los Angeles,

Los Angeles, CA). Cancer control interventions in Latino corn-munities were discussed by Eliseo Perez-Stable (University ofCalifornia at San Francisco). He emphasized elements of theLatino culture which should be incorporated into outreachprograms to enhance success: simpat(a, positive social intenac-tion, is very important; and fami!ismo, the well-being of the

entire family, is also quite important. Knowledge about cancerrisk factors is poorer among Latinos compared to Anglos, and

attitudes reflectfata!ismo, a greaten sense of fatalism comparedto Anglos. His ongoing programs have relied heavily on Span-ish language media, especially radio, participation in unique

community events (e.g. , Cinco de Mayo), and a focus on theuse of neighborhood volunteers who will remain in thecommunity after a particular intervention has ended.

Deborah Bowen (Fred Hutchinson Cancer Research Cen-ten) then presented recruitment and design issues in the feasi-bility study for dietary behavioral changes in minority popula-

tions for the Wornens’ Health Trial. Media, mass mailings,community contacts, and physician and personal contacts wereused to recruit in the three clinical centers (Georgia, Alabama,and Florida). All three centers met recruitment goals with

regard to ethnicity, but the most economically disadvantagedwere underrepresented, largely because of the requirement for

completion of relatively complex dietary assessment material.

African-American and Hispanic participants were most likely

to be recruited via mass mailings (69 and 55%, respectively)while Caucasian/other study participants responded most to

media recruitment (54%).Shelly Hamrell (University of California at Los Angeles)

followed with a consideration of conducting interventions inthe African-American community. She discussed several cul-tunal and contextual issues relevant to outreach programs inAfrican-American Communities. The “connectedness” of me-

searchers to the community is very important. Caring, trust, andconcern are more important than academic qualifications. Con-

sideration of sociopolitical realities is essential because theywill impact on the willingness of the community to participateand facilitate research. Vigilance to the possibility of beingexploited is even present; therefore, it is essential that the

community be left with something tangible when the grant andprogram end. She went on to describe hen work with Head Startmothers in Los Angeles.

The afternoon sessions ended with two concurrent pre-sented paper sessions. Gary Goodman (Swedish Hospital Tu-mom Institute, Seattle, WA) and Margie Clapper chained the oneon chernoprevention!nutnition. Patricia J. Elmer (University ofMinnesota) presented data on the feasibility of increasing veg-etable and fruit intake for colon cancer prevention based on ai-year randomized clinical trial in pathologically confirmedadenomatous polyp patients. Approximately 95% of the pa-

tients remained in the study to completion with data collectedat baseline, 3, 6, 9 and 12 months. Intake of fruits and vege-

tables high in n-carotene, lycopene, and lutein doubled intreatment versus control groups. Fruit showed a much larger

increase than vegetables. No changes in total calories on weightwere observed. Cholesterol and low-density bipoprotein

declined 3 mg/dl in treated subjects versus a 1 .8 rngJdl increasein controls (P = 0.05). Triglycerides increased in both groups

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432 Meeting Report

but the increase was not significant. No adverse outcomes wereobserved. It should be noted, however, that this population hadan unusually high intake of fruits and vegetables prior tointervention. The mean baseline consumption was 6 servings!day, higher than the current S-a-day goal.

Mack Ruffin (University of Michigan Medical School,Ann Arbor, MI) followed with a report on adherence to aspirinin a Phase I chemoprevention trial in normal subjects which

highlighted the need for multiple methods of monitoring ad-

henence. Sixty-five subjects recruited to participate in a trialwere monitored for 14 days by self-report and an electronic

medication event monitoring system located in the bottle cap.Adherence was defined as taking the medication as prescribed,which included both dose and interval, 80% or greaten of time.

The adherence rate by self-report alone was 73%, by medica-tion event monitoring system alone, 44%, and by both, 35%.

Dosing interval errors were more common than missed doses.

Conclusions were that a single method is inaccurate and thatdirections to enhance adherence must be clear.

Larry C. Clank (University of Arizona, Tucson, AZ) nextpresented the risk of mortality associated with baseline plasmaantioxidant status in the Nutritional Prevention of Cancer Trial.Follow-up in this trial, which has as its primary aim to deter-mine the efficacy and safety of selenium supplementation indecreasing the incidence of nonmelanoma skin cancer, is more

than 99% complete and includes over 10,000 person years of

observation. A significant decreased risk of death is observed inpatients with above mean baseline concentration of a-toco-phenol. The effect is more apparent in exsmokers than in current

or never-smokers and persists even when deaths occurring infirst year or two of the study (lag time) are excluded. �-canoteneand netinol have only marginal effects on mortality reductionafter adjustment for age and smoking.

Kenji Nishioka (M. D. Anderson Cancer Center) reportedon a Phase I trial with the use of polyamine metabolism as a

marker in assessing DFMO effects in chemoprevention of cem-vical cancer. DFMO was given in decreasing doses for 1 monthto 3 patients/dose, and patients were monitored with the use of

plasma and tissue to examine DFMO plasma levels, putnescinelevels in RBC, and spemmidine/spermine tissue levels. A con-sistent decrease in sperrnidine/spermine was observed only at a

dose of lg/rn2/d, indicating a tissue effect of DFMO at this

dose. Abnormal, but not normal, tissue contained detectablelevels of N’-acetyl spermidine, a product of spenrnidine!sper-mine acetyltransferase. The findings support a role forpolyarnine metabolism as a marker of DFMO effects.

Nicholas Petnakis (University of California at San Fran-cisco) completed this session with a study of the effect of soyprotein isolate on breast secretory activity in normal pre- andpostrnenopausal women. Isoflavones contained in soy, pnirnar-ily genistein and diazdin, act as phytoestrogens with an action

similar to that oftarnoxifan. In this study, 24 white women aged30-58 years underwent monthly nipple aspiration and gave

blood and urine specimens. Women ate 40 g of soy protein

isolate/day for months 4-8. An increase in nipple aspirate fluidwas observed in all premenopausab women and in those post-

menopausal women on estrogen replacement therapy during theperiod of soy ingestion compared to bevels before (months 1-3)

and after (months 9-12) treatment. This increase may occur asa result of the estrogenic effect of the isolate on prolactinsecretion or by a direct effect of genistein on breast tissue-enhancing secretion.

Richard Love chaired the concurrent session on cancer

screening. Kathleen Lee (Fox Chase Cancer Center) presented

an evaluation of a home self-testing protocol for microscopic

hematunia as a method of early detection of bladder canceramong chemical workers exposed to a known bladder carcin-

ogen. Compliance with the protocol was quite high (>75%),

and the procedures used in the portable protocol compare

favorably with standard laboratory procedures. The results fromthis study support the use of self-testing as an acceptable meansof screening and early detection of bladder cancer in an

occupationally exposed wonkforce.

Edward DeAntoni (University of Colorado Health Sci-ences Center, Denver, CO) followed with a presentation on

PSA and DRE. He took the opportunity to reiterate severalpoints presented in the point/counter-point discussions of IanThompson and Bannett Kramer regarding prostate cancer

screening. DeAntoni stressed that PSA and DRE are methods

for case findings and not screening. He suggested that, typi-

cabby, men come in with some urobogical problem and that the

effectiveness of DRE and PSA in detecting curable prostate

cancer has been established. The findings from this community-based longitudinal study delineate biopsy mates and patterns of

care following abnormal test results in typical communitypractice.

In the next study, presented by Gregory Hamper (AlbanyMedical College, Albany, NY), predictors of mammography

use were examined in two urban, lower socioeconomic status

communities. Baseline information was obtained from 473

women and follow-up surveys were completed by 216 women.

Data was obtained through in-home interviews conducted by

community health workers. Findings indicate that a recentwell-care visit, recent clinical breast exam, and having a doctor

or health care provider talk about mammography were all

predictive of mammography recency for both black and whitewomen. Results reinforce the importance of targeting cancer

screening interventions to health cane providers. Increasingdiscussion and recommendation of mammography by health

cane providers is an important aspect of cancer prevention andcontrol interventions with lower socioeconomic status women.

Elizabeth Coleman (University of Arkansas for Medical

Sciences, Little Rock, AR) presented the results of a programdesigned to use “standardized patients” to teach CBE to med-ical students. SPs were lay women trained in different clinical

scenarios. These SPs learned a clinical scenario in which awoman presented to the clinic for a breast exam and was

concerned about breast cancer. A student had to obtain her

medical history, delineate risk factors, and make mecornrnenda-tions for screening based on information obtained from aninterview. The performance of students trained in CBE by SPswas compared with that of students trained in CBE by viewinga videotape and participating in a didactic session. Students

trained using the SPs had a mean score of 84% on theirproficiency evaluation, compared with 70% mean score for theother group of students. Coleman emphasized that CBE is a

skill which needs to be evaluated objectively. A composite

measure of proficiency for students was evaluated with the use

of a scoring system developed from a survey of 21 expert

teachers of the MammaCane method of CBE.Ronald Myers (Thomas Jefferson University, Philadel-

phia, PA) presented findings of a study of physician intentionto refer fecal occult blood test positive patients for a complete

diagnostic evaluation. Five-hundred-seventeen primary carephysicians participated in the telephone survey. Myers pointedout that theme are not many models developed to explain the

behavior of primary care physicians. These authors used the

Theory of Reasoned Action for its theoretical framework. A

remarkably low number of physicians indicated that they would

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Cancer Epidemiology, Biomarkers & Prevention 433

refer for complete diagnostic evaluation and discussed the

factors associated with physician intention to refer.

Friday closed with a banquet featuring David Zanidze(Director, Institute of Cancinogenesis, Moscow, Russia), as the

guest speaker. He discussed new approaches to medical care inRussia and how political changes have affected prevention and

treatment, with particular emphasis on smoking control issues.Remarkable differences in the current prevalence of smoking inmen (50-55%) and women (10-12%) are reflected in theaverage life expectancy of Russian men, which has declinedsince 1965 to an average of 59 years. Smoking rates are in-

creasing in women. Russia is a relatively new market forimported cigarettes. Until 2-3 years ago, only Russian-pro-

duced cigarettes (very high in tan and nicotine) were availablefor sale. Today promotion and advertising of cigarettes is flour-ishing and is embraced enthusiastically by mass media there.The primary targets, as in this country, are women and teens.He also mentioned opportunities for research and collaboration.

The annual meeting concluded on Saturday morning. Aplenary session featuring the highest ranked submitted paperswas chaired by Bernard Levine (M. D. Anderson Cancer Cen-ten). Abstracts for this session were published in the March1995 issue of this journal.

The final symposium, chained by Jon Kemnen (Lombandi

Cancer Research Center-Georgetown University Medical Cen-ten, Washington, DC), covered the economic implications of

prevention and control for health policy. Judith Wagner (Officeof Technology Assessment, United States Congress, Washing-ton, DC) used colon cancer screening as an example of eco-

nomic evaluation of cancer prevention. In the model, all con-sequences of a strategy are first enumerated. Then the size of

each consequence is quantified. The measured consequencesare reduced to a common metric(s). “Good” consequences arebalanced against “bad,” and “winners” and “losers” are iden-tified from the strategy. Finally, the impact of uncertainties in

the evaluation need to be explored. A cost-effective strategy isa preventive strategy that saves health came costs and save lives(i.e. , cost saving) on is one that increases health came costs butsaves lives and improves quality of life so much that the extra

health cane costs are worth it. She noted that evaluation of

cost-effectiveness is essential because prevention equals a pub-lie investment and is based on intervention in the lives of

otherwise healthy people.

Jeanne Mandelblatt (Lombardi Cancer Research Center-Georgetown University Medical Center) discussed the cost-effectiveness of cancer screening with the use of an evaluationof cervical cancer in the elderly. The questions to be answeredrelative to such screening include: Will it extend life? What is

the cost of the program? Who will benefit? Special issues incost-effectiveness of screening interventions are: the effects are

distal from the intervention; bead and length bias are importantbut difficult to incorporate into the analysis; the availability ofnatural history data is often lacking; the time frame for theanalysis must be delineated; and the appropriate comparisonmust be selected. She evaluated the results of triennial cervical

cancer screening in an elderly (>65 years) population and

found a 74% reduction in mortality with 43,200 life-years saved

at a cost of $97 million, or a cost of $2,254/year life saved. This

appears reasonable and compares to $12,000/year life saved formammography screening in this same age group. She noted a

number of caveats which might impact on the estimate and

conclusions.Scott Cantor (M. D. Anderson Cancer Center) made the

final presentation in the session with a decision analysis ap-

proach to prostate cancer screening. Medical decision making is

an analytic approach to making clinical decisions in the pres-

ence of uncertainty. A sample (n = 10) of married couples were

interviewed to obtain quality of life data to incorporate into the

model. On the basis of the answers of husbands, no screeningwas preferred to screening. One-way sensitivity analysis mdi-

cated that the decision not to screen was robust to changes inmodel parameters. If life-expectancy is the only criterion for

decision-making without regard to quality of life, then screen-

ing may be appropriate. All three of the speakers acknowledgedthe numerous uncertainties in this important area but stressed its

utility when accompanied by an understanding that the data

used and assumptions made will determine the conclusionsreached.

A new Investigator Workshop chained by Alfred Neugut

(Columbia University School of Public Health, New York, NY)was held in the afternoon prior to the opening session as was a

joint meeting of National Cancer Institute Prevention Fellows

and Preventive Oncology awardees.

Study groups met at breakfast sessions throughout the

annual meeting. The Chernoprevention Study Group led by

Gary Goodman (Swedish Hospital Tumor Institute) and theDiet and Nutrition Study Group organized by Larry Kushi

(University of Minnesota) and Sue McPherson (The Universityof Texas School of Public Health, Houston, TX) held discus-sion sessions on the first day. Michael Fiore (University ofWisconsin, Madison, WI) and Victor Vogel (M. D. Anderson

Cancer Center) served as organizers of the Tobacco and Screen-ing Study Groups, respectively, which met on day two. On the

last day of the annual meeting, the Wornens’ Health Study

Group, led by Michael Stefanek (Johns Hopkins University)

and the Genetic Markers Study Group, bed by Peter G. Shields(National Cancer Institute), met.

Following the closing session, a special genetics workshop

was held, “Latest Developments in Molecular Genetics: 1mph-cations for Cancer Prevention.” Caryn Lerman and Bruce Trock

(Lombardi Cancer Research Center-Georgetown University)served as co-chairs again this year for the workshop which hadapproximately 60 participants. Presenters included Christopher

Amos (M. D. Anderson Cancer Center), Louise C. Strong (M.D. Anderson Cancer Center), Richard Kolodner (Dana-Farber

Cancer Institute, Boston, MA), Alexander Kamb (Myriad Ge-netics, Salt Lake City, UT), and Mark A. Rothstein (University

of Houston, Houston, TX). Because of the wide interest in this

topic, it will be included in the program next year as a sym-

posiurn rather than as a special workshop. The annual meetingnext year will be held in Bethesda, MD.

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