Texas Cancer Plan

Goal 1: Reduce smoking and e-cigarette use to decrease the number of new cases and deaths from smoking associated cancers.

The use of tobacco products is the leading preventable cause of cancer. It is associated with the development of lung cancer and at least 12 other types of cancer, including larynx (voice box), mouth, esophagus, throat, urinary bladder, kidney and renal pelvis, liver, stomach, pancreas, colon and rectum, cervix, and blood (acute myeloid leukemia). Tobacco products cause almost 20% of all cancer cases and 30% of all cancer-related deaths.¹

More than 2.6 million (11.8%) Texas adults smoke cigarettes. Smoking kills 28,000 Texans each year. Smoking related healthcare costs the state more than $10 billion and results in $24.4 billion in lost productivity.²

Researchers attribute 80-90% of all lung cancer deaths to smoking. It causes approximately 27.1% of all cancer deaths in Texas. The age adjusted incidence rates for tobacco-associated cancers in Texas men are 1.7 times higher than for Texas women. Cancers of the lung, bronchus, and trachea are the leading cause of cancer death for both men and women.³

Electronic cigarettes (e-cigarettes), including electronic nicotine delivery systems, vapes, vape pens, e-cigars, and hookah pens, are not safe alternatives to cigarettes. E-cigarettes produce an aerosol that contains nicotine and toxins known to cause cancer. Nicotine exposure also harms brain development, which continues into the mid-20s.⁴ Other toxic chemicals in e-cigarettes include some of the same products found in tobacco products, such as benzene, lead, and nickel. E-cigarettes also contain diacetyl, which scientists have linked to several toxic effects in lung and airway cells.

Nearly 48,000 Texas children under the age of 18 try tobacco products each year. Approximately 3.7% (63,700) of Texas high school students smoke tobacco products. This is higher than the overall United States average (1.9%) for high school students. Similarly, the percentage of Texas high school students who use e-cigarettes (18.7%) is greater compared to the United States average (10%)² and is associated with the use of other tobacco products.

Goal 2: Increase the adoption of healthy behaviors to reduce new cancer cases and deaths associated with alcohol, nutrition, obesity, and lack of physical activity.

The consumption of alcohol is linked to more than 200 diseases and increases the risk of six different types of cancer including certain types of head and neck cancer, throat, breast, colorectal, liver, and stomach cancers.¹ Researchers associate long-term alcohol consumption and binge-drinking with the greatest health risks. For those individuals who choose to drink alcohol, researchers recommend limiting intake to one drink or less a day for women and two drinks or less a day for men.²

In 2021, epidemiologists classified 70% of Texas adults as overweight or obese, and in 2022 Texas had the 18th highest rate of adult obesity in the United States. Excessive weight may increase an individual’s insulin and hormones levels and cause chronic inflammation, which can lead to cancer. Researchers have linked overweight/obesity to seven different cancers - post-menopausal breast, colorectal, kidney (renal cell), endometrial, pancreatic, liver, and throat cancers. Endometrial cancers have the highest proportion of diagnoses (60%) attributable to an individual being overweight or obese.³

Maintaining a healthy weight involves following a nutritious diet and participating in regular physical activity starting at an early age and continuing throughout life.⁴ Social, economic, and cultural factors, as well as policy, influence diet and physical activity behaviors. Individuals make choices on what to eat and how to exercise, but the communities and environments where people live facilitate or impede these choices.⁵ Experts recommend that adults should move more and sit less throughout the day. For substantial health benefits, adults should do at least 150 minutes to 300 minutes a week of moderate activity, or less if it involves vigorous physical activity.⁶ The Department of Health and Human Services recommends 60 minutes or more of daily moderate-to-vigorous physical activity for children aged 6-17. Unfortunately, almost 80% of Texas children do not meet this recommendation.⁷ As a state, we can address this issue by encouraging healthy physical activity including at least 30 minutes of daily recess for children in kindergarten through fifth grade, and structured physical education classes using evidence-based programs.⁸

Texas can also address the cancer risk associated with physical inactivity and obesity by building and restructuring communities in ways that make it safer and easier for residents to be physically active and choose healthy food options where they live, work, learn and play. Specific strategies to address risk factors related to physical inactivity and obesity include multi-component interventions for increasing healthy options for food and beverages in schools, reducing screen time among children, expanding opportunities for physical activity during the school day or school physical education improvements, building an environment that incorporates transportation system and land use/environmental design, and community-based digital health interventions to increase healthy eating and physical activity.⁹

Goal 3: Increase skin protection behaviors to reduce new cases and deaths from melanoma.

Ultraviolet (UV) radiation is a type of light emitted by the sun. UV radiation is also emitted by artificial sources, including tanning beds. Exposure to UV radiation can lead to the development of basal cell carcinoma, squamous cell carcinoma, and melanoma, the most aggressive form of skin cancer. Repeated and unprotected skin exposure to UV rays can damage the DNA inside skin cells. These genetic changes are responsible for most basal cell and squamous cell skin cancers.¹

A common misconception is that people cannot get sunburned on cloudy days. However, up to 80% of the sun’s harmful UV rays can penetrate clouds. Individuals should practice sun-safe habits anytime they are outside to limit exposure to harmful UV radiation.²

Individuals can prevent many cases of skin cancer by increasing UV-protective behaviors, including appropriate sunscreen use and limiting time in the sun especially during peak sun hours (10:00 a.m. to 4:00 p.m.). Multicomponent community-wide interventions in outdoor, recreational, occupational, child-care center, and primary and middle school-based settings should use combinations of individual-directed strategies, mass media campaigns, and environmental and policy changes across multiple settings within a defined geographic area.³

Goal 4: Reduce the risk of cancers associated with environmental carcinogens.

According to the National Cancer Plan, it is possible to prevent more than half of all cancers by applying existing knowledge, which includes reducing toxins and exposure to environmental carcinogens.¹ Environmental carcinogens are substances present in our environment that can lead to cancer. These include arsenic, asbestos, radon, lead, radiation, and other chemical pollutants.² People take in these environmental pollutants through the air we breathe and the food and water we eat and drink, making them difficult to avoid.

Radon is the number one cause of lung cancer among non-smokers and is the second leading cause of lung cancer overall. It is responsible for about 21,000 lung cancer deaths every year.³ Radon is a radioactive colorless, odorless, and tasteless soil gas that comes from the breakdown of uranium in soil, rock, and water.⁴ Radon exposure occurs when the gas migrates through permeable rocks and soils, eventually seeping into buildings and becoming trapped. Although many Texas homes are safe from radon, researchers have identified several areas of Texas where local geology likely contributes to the potential for elevated levels of indoor radon.

A growing body of evidence links other toxic environmental exposures to certain cancers. Researchers are still determining the full extent of environmental influences on cancer, including the types and magnitude of environmental contaminants, and the effects of lifetime human exposure to combinations of chemicals or other agents. Current challenges, such as inadequate exposure measurement tools and lack of policy related to the regulation of hazardous exposures, hinders research and cancer prevention efforts.

Certain population groups, such as workers who may be exposed to carcinogens on the job, are more likely to have cancers caused by involuntary exposures to environmental carcinogens. Outside of the workplace, some steps Texans can take to limit their exposure to known carcinogens include quitting smoking and testing for home radon levels.⁵

Goal 5: Eliminate cervical cancer and other cancers associated with the human papillomavirus (HPV) in Texas by increasing HPV vaccinations.

Scientists have determined that infections caused by certain pathogens, including the human papillomavirus (HPV), hepatitis B (HBV), hepatitis C (HCV), and Helicobacter pylori, can cause cancer. Globally, these four pathogens account for more than 90% of cancer cases.¹

HPV is a group of more than 100 related viruses. Researchers consider some types of HPV “high-risk.” High-risk HPV infections change the way a cell behaves, weaken the immune system, and cause chronic inflammation, all of which can lead to cancer.

HPV-associated cancer is a specific cellular type of cancer found in a part of the body susceptible to HPV infection. These parts of the body include the cervix, vagina, vulva, penis, anus, rectum, and oropharynx (back of the throat). Each year in the United States, HPV causes about 37,800 of the 47,984 (79%) cancer cases diagnosed in parts of the body where HPV infections occur: 26,280 among women, and 21,704 among men.² In Texas, the average age-adjusted incidence rate for all HPV-associated cancers is 12.4 per 100,000 population.³

The U.S. Centers for Disease Control and Prevention (CDC) estimates that HPV infection is responsible for 90% of cervical and anal cancers, 70% of oropharyngeal cancers, vaginal, and vulvar cancers, and 60% of penile cancers. The most common HPV-associated cancers are cervical cancer (women) and oropharyngeal (men). Men’s rate of HPV-associated oropharyngeal cancer is five-times higher than for women.

The most recently approved 9-valent HPV vaccine, protects against nine of the 13 distinct types of cancer-causing HPV strains. The HPV vaccine is safe and effective, but patients must get all the shots in the series for full protection. According to the CDC, scientific research shows the benefits of HPV vaccination far outweigh the potential risks.⁴

HPV routine vaccine can start as early as age 9 and should begin by age 11 or 12 to maximize the number of people protected through on-time vaccination.⁵ Healthcare policy experts recommend two doses of HPV vaccine when given before the child turns 15, and three doses for teens and young adults (up to age 26) who start the series after they are 15. Immunocompromised people should receive three doses of the HPV vaccine, even if they start the series before they are 15.

The rate of 13-17-year-olds (male and female) in Texas with up-to-date HPV vaccination coverage (58.5%) was lower than the overall rate in the United States (62.6%) in 2022.⁶

Goal 6: Increase Hepatitis B (Hep B) vaccination and completion rates to reduce the risk of liver cancer.

Hepatitis B is a serious disease caused by the hepatitis B virus (HBV) that attacks the liver.¹ Chronic HBV causes liver inflammation and damage that can lead to liver cancer and other malignancies if left untreated. Hepatocellular carcinoma (HCC) is the most common type of liver cancer in adults and typically develops in people with liver disease caused by HBV or cirrhosis.² Effective interventions to prevent live cancer include getting the hepatitis B vaccine, avoiding risk factors, increasing protective factors, and getting treatment for chronic hepatitis B infection.

The best way to prevent hepatitis B is by getting vaccinated. According to the CDC, the hepatitis B vaccine is safe and effective, but patients must get all the shots in the series for full protection. The U.S. Centers for Disease Control and Prevention recommends that all children and adults up to age 59, as well as older adults at risk for HBV, receive the HBV vaccine to reduce their risk of chronic hepatitis B and liver cancer.³ Adults who are 60 years or older with known risk factors for hepatitis B may also receive hepatitis B vaccine.¹

Goal 7: Increase screening and early detection to increase the number of cancers diagnosed at an early stage and reduce deaths from breast cancer.

Breast cancer is the leading cancer diagnosis among Texas women and is the second leading cause of death from cancer for women in Texas. The American Cancer Society estimates that there will be 23,290 new cases of breast cancer diagnosed in Texas in 2024.¹

In Texas, Black women receive more later stage breast cancer diagnoses than White women and are 40% more likely to die of breast cancer than White women.² The higher mortality rate for Black women diagnosed with breast cancer in Texas aligns with other health inequities, including disparities in access to high quality health care.³

Breast cancer screenings are responsible for a substantial reduction in cancer mortality. The United States Preventive Services Task Force (USPSTF) updated their breast cancer screening guidelines in 2024. The USPSTF recommends that women with average risk of breast cancer receive mammograms, the most common screening test for breast cancer, every other year starting at age 40 and continuing through age 74.⁴

Women with inherited changes in the BRCA1 and BRCA2 genes or in certain other genes have a higher risk of breast cancer and should talk with their doctor regarding the right time to begin mammograms and other diagnostic measures. Clinicians may use magnetic resonance imaging (MRI) to screen women who have an elevated risk of breast cancer. The United States Food and Drug Administration approved digital breast tomosynthesis (DBT) in 2018. Three out of four facilities now use DBT. Other screening tools include clinical and self-breast exams, thermography, and tissue sampling.⁵

The FDA recently required a breast density notification in mammography reports, stating in lay language if a patient's breast density is dense or not dense.⁶ Women with dense breast tissue are at higher risk of developing breast cancer than those with less dense tissue. Healthcare providers may develop different screening strategies, such as earlier and more frequent screenings, and breast ultrasound or MRI screening, for women with dense breast tissue, which will lead to improved detection rates. This new rule will enhance Texas women’s access to appropriate diagnosis and treatment.

Goal 8: Increase screening and early detection to reduce the number of new cases and deaths from cervical cancer.

According to the Centers for Disease Control and Prevention (CDC), routine cervical cancer screening is an effective way to reduce the cancer burden by finding cases earlier when the cancer is more responsive to treatment.¹ However, in 2024 almost 30% of eligible people with a cervix in the United States cannot or do not receive cervical cancer screening at the recommended intervals.

Cervical cancer screening is one of three age-based cancer screenings currently recommended for women. The Papanicolaou (Pap) test also detects precancerous cellular changes to cervical tissue, which doctors can treat before it develops into cancer.² The CDC recommends that women should begin Pap tests at age 21. If the Pap test result is normal, women may wait three years for the next Pap test.

Co-testing is another option for cervical cancer screening. This involves performing the human papillomavirus (HPV) test along with the Pap test. If a woman receives normal results for both tests, she can wait five years until her next screening test.² Health officials encourage shared decision making with a doctor to discuss Pap screening frequency and HPV co-testing.

The United States Food and Drug Administration recently expanded the approval of two tests that allow self-collection in a health care setting to detect cancer-causing types of HPV in the cervix. Cervical cancer screening by vaginal specimen self-collection for HPV testing expands access, making it easier to screen all people to prevent cervical cancer.

Although cervical cancer is the most common HPV-associated cancer among women, with rates in Texas higher than the United States average,² it is not the only cancer associated with HPV. In the United States doctors diagnosed approximately 46,711 new cases of cancer (25,689 cases in women and 21,022 cases in men) in parts of the body where HPV infection occurs. HPV causes about 37,000 of these cancers.3

In Texas, the average age-adjusted incidence rate for all HPV-associated cancers is 12.4 cases per 100,000 population. Approximately 3,650 new cases of HPV-associated cancers occur in Texas each year (2,120 in women and 1,530 in men). As of 2024, Texas women 40-49 years of age have the highest cervical cancer incidence rates (17.5 cases per 100,000 women). From 2017-2021, Hispanic women had the highest cervical cancer incidence rate in Texas (12.0 cases per 100,000) compared to other race/ethnic groups, and non-Hispanic Black women had the highest mortality rate (3.5 deaths per 100,000). In 2020, 75% of Texas women ages 21-65 self-reported having a Pap test within the past three years. In 2022, 58.5% of Texans ages 13-17 were considered up to date with the HPV vaccine series.⁴ In addition to HPV-related carcinomas of the cervix, HPV-related cancers include HPV-related squamous cell carcinomas of the vagina, vulva, penis, anus, rectum, and oropharynx (back of the throat). Many of these cancers are preventable with currently available vaccines.

Screening is a part of the puzzle on the way to prevention. While expanding access to HPV screening is vital for reducing the number cervical cancer cases, stakeholders should also address low levels of follow-up care.⁵ Underserved women at high risk of cervical cancer because of race or age likely have higher risks of noncompliance with screening guidelines, low quality/high deductible insurance, and lack of follow up from subsidized government or nonprofit clinics.^{6, 7, 8} Follow-up care in considering associations with racial and ethnic disparities in care and social determinants of health is not well researched and should be a priority, as an important area for future research.

Goal 9: Increase screening and early detection to reduce the number of new cases and deaths from colorectal cancer.

Colorectal cancer (CRC) incidence and mortality rates in the United States have dropped by over 30% among adults 50 and older in the last 15 years, substantially due to introduction and widespread use of colorectal screenings.¹ The United States Preventive Services Task Force, the American Cancer Society, and the United States Centers for Disease Control and Prevention (CDC) recommend starting CRC screening at the age of 45.²

Doctors use several screening tests to find polyps or colorectal cancer. Differences exist in the risks and benefits for the various CRC screening methods. A positive or abnormal result on screening tests such as a stool test, flexible sigmoidoscopy, or CT colonography, requires a colonoscopy test to complete the CRC screening process.²

The CDC provides information for those who may need to start CRC screening earlier due to variables that increase the individual’s CRC risk, such as family history, inflammatory bowel disease (Crohn’s or ulcerative colitis) or a genetic syndrome such as familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal cancer (Lynch syndrome). The individual and their healthcare provider should discuss the appropriate age to begin CRC screening and the right screening method.

CRC screening is effective in reducing CRC incidence and death, but it continues to be underutilized, particularly in under-resourced communities and populations.³ Texas remains behind the national average in CRC screening (61% vs. 67%,) ^{4, 5} despite numerous actions taken to reduce barriers, including new laws to remove out-of-pocket costs for patients needing a colonoscopy following a positive non-invasive screening test. Lead-time messaging - delivery of accurate, relevant, and actionable information regarding risk and risk-based screening options prior to the recommended starting age for average and high-risk individuals - is another tool used to reduce barriers and ensure on-time screening.⁶

Researchers have documented an increased CRC incidence among individuals younger than 50 years old, also known as early-onset CRC. Individuals born around 1990 have double and quadruple the risk of colon and rectal cancers.

Goal 10: Increase screening and early detection among Texans at high risk for lung cancer to increase the number of lung cancers diagnosed at an early stage and reduce lung cancer deaths.

Lung cancer is the nation's leading cancer killer, accounting for approximately 22% of all cancer deaths. Lung cancer screening is essential to saving lives. According to the American Lung Association’s “State of Lung Cancer” 2023 report, doctors diagnose only 26.6% of lung cancer cases at an early stage when the five-year survival rate is much higher (63%). Unfortunately, doctors diagnose 44% of lung cancer cases at a late stage when the survival rate is only 8%.¹

The National Cancer Institute-sponsored National Lung Screening Trial showed that low-dose computed tomography (LDCT) scans can decrease the risk of dying from lung cancer in people with a history of heavy smoking. The National Lung Screening Trial used chest x-rays or LDCT scans to check for signs of lung cancer. The trial results revealed that screening with LDCT once a year for three years was better than chest x-rays at finding early-stage lung cancer and decreased the risk of dying from lung cancer in current and former heavy smokers.²

The United States Preventive Services Task Force recommends annual LDCT screening for lung cancer in adults aged 50 to 80 years who have a 20 pack/year smoking history and currently smoke or quit within the past 15 years.³ This recommendation covers a larger age range eligible to receive screening and includes more current and former smokers than previously recommended. It also dramatically increases the number of women and Black Americans who researchers consider as having an elevated risk for developing lung cancer.

The American Lung Association also recommends LDCT screening and reports that researchers have determined that other screening tests, including chest X-rays and sputum cytology, are not effective and not recommended for screening.⁴ Those eligible for lung cancer screening should talk with their doctor and engage in shared decision making, which includes a discussion of potential benefits, harms and unknowns related to lung cancer screening.

For screening to be most effective in reducing the overall lung cancer mortality rate, healthcare providers should screen more of the high-risk population. Nationally, only 16% of those with an elevated risk received screening in 2022. In Texas, doctors screened only 10% of high-risk individuals, ranking 46th among all states, placing it in the bottom tier.⁵ Low screening rates may be due to a lack of access or reduced awareness of screening recommendations among patients and providers. It is possible that actual screening rates may be somewhat higher than reported in states like Texas with large, regional managed care providers because policy makers eliminated the requirement for screening facilities to participate in the lung cancer screening registry in order to receive reimbursement from Medicare for screening scans.

National guidelines emphasize the importance of tobacco cessation and treatment for current smokers, as well as actively encouraging former smokers to continue not smoking. If a healthcare provider recommends lung cancer screening, the patient should also receive tobacco treatment counseling.

Goal 11: Increase screening and early detection among Texans at an elevated risk for prostate cancer to increase the number of prostate cancers diagnosed at an early stage and reduce deaths from prostate cancer.

The incidence of prostate cancer continues to increase, with an estimated 299,010 projected cases in the United States in 2024.¹ Among Texas men, health care providers diagnosed nearly 17,000 cases of prostate cancer in 2022.² Prostate cancer affects Black men disproportionally; they have the highest prostate cancer incidence in the United States (183.4 new cases per 100,000)^3,4,5 and, compared with White men, are more likely to develop prostate cancer at almost every stage of the disease continuum and in every age group.^3,6 Black men are more likely to present with prostate cancer at a younger age and are more than two times more likely to die from prostate cancer compared to White men.^7,8

Prostate cancer screening tests include the digital rectal exam, the prostate-specific antigen PSA test, and the prostate cancer gene 3 (PCA3) RNA test. A health care provider may use the PCA3 test if the patient has a high PSA level following a negative biopsy of the prostate.⁹ A high PSA level does not necessarily indicate prostate cancer. Many factors, such as advanced age, an enlarged prostate, prostatitis, and certain medications, may contribute to higher PSA levels. Other factors such as herbal mixtures, 5-alpha reductase inhibitors, and long-term use of certain medicines, such as aspirin, statins (cholesterol-lowering drugs), and thiazide diuretics (such as hydrochlorothiazide) might lower PSA levels.¹⁰ Men who are considering prostate cancer screening should talk to their healthcare provider about anything that might affect their PSA level, as it might affect the accuracy of the test result.

Men with an average risk of prostate cancer should discuss the possible benefits, risks, and uncertainties of periodic prostate screening with their healthcare provider at age 50. For men at an elevated risk of developing prostate cancer, the discussion and screening should begin at age 45. Those with a higher risk of prostate cancer include Black men and men who have a father or brother diagnosed with prostate cancer before they were 65. Men with more than one first-degree relative diagnosed with prostate cancer at an early age should receive screening beginning at age 40.¹¹

In 2024 the United States Preventive Services Task Force is examining factors associated with differences in uptake of prostate cancer screening and disparities in utilization, as well as factors associated with differences in treatments used for screen-detected or early-stage prostate cancer.¹²

Goal 12: Increase screening and treatment for Texans at risk for Hepatitis B and C infections to reduce new cases and deaths from liver cancer.

Liver cancer is the sixth leading cause of cancer deaths in the United States. The most common type of liver cancer in adults is hepatocellular carcinoma (HCC), which typically develops in people with chronic liver disease caused by hepatitis virus infection or cirrhosis. Men are more likely to develop HCC than women.¹ According to the National Cancer Institute State Cancer Profiles, Texas has an age-adjusted incidence rate for liver and bile duct cancer of 12.1 per 100,000 people versus a national rate of 8.6 per 100,000.²

The most common risk factor for liver cancer is chronic infection with hepatitis B virus (HBV) or hepatitis C virus (HCV).³ According to the United States Centers for Disease Control and Prevention (CDC), in 2020, 640,000 adults living in the United States had chronic HBV, and an estimated 2.2 million adults had HCV.⁴ Texas has the highest rates of HCV, with an estimated 500,000 Texans currently infected with HCV.⁵ Some people have a chronic HBV or HCV infection without even knowing it.

There is an effective vaccine available for HBV. The CDC recommends universal HBV vaccination within 24 hours of birth followed by completion of the vaccine series, and for those adults aged 19–59 years not already vaccinated, including those with risk factors for HBV and those seeking protection.⁶ According to the CDC, healthcare providers should test all people 18 years of age or older for HBV and HCV at least once during their lifetime, as well as women in early pregnancy, infants born to pregnant people with HBV infection, and anyone with ongoing risk for exposure.⁷ Medicines are available currently to treat chronic HBV. Although these drugs do not cure HBV, they lower the risk of cirrhosis, which may also lower the risk of liver cancer.³

Although there is no vaccination for HCV, medications to treat chronic HCV infection can eliminate the virus in many people, which may in turn lower their risk of liver cancer. Treatments usually involve 8–12 weeks of oral therapy and cure over 90% of HCV infections with few side effects.⁸

As of 2024, people who are at average risk of liver cancer do not have a widely recommended liver cancer screening test, but testing might be recommended for some people at higher risk. For people at higher risk of liver cancer due to cirrhosis, hereditary hemochromatosis, or chronic HBV infection, some experts recommend screening for liver cancer with alpha-fetoprotein (AFP) blood tests and ultrasound exams every six months. Researchers have linked screenings with AFP and ultrasounds to improved survival from liver cancer in some studies.⁹

Goal 13: Increase timely access to quality cancer diagnostic and treatment for all Texans.

Goal 14: Increase survivorship for all child and adolescent cancers, as well as the long-term follow-up care for childhood survivors.

Childhood cancer is the most common cause of death by disease for children in the United States and Texas. Approximately 15,780 children, from birth to 19 years old receive a diagnosis of cancer each year in the United States.¹ Experts estimate that 129 Texas children (ages 0-14) and 67 adolescents (ages 15-19) will die of cancer in 2024.²

Like adult cancer survivors, the population of childhood cancer survivors has increased. Experts estimate that there are 270,000 survivors of childhood cancer in the U.S. in 2024. This equates to one in 640 young adults between the ages of 20 to 30 who are survivors of childhood malignancy.¹ In 2021, there were 27,582 survivors of childhood cancer in Texas.²

Childhood cancer differs from adult cancers by type and duration of treatment. The average adult with cancer undergoes treatment for six months to a year, but children undergo treatment for six months to three years depending on the diagnosis and type of treatment.¹ In addition, two-thirds of childhood cancer survivors face at least one chronic health condition related to their cancer or treatment. One quarter of survivors face a late effect from treatment classified as severe or life-threatening, including heart damage, second cancers, lung damage, infertility, cognitive impairment, growth deficits, and hearing loss.³

Children and adolescents with cancer and their caregivers have unique needs from diagnosis through the entire continuum of care, including survivorship, long-term effects of treatment, and end-of-life care. Childhood cancer survivors have specific life-long problems associated with this disease including employability, insurability, and educational and physical complications associated with treatment. While Texas focuses primarily on curing the cancer and preventing or reducing the late effects of treatment, the need remains to also address psychosocial and emotional demands impacting the long-term effects of cancer and cancer treatments for the child and family.³

According to the Children's Oncology Group guidelines, long-term follow-up and screening are imperative for early detection and mitigation of treatment-related late effects. The National Cancer Institute (NCI), in partnership with the Department of Veterans Affairs (VA) and other Health and Human Services Agencies developed and released the “National Standards for Cancer Survivorship Care” in 2024. These standards include distribution of a survivorship care plan (SCP) detailing estimates of late effects risk and recommended surveillance. Survivorship care plans improve long term adherence to follow-up surveillance by providing information and easing the transitions from cancer treatment to survivorship, and from pediatric care to adult care. However, few survivors and primary care physicians have a survivorship care plan. Increasing awareness of survivorship care plans may enhance their impact, but further research and resources are necessary to develop programs that effectively increase adherence.⁴

Multiple individual and systematic barriers to accessing survivorship services persist. Uninsured childhood cancer survivors face the highest risk for forgoing follow-up screening. Among those with private insurance, Blacks have the highest risk for not attending to recommended screenings, followed by non-Hispanic Whites and Hispanics. These disparities are not evident in survivors with public insurance.

Steps for maintaining survival for children and adolescent and young adult populations include consuming a healthy diet, maintaining a healthy weight, and exercising regularly to curtail obesity. Adolescent and young adult populations should also abstain from smoking cigarettes and tobacco use, and limit alcohol consumption. Children, adolescents, and young adults who receive a cancer diagnosis may have difficulty adhering to a healthy diet and an exercise regimen. However, for continued growth and development, doctors recommend that these patients should prioritize healthy lifestyle goals.

Goal 15: Promote overall health and well-being of people affected by cancer.

Cancer survivors often face physical, psychosocial, and financial challenges throughout their survivorship journey. Overall, health-related quality of life is lower among cancer survivors compared to those without cancer. Cancer survivors with the lowest health-related quality of life are more likely to be unemployed, lack social support, and are less prepared for survivorship. In addition, they have poor dietary habits, more comorbidities, and more concern about the risk of cancer recurrence or secondary cancers.¹

A primary concern for cancer survivors is the fear of cancer recurrence or diagnosis of a new cancer. Rates of cancer recurrence or diagnosis of new cancers are dependent on many factors, including type and stage of cancer, the type of treatment received, and physical and socioeconomic factors.² Cancer survivors often experience feelings of isolation and a lack of understanding by peers who have not faced a cancer diagnosis. They may also face challenges in returning to work, concerns about the quality of care, and a potential lack of coping strategies.³

Survivors can experience a wide range of short- and long-term challenges caused by cancer or its treatments. Short-term effects include hair loss, pain, nausea, vomiting, and loss of smell and appetite. The severity of symptoms depends on the person, cancer type, and treatment. As cancer survivors live longer after diagnosis, the development of long-term side effects such as heart damage (cardiotoxicity), lung damage, loss of bone density, and cognitive decline is becoming more common and demands a greater understanding to reduce or manage these conditions. Cancer survivors also experience higher functional limitations, such as the inability to sit for extended periods of time or participate in social activities. The proportion of survivors who experience these limitations has doubled over the past two decades.⁴

Those affected by cancer are not immune to nutritional challenges. As many as 80% of people with cancer experience malnutrition, a condition caused by not getting the right balance of nutrients. While nutritional screening and interventions may be valuable, they are not standard outpatient cancer care in the U.S. The lack of national clinical guidelines to prevent or treat cancer-associated malnutrition before or during cancer treatment highlights the need for more study. Researchers need more evidence to clarify which nutritional interventions are effective for specific patients, types of cancer, treatment settings, and treatment stages.⁵

Healthy behaviors, such as physical activity, a healthy diet, reduced alcohol consumption, and smoking cessation, can significantly improve both health outcomes and health-related quality of life for cancer survivors. Adopting healthy behaviors after a diagnosis of cancer, but prior to cancer treatment, can significantly improve outcomes for patients.⁶

Cancer survivors require appropriate care to address their many needs, including transitioning from active treatment, coordinating follow-up appointments, addressing financial needs, and gaining access to other survivorship resources. Coordinating cancer care is most effective when a designated individual or a team of people helps a cancer patient or survivor to gain access to the resources they need. Coordination approaches can lead to improvements among most survivors across multiple domains of cancer care, including screening, patient experience, and quality of end-of-life care.⁷

Goal 16: Increase timely access to quality supportive palliative care early and throughout life.

Supportive palliative care is not end-of-life care, rather it offers specialized, multi-disciplinary support to relieve a patient’s symptoms, pain, and stress at any stage of a life-threatening illness. Supportive palliative care focuses on disease modification and may involve curative or non-curative therapies aimed at enhancing a patient's quality of life. A collaborative and concurrent care team should provide supportive palliative care early in the course of serious illness, such as cancer. A growing body of evidence shows that supportive palliative care improves quality of life, reduces patient and caregiver burdens, and improves health care fiscal stewardship.

Caregivers can integrate supportive palliative care with curative and disease-modifying treatments to extend life or promote recovery from serious illness. The number of palliative care programs in Texas has steadily increased over the last decade despite the number of hospitals with 50 or more beds staying relatively constant.¹

Outpatient palliative care programs also support oncologists in some of their most challenging work. Palliative care extends survival and enhances quality of life and quality of care while reducing costs. Improved integration of palliative care into community-based oncology practices is a major focus to better serve the community and enhance the experience of patients with advanced cancer and their families.²

Goal 17: Strengthen the public health and clinical health care system infrastructure

Goal 18: Enrich the scope and impact of cancer research across Texas by enhancing clinical trial access, participation, and representation.

Although most cancer patients express interest in participating in clinical trials, only a small percentage of people with cancer or at risk of developing cancer enroll in clinical trials. Eight percent (8%) of adults with cancer participate in clinical trials,¹ and this percentage is even lower for many historically underrepresented groups.² Many trials fail to enroll enough participants to draw meaningful conclusions due to the minimal rate of participation.

Researchers attribute low clinical trial enrollment rates to structural barriers such as narrow eligibility criteria and inaccessibility, study burden, distrust, lack of awareness, and fear.³ Developing comprehensive solutions to increase clinical trial participation is critical for advancing medical knowledge, improving patient outcomes, and ensuring equitable access to cutting-edge treatments for all individuals affected by cancer.

Another significant concern is the lack of sociodemographic diversity among those who do enroll in cancer clinical trials. Clinical trials often fail to include participant populations that accurately reflect the real-world demographics of those affected by cancer, limiting the applicability of findings and potentially reinforcing disparities in care and outcomes.⁴ There is a range of structural and societal barriers that exist at individual (patient and health care provider) and systemic (health care system) levels that limit participation of racial and ethnic minority groups and medically underserved populations in cancer clinical trials. Interventions to address barriers must take into consideration the unique experiences of the target populations.

The American Association for Cancer Research Cancer Disparities Progress Report 2024 reports that a deeper understanding of barriers to clinical trial participation is enabling researchers, regulators, and policymakers to develop and apply evidence-based strategies. Efforts to improve clinical trial accessibility and equity focus on addressing social determinants of health, simplifying trial designs to reduce patient burden, broadening eligibility criteria, and streamlining data collection, including patient-reported outcomes. Additionally, fostering diversity within the clinical research workforce is crucial, ensuring that it better reflects the demographics of the patient populations it serves. These interventions aim to enhance both the inclusivity and effectiveness of clinical research.⁵

Community-based clinical trials improve the diversity of patients enrolled in clinical trials by engaging directly with community members to build trust and relationships and giving patients - including underrepresented patients - access to new treatment options. Research shows that community outreach and patient navigation enhance awareness and increase participation for racial and ethnic minority patients.⁶ Involving community-based partners in the design and execution of clinical trials, along with integrating patient and community feedback, can foster trust and credibility. This approach helps build meaningful relationships and encourages open, two-way communication, particularly with populations that may distrust the clinical system because of historic systemic injustices and discrimination.⁷

Goal 19: Encourage participation in cancer research and support of cancer programs through direct patient and community engagement.

As Texas plans for the future of cancer care, it is essential to engage stakeholders across the state and nation for guidance. Ensuring that the next generation of scientific leaders incorporates community needs and values the insights of individuals with lived experience when developing research initiatives is also important. This approach will drive more inclusive, impactful research initiatives and foster a deeper connection between scientific discovery and real-world patient outcomes.

Community engagement is vital for encouraging and increasing enrollment of historically marginalized populations in clinical research. Community-based participatory research is an approach where communities and researchers collaborate to co-create research agendas, identify priorities, and ensure mutual understanding. This approach integrates the cultural and social dynamics that are crucial to the success of research and program implementation. Through an iterative process, community-based participatory research establishes valuable relationships with communities and diverse partners through resource sharing, decision-making, results, and knowledge. Fostering community dialogue establishes trust, bridges socio-cultural differences, and brings multiple perspectives to the examination of an issue. When executed effectively, it allows communities to identify problems, explore solutions, and develop action plans to address community needs.¹

Researchers are increasingly conducting community-based clinical trials predominantly through primary-care physicians, community health centers, and local outpatient facilities, rather than academic research centers.² Involving the community in the research process helps develop more relevant and culturally-appropriate research questions, improves data collection and interpretation, and facilitates the translation of research findings into meaningful action and social change - ultimately leading to more impactful and valid results. By collaborating with communities across Texas, novel approaches in risk assessment, prevention, early detection, and interventions will translate into greater implementation. Texans can then tailor these innovations to meet the specific needs of diverse populations, ultimately leading to more effective prevention strategies and a broader impact on public health.

Goal 20: Expedite the development and accessibility of cancer interventions.

There is still so much to uncover about cancer – its development, progression, prevention, and treatment. Research is the foundation for answering these critical questions. Texas is well-positioned to lead in this effort, with a strong, bipartisan record of tackling major health and technology challenges. Programs like the Cancer Prevention and Research Institute of Texas, Texas Enterprise Fund, Governor’s University Research Initiative, Texas Comprehensive Research Fund, and other mechanisms and special item funding showcase the state's unparalleled commitment to bioresearch and innovation. These mechanisms, along with annual appropriations of approximately $3.5 billion, underscore Texas’ unequaled investment in its bioresearch and translational infrastructure.

Texas is home to a growing number of life science companies and hosts a wide range of active research initiatives, clinical trials, and pivotal studies. Both academic institutions and private companies conduct research on emerging cancers. Strengthening and expanding collaboration between these entities is crucial to accelerating new discoveries, improving screening methods, and establishing updated guidelines, particularly in addressing areas of unmet medical need.

Recruiting preeminent researchers enhances the state's cancer research ecosystem by bringing in fresh ideas, specialized expertise, and increased research funding. New researchers will bolster the scientific community, creating a critical mass that attracts investments in developing innovative products for cancer prevention, diagnosis, and treatment. Investments in core facilities support this effort and ensure researchers have access to the latest technologies, essential for advancing innovative cancer research. This expanded capacity not only drives scientific discovery but also generates evidence for novel strategies in cancer prevention and early detection and supports the development of novel tools—such as new diagnostics, imaging techniques, and medical devices—that improve options available for early cancer detection.

A well-documented barrier in advancing cancer treatment is the lack of funding to translate new discoveries into practical advances for cancer patients. Federal grants and foundations traditionally support early-stage discovery science, while venture fund investors and the pharmaceutical industry typically finance late-stage development. However, there is a critical funding gap in the intermediate stages of translational research.

Translational and early-stage clinical research, which bridges the journey from basic science to commercial products such as drugs, diagnostic tools, and medical devices, is essential for bringing new innovations to market but remains underfunded. Additional investment in these research areas will accelerate the development of preventive measures and cutting-edge technologies. Although translational and early clinical research takes time and resources, it offers immense potential to improve patient outcomes and advance cancer care. Addressing this funding gap enhances the pipeline of innovation, ensuring that groundbreaking scientific discoveries will make a tangible difference in the fight against cancer.

The 2024 Texas Cancer Plan emphasizes the role of precision medicine in improving cancer care by understanding genetic changes in tumors and identifying effective targeted therapies. These therapies, often paired with diagnostic tests for identifying specific biomarkers, are increasingly able to identify the potential effectiveness of specific cancer treatments, such as chemotherapy. The 88th Texas Legislature passed legislation mandating Medicaid and insurance coverage for evidence-based biomarker testing. As Texas continues to invest in innovative interventions, healthcare professionals should utilize appropriate evidence-based biomarker testing to enhance the accuracy of diagnosis and inform personalized treatment plans.