Journal of Cancer Education
ISSN: 0885-8195 (Print) 1543-0154 (Online) Journal homepage: http://www.tandfonline.com/loi/hjce20
Cancer prevention education in United States medical schools Robert M. Chamberlain PhD , Richard F. Bakemeier MD , Richard E. Gallagher PhD , Charles E. Kupchella PhD , Joseph F. O'Donnell MD , Janet A. Parker MD , George J. Hill MD & C. Michael Brooks EdD To cite this article: Robert M. Chamberlain PhD , Richard F. Bakemeier MD , Richard E. Gallagher PhD , Charles E. Kupchella PhD , Joseph F. O'Donnell MD , Janet A. Parker MD , George J. Hill MD & C. Michael Brooks EdD (1992) Cancer prevention education in United States medical schools, Journal of Cancer Education, 7:2, 105-114 To link to this article: http://dx.doi.org/10.1080/08858199209528152
Published online: 01 Oct 2009.
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Citing articles: 15 View citing articles
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Date: 13 March 2017, At: 19:25
J. Cancer Education. Vol. 7, No. 2, pp. 105-114, 1992 Printed in the U.S.A. Pergamon Press Ltd.
0885-8195/92 $5.00 + .00 © 1992 American Association for Cancer Education
CANCER PREVENTION EDUCATION IN UNITED STATES MEDICAL SCHOOLS Cancer Education Survey II: Cancer Education in United States Medical Schools ROBERT M. CHAMBERLAIN, PhD*; RICHARD F. BAKEMEIER, MD†; RICHARD E. GALLAGHER, PhD‡; CHARLES E. KUPCHELLA, PhD§; JOSEPH F. O'DONNELL, MD||; JANET A. PARKER, MD¶; GEORGE J. HILL, MD#; C. MICHAEL BROOKS, EdD** Abstract—The Cancer Education Survey collected data from 126 of 128 US Medical Schools on the current status of cancer-related educational activities for undergraduate medical students. The study was conducted by a Supervisory Committee of the American Association for Cancer Education, with funding from the American Cancer Society. The survey obtained data concerning institutional characteristics in support of undergraduate medical student cancer education, ie, administrative structures, current cancer-related curricula, sources of financial support, and anticipated changes in these characteristics. Institutions were also queried on specific topics of cancer prevention, detection, and diagnosis that might be taught as identifiable areas of instruction for medical students. Three-fourths of the institutions had a lecture on the principles of cancer screening, and, among those, nearly three-fourths classified it as a part of a required course or rotation. Detection of common cancers is taught in virtually all institutions. The least likely cancer prevention lecture topics are related to prevention and cessation of smoking, a well-verified cancer risk. Also, no consistent pattern emerges that might indicate that association with a cancer center imparts to a medical school a greater emphasis on delivery of cancer prevention topics.
practice of prevention and by the awareness and expectations of patients. Cancer prevention activities at the clinical level have been added as an important adjunct to diagnosis and treatment.1'2 The Pap test was among the first widely accepted methods for the early The work was funded by the American Cancer Society. detection of cancer. As scientific evidence de*University of Texas M. D. Anderson Cancer Center, Dept. of Cancer Prevention and Control, Houston, TX veloped, clinical physicians added primary prevention, such as tobacco cessation and nu77030. †University of Colorado Cancer Center, Denver, CO trition counseling, to their practices.3"5 80220. Medical education has played an important ‡Wayne State University School of Medicine, Detroit, role in moving prevention into clinical pracMI 48201. §Western Kentucky University, Bowling Green, KY tice.6-7 Recent surveys indicate that almost all 42101. practicing physicians know and agree with Dartmouth Medical School, Hanover, NH 03756. ¶ Medical College of Pennsylvania, Philadelphia, PA cancer prevention guidelines that have been 19129. established by the National Cancer Institute #UMDNJ New Jersey Medical School, Newark, NJ and the American Cancer Society.8"14 How07103. **University of Alabama School of Medicine, Bir- ever, despite this positive commitment, many mingham, AL 35294. physicians are pessimistic about the effectiveReprint requests to: Robert M. Chamberlain, PhD, ness of their prevention efforts.3'5'6'8 Their University of Texas M.D. Anderson Cancer Center, 1515 responses underscore the obstacles of patient Holcombe, Houston, TX 77030. INTRODUCTION The clinical practice of medicine in the United States has been transformed in the past few decades by the physician-directed
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apathy, undereducation, and misinformation as well as the medical care economic system, which rewards time spent on diagnostic testing and therapeutic procedures.3*5'15"18 Despite the barriers to preventive practice, studies indicate that some types of physicians are more likely than others to incorporate cancer prevention into their practices.5'6-8"14-16'17-19'20 They are younger and more likely to be in family practice. Younger physicians have benefitted from changes in the medical school curriculum in the past 20 years that have emphasized some forms of cancer prevention, particularly early detection procedures. Studies also indicate that family practitioners more frequently incorporate cancer prevention in clinical practice. Coincidentally, the curricula of medical school rotations and residencies in the relatively new specialty of family practice have emphasized the application of prevention in clinical practice.4'21 This evidence points to the importance of the concerted effort among medical educators in certain quarters to promote cancer prevention. Clearly, medical education can make a difference in promoting cancer prevention in medical practice.22*23 Our analysis of the data from a survey on cancer prevention education in US medical schools highlights some problems and points the direction for improving the curricular strengths that have promoted prevention practices in some sectors. The data also show missed opportunities and instances where the cancer curriculum has marked time as a result of weakened financial support for cancer education. METHODS Survey questionnaires We formed the Supervisory Committee of the American Association for Cancer Education (AACE) to carry out a two-part survey of US medical schools in 1989-1990. The study was funded by the American Cancer Society. A similar survey was conducted about ten years earlier by the AACE with funding from the National Cancer Institute.24-25 The present
survey included: (1) an Educational Resources Questionnaire (ERQ), completed by deans and/or cancer curriculum coordinators, and (2) a Faculty and Curriculum Questionnaire (FCQ) completed by key faculty involved in cancer teaching. The ERQ was designed to obtain data concerning the institutional characteristics relevant to the support of undergraduate medical student education, including administrative structures, current cancer-related curricula, sources of financial support, and anticipated changes in these characteristics. The FCQ was designed to collect data concerning individual and departmental cancer teaching activities, including involvement of both American Cancer Society and National Cancer Institute cancer education programs and anticipated changes in these activities. The questionnaires were developed and refined in a multistage process carried out by the Supervisory Committee and Gordon S. Black, PhD, whose firm was contracted to perform data processing. For comparison purposes, the questionnaires were developed to parallel the instruments used in the earlier study, although new questions about cancer prevention were added that did not appear in the earlier questionnaire. Of the 128 US medical schools identified from the AAMC Directory of American Medical Education 198889,26 the ERQ was completed and returned by administrators or cancer coordinators from 126 institutions, and 1,035 key faculty subsequently responded to the FCQ. The data analysis plan included extensive descriptive statistics. Tests of statistical significance were not judged appropriate because the high response rate essentially profiled the universe of medical schools rather than a sample of those schools. The information analyzed in this study is self-reported and therefore subject to the limitations of this form of data. The careful selection of the designated respondents and the survey endorsement by the American Cancer Society and the National Cancer Institute lend confidence concerning the accuracy of the data, as does the thorough follow-up of incomplete responses. The FCQ provides an important source of verification
Cancer prevention education in U.S. medical schools
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Table 1. Percentage of institutions teaching cancer prevention, detection, and diagnosis by lecture or other methods Topic Cancer detection: mean of 6 sites Principles of cancer screening Risk factors/assessment Cancer risk reduction: mean of 6 items Smoking cessation methods Smoking prevention methods
Lecture offered (n = 125)
Required if offered
Other mode* (n = 125)
Required if offered
73% 72 66 52 34 32
74% 73 69 73 52 55
30% 28 30 27 30 30
47% 51 42 34 21 26
•Other: Includes computer-assisted instructions, small group discussions, etc. Source: Question 9B in the ERQ questionnaire.
for the ERQ responses since there is a subset of identical questions in each. Cancer prevention topics Medical school respondents were queried on specific topics of cancer prevention, detection, and diagnosis that might be taught as identifiable areas of instruction for medical students. As shown in Table 1, 72% of the institutions had a lecture on the principles of cancer screening, and among this 72%, nearly three-fourths classified it as a part of a required course or rotation. In addition to, or instead of a required lecture, 28% of responding institutions taught principles of cancer screening by other means, such as computerassisted instruction or small group discussions, and half of these schools required this activity for their students. Remarkably, Table 1 shows that the least frequent topic of cancer prevention lectures is smoking prevention and cessation, although smoking poses a well-verified cancer risk. The lack of lecture frequency is not compensated by other forms of instruction, as the "Other mode" column shows. These data indicate that the low incidence of tobacco intervention by physicians in practice,4"7 then, can be logically traced to the absence of training in medical schools. Although lecture was the most common teaching method in the clinical areas, an increasing use of other teaching methods was reported. In the areas of smoking prevention and cessation, and in patient counseling, the
use of other methods was equal to use of the lecture as a teaching method. It was notable that nearly one-third of the institutions offered cancer prevention topics in a format other than lecture. These topics are amenable to skills-development learning in screening and prevention clinics and other settings. Other teaching methods shown in the "Other mode" category of Table 1 may be alternatives or additions to lecture teaching. Required attendance or participation in the educational program was highly variable. Attendance at lectures was required in over 70% of institutions using lectures, but less than 50% of institutions required attendance for other teaching modalities. In the three areas with coverage by fewer institutions (smoking prevention, smoking cessation, and patient counseling) less than 50% of the institutions require lecture attendance and less than 30% of the institutions require attendance for other types of instruction. Detection of common cancers was taught in virtually all institutions, frequently in a lecture format, which was required in 70% of the institutions offering them. Detection taught in other instructional forms was required in less than 50% of the responding institutions. Cancer detection topics Cancer detection topics prevailed as the most frequently taught and are the most usually required among the cancer prevention topics in the medical school curriculum. Table 2 shows similar percentages for the teach-
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Table 2. Percentage of institutions teaching cancer detection by lecture or other methods
Topic Breast cancer detection Colon cancer detection Cervical cancer detection Lung cancer detection Skin cancer detection
Testicular cancer detection
Lecture offered (n = 125)
Required if offered
Other mode* (n = 125)
Required if offered
78% 75 74 72 71 66
74% 75 75 74 74 71
34% 32 30 30 29 26
51% 45 53 42 50 42
73%
74%
30%
47%
Cancer detection: Mean of 6 sites above
*Other: Includes computer-assisted instructions, small group discussions, etc. Source: Question 9B in the ERQ questionnaire.
ing of cancer detection for cancers of the breast, colon, cervix, lung, skin, and testicles. All six detection sites were offered in required courses in nearly three-quarters of medical schools. About one-third of the schools reported teaching detection by other modes, often in skills labs with anatomical models to palpate solid tumors.27 Cancer risk reduction topics Topics in cancer risk reduction were less frequently taught in medical schools, as indicated in Table 1. These included six areas of risk-reduction intervention: tobacco, nutrition, occupation, familial, alcohol, and patient counseling. This six-part question on risk reduction followed a question on risk assessment. The question sequence was intended to
focus this six-part question on risk reduction interventions that might logically follow assessment. Table 3 shows that tobacco (all forms) risk reduction was a topic taught in 61% of medical schools, and among them, 72% taught this topic in required courses. Patient counseling was taught in only 34% of medical schools, and among them, 64% taught this topic in required courses. This result is consistent with the data in Table 1, showing that although tobacco risk is prominent in the curriculum, specific skills in patient counseling were rarely taught to medical students. Figure 1 shows an inconsistent pattern of association between cancer center status and cancer prevention topics in the curriculum. Despite expectations, Fig. 1 shows that institutions with NCI designated or locally funded
Table 3. Percentage of institutions teaching cancer risk reduction by lecture or other methods Lecture offered (n = 125)
Required if offered
Other mode* (n = 125)
Required if offered
Occupational risk Familial risk Alcohol risk Patient risk counselling
61% 56 54 54 50 34
72% 77 77 72 74 64
30% 26 25 23 26 31
43% 30 32 35 25 39
Cancer risk reduction: Mean of 6 topics above
52%
73%
27%
34%
Topic Tobacco risk (all forms)
Nutrition risk
*Other: Includes computer-assisted instructions, small group discussions, etc. Source: Question 9B in the ERQ questionriaire.
Cancer prevention education in U.S. medical schools
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Cancer detection
Cancer screening
Risk factors
Risk reduction
Smoking cessation
NCI Center Local Center
Smoking prevention
No Center
40
60 Percent
80
100
~~
Figure 1. Association between cancer prevention teaching topics and cancer center status.
cancer centers are not more likely than institutions with no cancer center, to include instruction on smoking prevention and cessation. Figure 1 shows the association between the cancer prevention teaching topics and cancer center status. NCI-designated comprehensive
and specialized centers are grouped together. A mean of 57% of NCI-designated cancer centers offered cancer prevention instruction, compared with a mean of 50% in institutions with locally funded centers, and a mean of 57% in institutions with no cancer center.
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lower percentage (39%) of respondents who agreed that "Cancer treatment is given too little emphasis." Table 4 shows faculty responses regarding the relative emphasis of cancer treatment compared with cancer prevention topics in the curriculum. Faculty respondents reported on cancer topics in both the basic science and the clinical curriculum. They reported that basic science courses included many aspects of cancer prevention along with cancer treatment. A Faculty involvement in cancer ranking of the teaching of these cancer topics prevention teaching The goal of the Faculty and Curriculum in Table 5 shows many faculty (27%) reported Questionnaire was to obtain responses from that their basic science teaching related to canfaculty members who played a major teaching cer treatment. Table 5 shows which faculty, by role in the cancer curriculum. The 1,035 us- departmental affiliation, are most involved in able questionnaires returned should not be teaching each topic. Faculty in physiology and construed as a scientifically selected sample of pharmacology dominated, with 57% of them faculty. They were purposely chosen on the reporting that they taught cancer treatment basis of their involvement and knowledge of topics in the basic science curriculum, followed the cancer curriculum by their dean or cancer by 46% of the faculty in radiation oncology. curriculum coordinator. The average number Table 5 ranks topics related to cancer biolof these key faculty respondents was 8.2 per ogy, cancer treatment, and cancer prevention. medical school. The cancer prevention topics are the main focus Overall, medical school faculty reported of this article, and Table 5 allows the reader that cancer prevention was an important com- to contrast these with other topics. It is notable ponent of the curriculum and should receive that a relatively high percentage of patholomore emphasis, teaching time, and resources. gists and microbiologists reported that they are A strong majority of faculty respondents teaching topics related to cancer prevention. (79%) agreed or strongly agreed with the stateFaculty consider most topics in the mediment that "Cancer prevention is given too lit- cal curriculum as "important" or "very importle emphasis in the curriculum of my medical tant." Few topics listed in Table 6 received school." This response contrasted with a many "unimportant" ratings. The faculty were asked, "Based on recent medical school graduates you have seen, and your own students, please indicate the degree of imporTable 4. Faculty assessment of curriculum emphasis tance of these cancer teaching activities for on cancer prevention and cancer treatment medical students in strengthening the skills Agree Disagree and knowledge of residents, in relation to cancer." Table 6 lists the topics, ranking them by the number of faculty who judged that the Cancer prevention is given too little emphasis topic was "very important" to making mediin the curriculum of my cal students into stronger residents. medical school 79 21 815 Table 6 rates topics in cancer prevention Cancer treatment is given according to their degree of importance to the too little emphasis in the curriculum of my medical faculty. It is noteworthy that "teaching early school 39 61 824 detection" and "teaching cancer prevention" Source: Question 14A, Faculty and Curriculum Ques- were topics judged by the faculty to contribute tionnaire. highly to a medical student's skill in making These data may corroborate the belief, held by many observers, that locally funded cancer centers often have their primary strength in clinical areas and not in cancer prevention and detection. However, no consistent pattern emerges to indicate that affiliation with a cancer center imparts to a medical school a greater concentration on instruction in topics of cancer prevention to medical students.
Cancer prevention education in U.S. medical schools
111
Table 5. Cancer topics in the basic science curriculum All faculty responding Vo
A"
Principles of cancer treatment
27
278
Cancer epidemiology
20
209
Principles of cancer prevention
16
163
Oncogenes
16
161
Tumor markers
15
157
Growth factors and cancer
14
142
Cancer genetics
14
143
Chemical carcinogenesis
14
142
Viral carcinogenesis
13
129
Mechanisms of invasion and metastasis
13
134
Tumor immunology
12
123
Biologic response modifiers and cancer
12
123
Radiation carcinogenesis
11
113
Metabolism of cancer cells
9
94
Dietary aspects of carcinogenesis
9
93
Vitamins and cancer prevention
7
71
Other topics
7
67
Membrane transport in cancer cells
5
56
Highest 2 specialties
physiology & pharm. radiation oncology pathology, family medicine pathology, family medicine microbiology, pathology microbiology, radiation oncology microbiology, pathology microbiology, pathology pathology, microbiology microbiology, pathology pathology, biochemistry microbiology, pathology microbiology, pathology pathology, microbiology pathology, microbiology pathology, family medicine biochemistry, family medicine psychiatry. family medicine microbiology, pathology
%
N
57 46 53 28 37 36 56
20 11 57 10 40 13 14 51 13 11 11 42 10 41 51 7 18 47 54 6 17 39 11 31 38 5
48 52 46 44 39 40 38 48 28 72 44 51 25 68 36 44 29 36 20 28 24 34 14 29 19 38 14 16 14
30 6 36 5 7
7 9 5 4 15
Source: Question 7A, items 1-18, Faculty and Curriculum Questionnaire.
him or her a stronger resident in the future. Impact of losing grant support Generally, topics related to cancer prevention on cancer prevention teaching Sixty-six medical schools reported losing were rated in the top category of importance. A notable exception was "teaching nutrition federal grant funds that supported cancer edand cancer," a response that may reflect a ucation. These were funds historically awarded lack of scientific consensus about the relation- to medical schools by the National Cancer Inship of nutrition and cancer risk. Therapeu- stitute for the purpose of supporting auricular tic modalities, such as chemotherapy and development, oncology faculty, and students.28 radiation oncology, also ranked lower in "very Beginning in 1948, the National Cancer Instiimportant" rating by the faculty, possibly be- tute awarded these funds on a noncompetitive cause these are topics that could yield teaching basis to increase cancer teaching and encourage faculty to pursue oncology. Between 1966 hours to prevention.
R. M. CHAMBERLAIN et al
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Table 6. Faculty ratings of the importance of cancer teaching activities to making medical students better residents Very important*
Important*
Unimportant*
532 463 401 388 386 380 357
367 412 482 444 483 476 485
21 40 29 61 54 58 55
315 294 264 256 253 239 233 212 201
514 515 555 510 546 545 423 543 545
65 92 74 126 97 117 251 156 143
High ranking topics Teaching early detection Teaching tumor biology Teaching diagnostic methods Availability of clinical electives Teaching of cancer prevention Teaching the natural history of cancer Cancer outpatient workups Lower ranking topics Teaching palliative care Teachingpatient/family counseling Cancer inpatient workups Teaching surgical oncology Teaching psychosocial oncology Teaching chemotherapy Availability of basic science electives Teaching nutrition and cancer Teaching radiation therapy Source: Q. 16, Faculty and Curriculum Questionnaire. •Number of respondents answering as indicated.
and 1983, medical schools competed for grants under the NCI R25 Program, which supported Cancer Curriculum Coordinators and consolidated curricular progress. Following severe NCI budget reductions in the R25 Grant Program, many medical schools lost the faculty designated to form the foundation for cancer teaching. However, some medical schools retained these personnel with local resources and maintained their momentum in cancer education. Faculty responding to the FCQ were asked if the loss of an R25 Cancer Education Grant resulted in a reduction in cancer prevention teaching. Among these 66 schools, faculty at 22 (33%) reported that their cancer prevention teaching had decreased, and 44 (67%) reported no reduction. A cross-tabulation with the question about identifiable cancer prevention topics in the curriculum shows generally that schools reporting a decrease in cancer prevention teaching indeed were less likely to identify specific topics in their curriculum. Table 7 shows each
identifiable cancer prevention topic reported by the 66 schools that lost NCI R25 support. When individual topics listed in Table 5 were analyzed, schools that reported decreased teaching of cancer prevention in general also showed a lower incidence of teaching specific topics related to prevention. In fact, these schools show a level similar to that of schools that never had an R25 Cancer Education Grant. DISCUSSION AND CONCLUSIONS
Medical school deans, cancer curriculum coordinators, and faculty all indicate that cancer prevention and detection are important topics in the medical school curriculum and need more emphasis, time, and resources. Cancer prevention topics uniformly ranked above cancer treatment and other related topics in questions that forced discrimination on where to place future curriculum emphasis and resources. Cancer detection topics were among those given the highest priority for improve-
Cancer prevention education in U.S. medical schools
113
Table 7. Percentage (%) of institutions providing lectures on specific cancer prevention topics as a function of previous R25 grant experience Schools losing R25 grants
Topic Cancer detection: Mean of 6 sites Principles of cancer screening Risk factor/Assessment Cancer risk reduction: Mean of 6 items Smoking prevention methods Smoking cessation methods Mean percentage
No reduced teaching (n = 44)
Reduced teaching (n=22)
Schools never having an NCI R25 grant (n = 54)
82% 80 80 63 46 50 66.8%
-75% 68 68 45 27 27 51.6%
65% 67 54 45 24 26 46.8%
Source: Question 9B, in the FRQ questionnaire.
merit through building on an established base in the curriculum. Primary cancer prevention topics such as risk reduction, especially tobacco intervention, ranked very high, but such topics currently lack an established base in the curriculum. Training in patient counseling, required in many primary-prevention clinical interventions, was lacking in most medical schools. Grant support for cancer education has historically been an important factor in the development and maintenance of the cancer curriculum. A reduction of available federal grant support in the 1980s had a negative impact on the broad cancer curriculum and erased cancer prevention gains made at about onethird of US medical schools. Yet, on the positive side, administrators and teaching faculty in all disciplines recognize and support an increased emphasis on cancer prevention.
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ISSN: 0885-8195 (Print) 1543-0154 (Online) Journal homepage: http://www.tandfonline.com/loi/hjce20
Cancer prevention education in United States medical schools Robert M. Chamberlain PhD , Richard F. Bakemeier MD , Richard E. Gallagher PhD , Charles E. Kupchella PhD , Joseph F. O'Donnell MD , Janet A. Parker MD , George J. Hill MD & C. Michael Brooks EdD To cite this article: Robert M. Chamberlain PhD , Richard F. Bakemeier MD , Richard E. Gallagher PhD , Charles E. Kupchella PhD , Joseph F. O'Donnell MD , Janet A. Parker MD , George J. Hill MD & C. Michael Brooks EdD (1992) Cancer prevention education in United States medical schools, Journal of Cancer Education, 7:2, 105-114 To link to this article: http://dx.doi.org/10.1080/08858199209528152
Published online: 01 Oct 2009.
Submit your article to this journal
View related articles
Citing articles: 15 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hjce20 Download by: [University of Cambridge]
Date: 13 March 2017, At: 19:25
J. Cancer Education. Vol. 7, No. 2, pp. 105-114, 1992 Printed in the U.S.A. Pergamon Press Ltd.
0885-8195/92 $5.00 + .00 © 1992 American Association for Cancer Education
CANCER PREVENTION EDUCATION IN UNITED STATES MEDICAL SCHOOLS Cancer Education Survey II: Cancer Education in United States Medical Schools ROBERT M. CHAMBERLAIN, PhD*; RICHARD F. BAKEMEIER, MD†; RICHARD E. GALLAGHER, PhD‡; CHARLES E. KUPCHELLA, PhD§; JOSEPH F. O'DONNELL, MD||; JANET A. PARKER, MD¶; GEORGE J. HILL, MD#; C. MICHAEL BROOKS, EdD** Abstract—The Cancer Education Survey collected data from 126 of 128 US Medical Schools on the current status of cancer-related educational activities for undergraduate medical students. The study was conducted by a Supervisory Committee of the American Association for Cancer Education, with funding from the American Cancer Society. The survey obtained data concerning institutional characteristics in support of undergraduate medical student cancer education, ie, administrative structures, current cancer-related curricula, sources of financial support, and anticipated changes in these characteristics. Institutions were also queried on specific topics of cancer prevention, detection, and diagnosis that might be taught as identifiable areas of instruction for medical students. Three-fourths of the institutions had a lecture on the principles of cancer screening, and, among those, nearly three-fourths classified it as a part of a required course or rotation. Detection of common cancers is taught in virtually all institutions. The least likely cancer prevention lecture topics are related to prevention and cessation of smoking, a well-verified cancer risk. Also, no consistent pattern emerges that might indicate that association with a cancer center imparts to a medical school a greater emphasis on delivery of cancer prevention topics.
practice of prevention and by the awareness and expectations of patients. Cancer prevention activities at the clinical level have been added as an important adjunct to diagnosis and treatment.1'2 The Pap test was among the first widely accepted methods for the early The work was funded by the American Cancer Society. detection of cancer. As scientific evidence de*University of Texas M. D. Anderson Cancer Center, Dept. of Cancer Prevention and Control, Houston, TX veloped, clinical physicians added primary prevention, such as tobacco cessation and nu77030. †University of Colorado Cancer Center, Denver, CO trition counseling, to their practices.3"5 80220. Medical education has played an important ‡Wayne State University School of Medicine, Detroit, role in moving prevention into clinical pracMI 48201. §Western Kentucky University, Bowling Green, KY tice.6-7 Recent surveys indicate that almost all 42101. practicing physicians know and agree with Dartmouth Medical School, Hanover, NH 03756. ¶ Medical College of Pennsylvania, Philadelphia, PA cancer prevention guidelines that have been 19129. established by the National Cancer Institute #UMDNJ New Jersey Medical School, Newark, NJ and the American Cancer Society.8"14 How07103. **University of Alabama School of Medicine, Bir- ever, despite this positive commitment, many mingham, AL 35294. physicians are pessimistic about the effectiveReprint requests to: Robert M. Chamberlain, PhD, ness of their prevention efforts.3'5'6'8 Their University of Texas M.D. Anderson Cancer Center, 1515 responses underscore the obstacles of patient Holcombe, Houston, TX 77030. INTRODUCTION The clinical practice of medicine in the United States has been transformed in the past few decades by the physician-directed
105
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apathy, undereducation, and misinformation as well as the medical care economic system, which rewards time spent on diagnostic testing and therapeutic procedures.3*5'15"18 Despite the barriers to preventive practice, studies indicate that some types of physicians are more likely than others to incorporate cancer prevention into their practices.5'6-8"14-16'17-19'20 They are younger and more likely to be in family practice. Younger physicians have benefitted from changes in the medical school curriculum in the past 20 years that have emphasized some forms of cancer prevention, particularly early detection procedures. Studies also indicate that family practitioners more frequently incorporate cancer prevention in clinical practice. Coincidentally, the curricula of medical school rotations and residencies in the relatively new specialty of family practice have emphasized the application of prevention in clinical practice.4'21 This evidence points to the importance of the concerted effort among medical educators in certain quarters to promote cancer prevention. Clearly, medical education can make a difference in promoting cancer prevention in medical practice.22*23 Our analysis of the data from a survey on cancer prevention education in US medical schools highlights some problems and points the direction for improving the curricular strengths that have promoted prevention practices in some sectors. The data also show missed opportunities and instances where the cancer curriculum has marked time as a result of weakened financial support for cancer education. METHODS Survey questionnaires We formed the Supervisory Committee of the American Association for Cancer Education (AACE) to carry out a two-part survey of US medical schools in 1989-1990. The study was funded by the American Cancer Society. A similar survey was conducted about ten years earlier by the AACE with funding from the National Cancer Institute.24-25 The present
survey included: (1) an Educational Resources Questionnaire (ERQ), completed by deans and/or cancer curriculum coordinators, and (2) a Faculty and Curriculum Questionnaire (FCQ) completed by key faculty involved in cancer teaching. The ERQ was designed to obtain data concerning the institutional characteristics relevant to the support of undergraduate medical student education, including administrative structures, current cancer-related curricula, sources of financial support, and anticipated changes in these characteristics. The FCQ was designed to collect data concerning individual and departmental cancer teaching activities, including involvement of both American Cancer Society and National Cancer Institute cancer education programs and anticipated changes in these activities. The questionnaires were developed and refined in a multistage process carried out by the Supervisory Committee and Gordon S. Black, PhD, whose firm was contracted to perform data processing. For comparison purposes, the questionnaires were developed to parallel the instruments used in the earlier study, although new questions about cancer prevention were added that did not appear in the earlier questionnaire. Of the 128 US medical schools identified from the AAMC Directory of American Medical Education 198889,26 the ERQ was completed and returned by administrators or cancer coordinators from 126 institutions, and 1,035 key faculty subsequently responded to the FCQ. The data analysis plan included extensive descriptive statistics. Tests of statistical significance were not judged appropriate because the high response rate essentially profiled the universe of medical schools rather than a sample of those schools. The information analyzed in this study is self-reported and therefore subject to the limitations of this form of data. The careful selection of the designated respondents and the survey endorsement by the American Cancer Society and the National Cancer Institute lend confidence concerning the accuracy of the data, as does the thorough follow-up of incomplete responses. The FCQ provides an important source of verification
Cancer prevention education in U.S. medical schools
107
Table 1. Percentage of institutions teaching cancer prevention, detection, and diagnosis by lecture or other methods Topic Cancer detection: mean of 6 sites Principles of cancer screening Risk factors/assessment Cancer risk reduction: mean of 6 items Smoking cessation methods Smoking prevention methods
Lecture offered (n = 125)
Required if offered
Other mode* (n = 125)
Required if offered
73% 72 66 52 34 32
74% 73 69 73 52 55
30% 28 30 27 30 30
47% 51 42 34 21 26
•Other: Includes computer-assisted instructions, small group discussions, etc. Source: Question 9B in the ERQ questionnaire.
for the ERQ responses since there is a subset of identical questions in each. Cancer prevention topics Medical school respondents were queried on specific topics of cancer prevention, detection, and diagnosis that might be taught as identifiable areas of instruction for medical students. As shown in Table 1, 72% of the institutions had a lecture on the principles of cancer screening, and among this 72%, nearly three-fourths classified it as a part of a required course or rotation. In addition to, or instead of a required lecture, 28% of responding institutions taught principles of cancer screening by other means, such as computerassisted instruction or small group discussions, and half of these schools required this activity for their students. Remarkably, Table 1 shows that the least frequent topic of cancer prevention lectures is smoking prevention and cessation, although smoking poses a well-verified cancer risk. The lack of lecture frequency is not compensated by other forms of instruction, as the "Other mode" column shows. These data indicate that the low incidence of tobacco intervention by physicians in practice,4"7 then, can be logically traced to the absence of training in medical schools. Although lecture was the most common teaching method in the clinical areas, an increasing use of other teaching methods was reported. In the areas of smoking prevention and cessation, and in patient counseling, the
use of other methods was equal to use of the lecture as a teaching method. It was notable that nearly one-third of the institutions offered cancer prevention topics in a format other than lecture. These topics are amenable to skills-development learning in screening and prevention clinics and other settings. Other teaching methods shown in the "Other mode" category of Table 1 may be alternatives or additions to lecture teaching. Required attendance or participation in the educational program was highly variable. Attendance at lectures was required in over 70% of institutions using lectures, but less than 50% of institutions required attendance for other teaching modalities. In the three areas with coverage by fewer institutions (smoking prevention, smoking cessation, and patient counseling) less than 50% of the institutions require lecture attendance and less than 30% of the institutions require attendance for other types of instruction. Detection of common cancers was taught in virtually all institutions, frequently in a lecture format, which was required in 70% of the institutions offering them. Detection taught in other instructional forms was required in less than 50% of the responding institutions. Cancer detection topics Cancer detection topics prevailed as the most frequently taught and are the most usually required among the cancer prevention topics in the medical school curriculum. Table 2 shows similar percentages for the teach-
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Table 2. Percentage of institutions teaching cancer detection by lecture or other methods
Topic Breast cancer detection Colon cancer detection Cervical cancer detection Lung cancer detection Skin cancer detection
Testicular cancer detection
Lecture offered (n = 125)
Required if offered
Other mode* (n = 125)
Required if offered
78% 75 74 72 71 66
74% 75 75 74 74 71
34% 32 30 30 29 26
51% 45 53 42 50 42
73%
74%
30%
47%
Cancer detection: Mean of 6 sites above
*Other: Includes computer-assisted instructions, small group discussions, etc. Source: Question 9B in the ERQ questionnaire.
ing of cancer detection for cancers of the breast, colon, cervix, lung, skin, and testicles. All six detection sites were offered in required courses in nearly three-quarters of medical schools. About one-third of the schools reported teaching detection by other modes, often in skills labs with anatomical models to palpate solid tumors.27 Cancer risk reduction topics Topics in cancer risk reduction were less frequently taught in medical schools, as indicated in Table 1. These included six areas of risk-reduction intervention: tobacco, nutrition, occupation, familial, alcohol, and patient counseling. This six-part question on risk reduction followed a question on risk assessment. The question sequence was intended to
focus this six-part question on risk reduction interventions that might logically follow assessment. Table 3 shows that tobacco (all forms) risk reduction was a topic taught in 61% of medical schools, and among them, 72% taught this topic in required courses. Patient counseling was taught in only 34% of medical schools, and among them, 64% taught this topic in required courses. This result is consistent with the data in Table 1, showing that although tobacco risk is prominent in the curriculum, specific skills in patient counseling were rarely taught to medical students. Figure 1 shows an inconsistent pattern of association between cancer center status and cancer prevention topics in the curriculum. Despite expectations, Fig. 1 shows that institutions with NCI designated or locally funded
Table 3. Percentage of institutions teaching cancer risk reduction by lecture or other methods Lecture offered (n = 125)
Required if offered
Other mode* (n = 125)
Required if offered
Occupational risk Familial risk Alcohol risk Patient risk counselling
61% 56 54 54 50 34
72% 77 77 72 74 64
30% 26 25 23 26 31
43% 30 32 35 25 39
Cancer risk reduction: Mean of 6 topics above
52%
73%
27%
34%
Topic Tobacco risk (all forms)
Nutrition risk
*Other: Includes computer-assisted instructions, small group discussions, etc. Source: Question 9B in the ERQ questionriaire.
Cancer prevention education in U.S. medical schools
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Cancer detection
Cancer screening
Risk factors
Risk reduction
Smoking cessation
NCI Center Local Center
Smoking prevention
No Center
40
60 Percent
80
100
~~
Figure 1. Association between cancer prevention teaching topics and cancer center status.
cancer centers are not more likely than institutions with no cancer center, to include instruction on smoking prevention and cessation. Figure 1 shows the association between the cancer prevention teaching topics and cancer center status. NCI-designated comprehensive
and specialized centers are grouped together. A mean of 57% of NCI-designated cancer centers offered cancer prevention instruction, compared with a mean of 50% in institutions with locally funded centers, and a mean of 57% in institutions with no cancer center.
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lower percentage (39%) of respondents who agreed that "Cancer treatment is given too little emphasis." Table 4 shows faculty responses regarding the relative emphasis of cancer treatment compared with cancer prevention topics in the curriculum. Faculty respondents reported on cancer topics in both the basic science and the clinical curriculum. They reported that basic science courses included many aspects of cancer prevention along with cancer treatment. A Faculty involvement in cancer ranking of the teaching of these cancer topics prevention teaching The goal of the Faculty and Curriculum in Table 5 shows many faculty (27%) reported Questionnaire was to obtain responses from that their basic science teaching related to canfaculty members who played a major teaching cer treatment. Table 5 shows which faculty, by role in the cancer curriculum. The 1,035 us- departmental affiliation, are most involved in able questionnaires returned should not be teaching each topic. Faculty in physiology and construed as a scientifically selected sample of pharmacology dominated, with 57% of them faculty. They were purposely chosen on the reporting that they taught cancer treatment basis of their involvement and knowledge of topics in the basic science curriculum, followed the cancer curriculum by their dean or cancer by 46% of the faculty in radiation oncology. curriculum coordinator. The average number Table 5 ranks topics related to cancer biolof these key faculty respondents was 8.2 per ogy, cancer treatment, and cancer prevention. medical school. The cancer prevention topics are the main focus Overall, medical school faculty reported of this article, and Table 5 allows the reader that cancer prevention was an important com- to contrast these with other topics. It is notable ponent of the curriculum and should receive that a relatively high percentage of patholomore emphasis, teaching time, and resources. gists and microbiologists reported that they are A strong majority of faculty respondents teaching topics related to cancer prevention. (79%) agreed or strongly agreed with the stateFaculty consider most topics in the mediment that "Cancer prevention is given too lit- cal curriculum as "important" or "very importle emphasis in the curriculum of my medical tant." Few topics listed in Table 6 received school." This response contrasted with a many "unimportant" ratings. The faculty were asked, "Based on recent medical school graduates you have seen, and your own students, please indicate the degree of imporTable 4. Faculty assessment of curriculum emphasis tance of these cancer teaching activities for on cancer prevention and cancer treatment medical students in strengthening the skills Agree Disagree and knowledge of residents, in relation to cancer." Table 6 lists the topics, ranking them by the number of faculty who judged that the Cancer prevention is given too little emphasis topic was "very important" to making mediin the curriculum of my cal students into stronger residents. medical school 79 21 815 Table 6 rates topics in cancer prevention Cancer treatment is given according to their degree of importance to the too little emphasis in the curriculum of my medical faculty. It is noteworthy that "teaching early school 39 61 824 detection" and "teaching cancer prevention" Source: Question 14A, Faculty and Curriculum Ques- were topics judged by the faculty to contribute tionnaire. highly to a medical student's skill in making These data may corroborate the belief, held by many observers, that locally funded cancer centers often have their primary strength in clinical areas and not in cancer prevention and detection. However, no consistent pattern emerges to indicate that affiliation with a cancer center imparts to a medical school a greater concentration on instruction in topics of cancer prevention to medical students.
Cancer prevention education in U.S. medical schools
111
Table 5. Cancer topics in the basic science curriculum All faculty responding Vo
A"
Principles of cancer treatment
27
278
Cancer epidemiology
20
209
Principles of cancer prevention
16
163
Oncogenes
16
161
Tumor markers
15
157
Growth factors and cancer
14
142
Cancer genetics
14
143
Chemical carcinogenesis
14
142
Viral carcinogenesis
13
129
Mechanisms of invasion and metastasis
13
134
Tumor immunology
12
123
Biologic response modifiers and cancer
12
123
Radiation carcinogenesis
11
113
Metabolism of cancer cells
9
94
Dietary aspects of carcinogenesis
9
93
Vitamins and cancer prevention
7
71
Other topics
7
67
Membrane transport in cancer cells
5
56
Highest 2 specialties
physiology & pharm. radiation oncology pathology, family medicine pathology, family medicine microbiology, pathology microbiology, radiation oncology microbiology, pathology microbiology, pathology pathology, microbiology microbiology, pathology pathology, biochemistry microbiology, pathology microbiology, pathology pathology, microbiology pathology, microbiology pathology, family medicine biochemistry, family medicine psychiatry. family medicine microbiology, pathology
%
N
57 46 53 28 37 36 56
20 11 57 10 40 13 14 51 13 11 11 42 10 41 51 7 18 47 54 6 17 39 11 31 38 5
48 52 46 44 39 40 38 48 28 72 44 51 25 68 36 44 29 36 20 28 24 34 14 29 19 38 14 16 14
30 6 36 5 7
7 9 5 4 15
Source: Question 7A, items 1-18, Faculty and Curriculum Questionnaire.
him or her a stronger resident in the future. Impact of losing grant support Generally, topics related to cancer prevention on cancer prevention teaching Sixty-six medical schools reported losing were rated in the top category of importance. A notable exception was "teaching nutrition federal grant funds that supported cancer edand cancer," a response that may reflect a ucation. These were funds historically awarded lack of scientific consensus about the relation- to medical schools by the National Cancer Inship of nutrition and cancer risk. Therapeu- stitute for the purpose of supporting auricular tic modalities, such as chemotherapy and development, oncology faculty, and students.28 radiation oncology, also ranked lower in "very Beginning in 1948, the National Cancer Instiimportant" rating by the faculty, possibly be- tute awarded these funds on a noncompetitive cause these are topics that could yield teaching basis to increase cancer teaching and encourage faculty to pursue oncology. Between 1966 hours to prevention.
R. M. CHAMBERLAIN et al
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Table 6. Faculty ratings of the importance of cancer teaching activities to making medical students better residents Very important*
Important*
Unimportant*
532 463 401 388 386 380 357
367 412 482 444 483 476 485
21 40 29 61 54 58 55
315 294 264 256 253 239 233 212 201
514 515 555 510 546 545 423 543 545
65 92 74 126 97 117 251 156 143
High ranking topics Teaching early detection Teaching tumor biology Teaching diagnostic methods Availability of clinical electives Teaching of cancer prevention Teaching the natural history of cancer Cancer outpatient workups Lower ranking topics Teaching palliative care Teachingpatient/family counseling Cancer inpatient workups Teaching surgical oncology Teaching psychosocial oncology Teaching chemotherapy Availability of basic science electives Teaching nutrition and cancer Teaching radiation therapy Source: Q. 16, Faculty and Curriculum Questionnaire. •Number of respondents answering as indicated.
and 1983, medical schools competed for grants under the NCI R25 Program, which supported Cancer Curriculum Coordinators and consolidated curricular progress. Following severe NCI budget reductions in the R25 Grant Program, many medical schools lost the faculty designated to form the foundation for cancer teaching. However, some medical schools retained these personnel with local resources and maintained their momentum in cancer education. Faculty responding to the FCQ were asked if the loss of an R25 Cancer Education Grant resulted in a reduction in cancer prevention teaching. Among these 66 schools, faculty at 22 (33%) reported that their cancer prevention teaching had decreased, and 44 (67%) reported no reduction. A cross-tabulation with the question about identifiable cancer prevention topics in the curriculum shows generally that schools reporting a decrease in cancer prevention teaching indeed were less likely to identify specific topics in their curriculum. Table 7 shows each
identifiable cancer prevention topic reported by the 66 schools that lost NCI R25 support. When individual topics listed in Table 5 were analyzed, schools that reported decreased teaching of cancer prevention in general also showed a lower incidence of teaching specific topics related to prevention. In fact, these schools show a level similar to that of schools that never had an R25 Cancer Education Grant. DISCUSSION AND CONCLUSIONS
Medical school deans, cancer curriculum coordinators, and faculty all indicate that cancer prevention and detection are important topics in the medical school curriculum and need more emphasis, time, and resources. Cancer prevention topics uniformly ranked above cancer treatment and other related topics in questions that forced discrimination on where to place future curriculum emphasis and resources. Cancer detection topics were among those given the highest priority for improve-
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Table 7. Percentage (%) of institutions providing lectures on specific cancer prevention topics as a function of previous R25 grant experience Schools losing R25 grants
Topic Cancer detection: Mean of 6 sites Principles of cancer screening Risk factor/Assessment Cancer risk reduction: Mean of 6 items Smoking prevention methods Smoking cessation methods Mean percentage
No reduced teaching (n = 44)
Reduced teaching (n=22)
Schools never having an NCI R25 grant (n = 54)
82% 80 80 63 46 50 66.8%
-75% 68 68 45 27 27 51.6%
65% 67 54 45 24 26 46.8%
Source: Question 9B, in the FRQ questionnaire.
merit through building on an established base in the curriculum. Primary cancer prevention topics such as risk reduction, especially tobacco intervention, ranked very high, but such topics currently lack an established base in the curriculum. Training in patient counseling, required in many primary-prevention clinical interventions, was lacking in most medical schools. Grant support for cancer education has historically been an important factor in the development and maintenance of the cancer curriculum. A reduction of available federal grant support in the 1980s had a negative impact on the broad cancer curriculum and erased cancer prevention gains made at about onethird of US medical schools. Yet, on the positive side, administrators and teaching faculty in all disciplines recognize and support an increased emphasis on cancer prevention.
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