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In New Jersey, Focus in Fight Against Cancer Changes, and Care Comes Closer to Home

Mary K. Caffrey
If one thinks “cancer” and “New Jersey,” the images that come to mind might be those that have long defined the state: plumes of smoke along the Turnpike, acres of oil refineries, or fleets

of trucks spewing exhaust.

An actual map of  cancer incidence reveals something else. For starters, most of the cancer occurs in South Jersey (Figure), where cornfields have given way to retirement communities. As for images that evoke emerging threats, think sun and sand, not smokestacks.

In line with the recent warning from Acting US Surgeon General Boris D. Lushniak,1 rising rates of melanoma in counties along the famous 126-mile shoreline have drawn attention from both state health officials and leading researchers.2 In summer months, the NJ Department of Health (DOH) sends teams right on to the beaches, both to educate sun worshippers and to screen for early cases of skin cancer, according to spokeswoman Dawn Thomas.

New Jersey’s cancer threats are similar to the rest of the nation’s; the difference is the degree (Table 1). While overall cancer rates have fallen over the past 20 years, the state still ranked seventh in cancer incidence in 2011 with 49,080 cases, according to the American Cancer Society.3 That report stated the “big 4”—lung, prostate, breast, and colorectal cancer—still account for most of the state’s cancers; 52% of all cancer incidence and 49% of all cancer deaths. Lung cancer, with most cases caused by smoking, is the single biggest killer, accounting for 4100 of the state’s 16,370 cancer deaths in 2011.4 Rising rates of melanoma among the young and overall higher rates of thyroid cancer, which may or may not be explained by better detection, 4,5 are also part of New Jersey’s complicated cancer story, which is one of great strides on some fronts and frustration in others.

If New Jersey once sat in the shadow of New York City and Philadelphia, it doesn’t act that way anymore. In the wake of Lushniak’s warning, the home page for the Cancer Institute of New Jersey (CINJ) was overhauled to highlight the “Call to Action” on melanoma, featuring both the work of CINJ behavioral scientist Eliot Coups, PhD, and of Howard L. Kaufman, MD, FACS, associate director of clinical science, who had just presented important phase 3 results using talimogene laherparepvec to treat melanoma at the American Society of Clinical Oncology in Chicago.6

To be sure, New Jersey has come a long way from the 1970s, when it had the highest cancer rates in the country2,3 and a hard-to-treat case almost certainly meant crossing a river to one of its neighboring cities for treatment. Today, cancer rates among African American men have fallen and disparities between whites and minorities are narrower than in many other states.3,4,7

Best of all, a state known for its bruising politics has achieved a bipartisan consensus that cancer patients should not have to travel out of state for care. Against a backdrop of state budget cuts and a recession that was deeply felt, cancer care for many has come closer to home, with governors and legislators from both parties overseeing significant investments in infrastructure. A $139 million medical school to serve South Jersey, discussed for decades, opened in Camden in 2012.8 Next door is the $100 million MD Anderson Cancer Center at Cooper, which opened in October 2013, transforming both a section of a beleaguered city and care itself.9

More hard-won was a 2012 law, brokered by Republican Governor Chris Christie and Democratic Senate President Stephen Sweeney, who comes from Gloucester County in South Jersey, that restructured New Jersey’s higher education assets.10 Leaders of the major research institutions say this step is finally dismantling the silo effect that for decades prevented research entities from collaborating as fully as they might have and from taking full advantage of their close proximity to leading pharmaceutical manufacturers.Research today emanates from CINJ, a National Cancer Institute-designated center based in New Brunswick, NJ, that became part of Rutgers University in 2013 and had 476 active clinical trials last year, according to spokeswoman Michele Fisher.10

Eight medical centers across the state enjoy major partnerships with CINJ, and even more have relationships. In South Jersey, the hub for cancer care is Camden, NJ, where a year-old collaboration between Cooper Medical School at Rowan University and the world-famous MD Anderson Cancer Center is ramping up; spokeswoman Wendy Marano reports that between October 2013 and June 2014, the center experienced 18% growth in patient volumes across all areas, including an 11% increase in complex cancer cases.

The medical school itself is still very new, having accepted its first class in 2012 (third- and fourth-year medical students from Robert Wood Johnson Medical School had previously trained at Cooper).9 At both CINJ in New Brunswick and MD Anderson at Cooper, leading oncologists report that the old pattern of New Jersey patients automatically going out of state for cancer care is quickly ebbing. In some cases, they say, cancer patients cross the Delaware or Hudson rivers into New Jersey to receive care. Marano said between October 2013 and June 2014, MD Anderson at Cooper experienced a 30% increase in cases from outside the traditional service area, including cases from Pennsylvania.

Amid these good signs, however, is a lingering undercurrent: the state’s ongoing financial distress. For more than 20 years, multiple governors have patched over or ignored the growing unfunded retirement obligations for New Jersey’s public employees. This spring, another revenue shortfall caused Gov. Chris Christie to propose cutting $1 million from the New Jersey Commission on Cancer Research and $10 million from CINJ.11 In April, Christie blamed the cost of public employee pensions for the proposed cut.12 Although the Legislature restored all the funding for budget for the fiscal year that began July 1, 2014,13 New Jersey’s ongoing challenge of how to meet the cost of retirement obligations to public employees threat-en every part of the budget, including cancer research, which has widespread support.

Overlooked in the budget debate is the fact that not a dime that New Jersey receives from the 1998 Master Settlement Agreement (MSA) with the 4 largest tobacco companies goes to combat smoking.14 Like 17 other states, New Jersey took the payout from the agreement upfront, and sold bonds that are paid off as settlement dollars arrive, a process called securitization. Unlike some states, New Jersey did not carve out settlement funds for smoking cessation.15 Instead, New Jersey uses $2.2 million in federal dollars for cancer screening and prevention; Generosa Grana, MD, director of MD Anderson at Cooper, had strong praise for the state health department efforts, which DOH’s Thomas said are based in all 21 counties. “We are catching cancer at an earlier stage,” Grana said, attributing this to 3 factors:

• sustained public education efforts, including attention from the media

• better screening and detection services, including broader access

• more access to genetic testing services, and a recognition of the role that testing and genetic counseling play in overall survival.

As with other parts of New Jersey’s cancer story, the onset of the Affordable Care Act (ACA) has been a mixed bag.

While some patients who previously lacked insurance now have it, CINJ’s Kaufman said some patients insured by the exchanges who have tried to get a test or scan out of state had trouble doing so (Table 2).

Fighting Cancer in New Jersey

The state’s environmental history is strongly connected to cancer’s footprint here, but just how much has been the subject of debate for decades.

Concerns about air and water pollution, and about toxins in landfills in a state where people are abundant and open space increasingly scarce, have driven state planning and environmental policies since the 1980s. New Jersey remains home to one of a handful of cancer clusters tracked by the CDC: the area around Toms River, NJ, where local concerns over possible connections between childhood leukemia and waste from Ciba-Geigy arose in 1996.16

But Grana said studies of connections between environmental causes and cancer have not pinpointed a single factor. By contrast, she said, higher rates of smoking in South Jersey undoubtedly contribute to higher cancer rates in those counties, along with the older demographics of the population.

Overall, only 16.8% of New Jersey adults over the age of 18 years smoked in 2011, according to the CDC,17 but Grana said rates are higher in South Jersey, and this is reflected in lung cancer statistics. She said, however, that treatment for lung cancer is improving: CDC figures reflect that of the 4 major cancers, only lung cancer rates are lower than national averages (Table 1).

The state’s cancer prevention efforts flow through NJ Cancer Control and Early Detection (NJ CEED) program, which operates through the state’s counties to provide education, outreach, and screening for breast, cervical, prostate, and colorectal cancer, according to Thomas. She said in the fiscal year that ended June 30, 2014, the program screened 24,700 women for breast, cervical, and colorectal cancer, as well as 847 men for prostate cancer. Ten task forces that cover 2 counties apiece operate statewide (including 1 through MD Anderson at Cooper). In a state that has long valued local control, this disbursement of screening services matters.

Evelyn Robles-Rodriguez, RN, MSN, APN-C, AOCN, who is the director of Oncology Outreach Programs at MD Anderson at Cooper, offered an example of the kind of program NJ CEED funds. Robles-Rodriguez received a call from an Indian temple in a nearby suburb a decade ago informing her that women at the temple weren’t being screened for cancers, and she was able to get funds for a screening program and a translator to ensure “culturally competent” services. On the very first visit, 38 women were screened, and today that clinic sees women at the temple once a month.

Another effort addresses the needs of Vietnamese women living in Camden, many of whom work as nail technicians throughout the area. A nurse practitioner at the hospital has just received funding to examine data from these 2 initiatives, “to see what inroads we have made,” Robles-Rodriguez said. Could New Jersey do more? Cancer control advocates succeeded in getting the legislature to ban minors under the age of 17 years from using commercial tanning beds, after the infamous case of the “tanning Mom,” whose 5-year-old showed up at school with burns.18

Most of the 2013 recommendations from the American Cancer Society advocate getting more money aimed at the war against tobacco.4 A February 2014 report by another national group, the Campaign for Tobacco-Free Kids, criticized several states for the gaps between what they collect in tobacco taxes and MSA funds and what they spend on smoking cessation. In that report, New Jersey was listed with $947.2 million in overall tobacco-related revenue for fiscal year 2014. Instead of spending the CDC-recommended amount of $103.3 million on tobacco prevention, New Jersey was spending zero, according to the group.14

 
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