Dana-Farber group aims to reduce cancer risk in the community
Lunchtime at Tympanium Corp. in Malden, Mass., offers a welcome diversion from soldering, assembling, and testing parts for small engines. Workers—most of them women—gather to enjoy light meals and laughs in the corner of the factory. Today, however, there's something different. Against one wall is a table spread with broccoli, fish sticks, and other grocery items; buttons urging workplace safety; and bright posters promoting healthful eating.
During their breaks, some of the employees approach the table and take turns selecting items for a pretend meal. They chat with a health educator about the value of eating fruits and vegetables, avoiding red meat, and taking multivitamins; and they help themselves to bowls of fresh melon.
The display is part of an ongoing research project at Tympanium and other small businesses in Massachusetts designed to encourage workers to eat better, exercise, and quit smoking—and, ultimately, reduce their chances of developing cancer. Another aim is to help managers enhance policies and conditions to protect their employees and support healthful habits.
"Healthy Directions—Small Businesses" is one of many studies currently being led by Dana-Farber's Center for Community-Based Research (CCBR), a nationally recognized group that examines the most effective ways to lower cancer risk. Its goals are to alter potentially harmful behaviors, minimize exposures to cancer-causing substances in the environment, and increase early detection through cancer screenings, such as mammograms and colonoscopies.
What distinguishes the center from its peers is its outreach to low-income, blue-collar, and ethnically diverse populations—those at higher risk for certain cancers and for whom health-promotion campaigns have traditionally failed. The CCBR's success lies in combining rigorous science and innovative community partnerships with employers, health-care centers, churches, labor unions, and other organizations.
"We are one of the few places in the country that focuses on developing cancer-prevention interventions to help address some of the social inequalities in cancer risk," notes the center's director, Glorian Sorensen, PhD, MPH. "We try to understand how the social context of people's lives influences their health behaviors, their exposures to hazards, and their likelihood of getting screened."
As it advances knowledge about cancer prevention and control, the center's research often has a direct impact on participants' lives. One of them is Margie Mamzur of Revere, a long-time Tympanium employee who kicked the smoking habit after 35 years with the help of nicotine patches and a support group arranged by the CCBR. "I tried to quit cold turkey before, but it didn't work," Mamzur attests. "This really works. I feel good."
A growing operation
Over the next several decades, cancer is expected to overtake heart disease as the leading cause of death in the United States. Yet, according to the Harvard Center for Cancer Prevention, 50 percent of all cancers can be prevented by maintaining a healthy weight, not smoking, protecting oneself from the sun, and taking other steps to lower cancer risk.
For this reason, the Center for Community-Based Research was established in 1992, after Sorensen joined Dana-Farber from the University of Massachusetts Medical School in Worcester. The idea was to bolster the prevention arm of the Institute's mission—required for Comprehensive Cancer Center status—and to explore how lifestyle and community can affect health behaviors. The center's purpose reflects Dana-Farber founder Sidney Farber, MD's, belief that "prevention is better than cure."
A staff of nine working on one project has grown to roughly 70 people, with more than seven studies completed, 10-plus currently under way, and even larger ones pending approval. Part of the Population Sciences unit within Adult Oncology, the center draws faculty and staff from many social sciences, among them psychology, occupational health, nutrition, epidemiology, biostatistics, and anthropology. Sorensen, a sociologist by training, is one of three faculty leaders, along with Karen Emmons, PhD, a clinical psychologist; and Elizabeth Barbeau, ScD, MPH, a specialist on tobacco-control research.
In addition, the CCBR works closely with Dana-Farber's many treatment programs, its outcomes experts (for help applying findings to the general population), and its Com-munity Benefits unit, which provides cancer-related outreach services in the community. It also teams with institutions in and around the Longwood Medical Area.
"We build bridges with other Harvard-affiliated hospitals and programs," says Emmons. In one breast cancer effort, center staffers Jennifer Dacey Allen, ScD, and Roberta Goldman, PhD, are joining Bruce Chabner, MD, of Dana-Farber and Massachusetts General Hospital to probe why some women don't seek follow-up care when their mammograms show abnormalities. "There's an alarmingly high prevalence of this in low-income and minority communities," observes Emmons. "It could be due to access to treatment, fear, religious beliefs, or any number of reasons. We don't know why."
Among the center's notable collaborations are those involving labor unions. In July, Barbeau traveled to Washington, D.C., to help unveil a national consortium aimed at reducing smoking and secondhand-smoke exposure among working families. The project, spearheaded by DFCI, the University of Massachusetts at Lowell, and the American Legacy Foundation, will study strategies for reaching young workers through union-based training and apprentice programs.
Explains Barbeau, "We're trying to bring these two very powerful movements — labor and tobacco control — closer together toward the goal of reducing class-based differences in health related to tobacco, which is linked to lung cancer and other diseases."
Launching projects
The summaries of the center's current research projects appearing on the CCBR Web site (www.dana-farber.org/ccbr) belie the effort that goes into each one.
Consider Healthy Directions — Small Businesses, funded by the National Cancer Institute for four years and scheduled to wrap up in February 2003. The undertaking, says Project Director Lorraine Wallace, MPH, has involved recruiting companies, developing the "intervention" and carrying it out, and surveying employees both before and after the program to see whether any changes have occurred. The initial survey involved more than 2,000 workers and managers in participating companies — a task that took six months. (Its companion study, Healthy Directions — Health Centers, entailed querying some 2,000 patients.) Like many of the CCBR's projects, Healthy Directions has a strong occupational-health component and has included visits by the center's industrial hygienists, Richard Youngstrom and Wesley Straub, to advise on hazards in the workplace.
"The work we do is heavily based on the epidemiology of cancer risk," notes Sorensen, principal investigator for Healthy Directions and several other center projects. "From epidemiology, we learn cutting-edge information about the risk factors we should be focusing on, the prevalence of risk in different populations, and the social causes of risk."
Along the way, projects often get tweaked for effectiveness. At Tympanium, CCBR staff found that although the healthy-diet messages were appropriate for Caucasian employees, they did not resonate with many of the Vietnamese workers — who already eat plenty of fruits and vegetables. These employees needed reinforcement rather than education.
"That's a key challenge that cuts across all our projects, whether it's working with unions, churches, health centers, or work sites," says Barbeau. "We have to figure out ways to ask questions that are relevant not only to the scientific community, but to the community in which we're doing our research."
Getting out the message
Developing communication tools is a critical part of each intervention project. Many of the center's materials are tailored to the study group and must reflect different languages and cultural and age preferences. A food pyramid aimed at Latino people, for example, might include a tortilla rather than sliced bread; a project involving smoking among teenagers gave out popular fisherman's hats. Some of the center's literature — created in-house by the Health Communication Core — is customized for individuals. In one project, each participant who meets with a health educator later receives a flier containing a photo of that educator and feedback from their conversation.
Whereas health communicators of the past typically told people to "change" their lifestyles, today's messages tend to be more subtle and realistic. In a recent study on secondhand smoke, Emmons used a method called "motivational interviewing" to talk with parents about the impact of their smoking habits on young children, including an elevated risk of ear infections and asthma.
"People come with their own agendas, and if you give them information in a context that relates to their own goals and motivations, they will make their own decisions — and it will be more effective," she reasons. "It's a technique in which you offer choice and constructive feedback." Adds CCBR Communication Director Elizabeth Harden, "Everybody wants to make some change for the better — even if it's just increasing your daily fruit intake by half a pear. We need people to find reasons that are meaningful to them."
According to Emmons, center staff take an "asset-based approach" to the people they're studying. Rather than assuming their subjects are unhappy because of their economic status, CCBR staff recognize that "they have a lot of good things in their lives. Much of what our projects do is help people take those positives and act on them."
Marking successes
Over the past nine years, the Center for Community-Based Research has fine-tuned many health education models and enlightened thousands of individuals and organizations about cancer risk. One recent success story is Emmons' second-hand smoke study, Project KISS, which found that adult smokers who received counseling and feedback about nicotine levels in their homes were able to reduce the smoke exposure of young children living with them.
At Tympanium Corp., the stop-smoking program inspired 13 of the company's 80-odd workers to quit the habit this past summer and others to lose weight and exercise more. Company President James Liberty is pleased by his employees' enthusiasm. And, as a result of this project, Tympanium changed a 30-year-old policy and thrilled many staff in July by deciding to become a smoke-free company.
Dana-Farber's Nancy Lightman, a coordinator for Healthy Directions, points to the benefits of these kinds of activities.
"To see that little spark go off when people want to make a lifestyle change — not for me, but for themselves — is very gratifying," she says. "They encourage one another to practice healthier habits and come up with ideas for improving their working conditions. I've seen employees and managers form partnerships to create a better environment for everyone. This is tiring work," Lightman acknowledges, "but it's incredibly rewarding."
