From investigating racial disparities in breast cancer mortality to looking at the relationship between the microbiome and colorectal cancer, or from building cancer surveillance infrastructure in India to evaluating the cost effectiveness of various cancer therapies, Rollins scientists have emerged as a powerful force in cancer prevention research.

“Rollins has a particular strength in this area,” says Dr. Timothy Lash, Rollins professor and chair of the Department of Epidemiology. “We have close ties with the Winship Cancer Institute. The Georgia Cancer Registry and the Emory Prevention Research Center are both located in our school. We probably have 50 researchers at the school working on some aspect of cancer prevention, and we just brought on a renowned ovarian cancer researcher, Joellen Schildkraut.”

Here’s a look at some of the work being done.

Dr. Timothy Lash, left, leads Winship’s Cancer Prevention and Control program and Dr. Kevin Ward directs the Georgia Center for Cancer Statistics.

A powerful partner

Winship’s Cancer Prevention and Control program coordinates and promotes all of the cancer prevention and control-related research activities within Winship. Lash leads the program, and Rollins researchers are among its most active investigators. Dr. Terry Hartman, professor of epidemiology, studies the role of diet and nutrition in the prevention of cancer. Dr. Nika Fedirko, associate professor of epidemiology, studies the influence of the microbiome on colorectal cancer risk and progression. And Dr. Robert Bednarczyk, assistant professor of global health, leads a program focused on human papillomavirus (HPV) vaccination uptake.

Bednarczyk’s study builds off the fact that only 46 percent of teens in Georgia completed the HPV vaccination series by age 17 in 2016, according to the CDC, despite the vaccine’s effectiveness at preventing cervical and other cancers. Through hosts of focus groups across the state, Bednarczyk found various reasons for the low uptake, including distrust of vaccines in general and the perception that the HPV vaccine could encourage promiscuity, a theory that has been refuted by numerous studies.

Bednarczyk says the research highlights the importance of understanding belief systems and how people make decisions. Discussing people’s misconceptions is more effective than dismissing them. “Everybody is trying to do the best for their children,” he says. “We’ve discovered that it’s not just what we are communicating, but how we are communicating it.”

A rich resource

The Georgia Cancer Registry collects information on each new diagnosis of cancer within the state and contributes these data to two national population-based databases. The Georgia Center for Cancer Statistics, directed by Dr. Kevin Ward, is the designated agent of the Georgia Department of Public Health for the purpose of collecting, editing, consolidating, and monitoring cancer data in the state. The registry allows cancer prevention and control leaders to follow cancer trends, identify cancer patterns within the state, prioritize resource utilization, and monitor state progress over time. It’s also a valuable resource for countless researchers and students. The registry serves as a sampling frame for recruiting patients to research studies, a linkage source for building enhanced research datasets, a resource for increasing clinical trial participation, and a rich dataset for research mining.

Dr. Joseph Lipscomb, professor of health policy and management, worked with Ward and several other researchers to answer a question posed by the CDC—can population-based cancer registries be used not only to track cancer incidence, but also to identify survivors who are at elevated risk for cancer recurrence or a second primary cancer diagnosis. The team used the state registry to identify breast cancer survivors who were diagnosed between 2000 and 2009, focusing on women who were diagnosed at age 45 or younger since this group has a higher risk of additional cancer than women who got cancer later in life. In addition, they worked directly with these survivors to identify and locate their first-degree female relatives, who are also at heightened risk for developing breast cancer. Then they focused on the subset of survivors and first-degree relatives who reported not having had a breast cancer screening in the past 12 months—and thus were not adhering to nationally recognized screening guidelines.

Half of the breast cancer survivors, and likewise half of the first-degree relatives, were randomized into a high-intensity intervention that included a brochure encouraging screening, phone counseling, mailed reminders, and communications with their primary care providers to encourage screening. The other half of the women received only the brochure. After 12 months, the investigators found that 72 percent of the survivors across both intervention groups had received mammography screening, though there was no significant difference in the effectiveness of the high- and low-intensity approaches. For first-degree relatives, the high-intensity intervention was significantly more effective than the brochure alone. For Lipscomb and his team, the study showed that cancer registries can be used to identify both high-risk breast cancer survivors and, subsequently, their first-degree relatives as a means to work closely with them to promote guideline cancer screening.

Lash is working with Ward to expand the registry’s scope. Like every other registry in the country, the Georgia Cancer Registry has collected data only on primary occurrences of cancer. Lash and Ward have been working for years to add population-wide recurrence data, and they finally got funding to do so.

“Today, when more people are surviving their cancer and perhaps even being cured, it’s no longer acceptable to focus only on mortality,” says Lash. “With this recurrence registry—the first of its kind in the nation—we will be able to study things like the course of different cancers, how successful we are at treating them, what groups are more at risk for recurrence, and what factors predict good outcomes. This will help us fill in a lot of holes in our knowledge of cancer.”

Dr. Michelle Kegler leads the Emory Prevention Research Center where she works on several studies focused on the home environment.

Serving rural communities

The Emory Prevention Research Center was recently funded by the CDC to expand its work, much of which focuses on cancer prevention and control in rural Southwest Georgia. The center has a broad portfolio, including a study to test whether a smoke-free homes program can support smoking cessation in primary care and another to test whether community coalitions can reduce exposure to secondhand smoke in Armenia and Georgia.

By virtue of joining the CDC Prevention Research Center Network, Rollins and Winship faculty obtained two additional cancer-related grants. Dr. Cam Escoffery, associate professor of behavioral, social, and health education sciences, leads the Emory Cancer Prevention and Control Research Network, which does collaborative research with other cancer researchers across the US, in combination with a local project to increase HPV vaccination in Southwest Georgia. Drs. Sarah Blake and Kathleen Adams, assistant professor and professor of health policy and management respectively, lead a project evaluating the implementation, cost-effectiveness, and scalability of interventions to increase cancer screening completion among medically underserved women.

In the core research funded by CDC, Dr. Michelle Kegler, principal investigator of the center, is partnering with United Way agencies to expand a successful weight-gain prevention intervention her team and community partners developed in the early 2010s. In the original version, the project paired households with a health coach to focus on their home environment. Participants were asked to select six healthy actions from a list—identifying an unhealthy food often in the house and banning it, always having a low-calorie beverage available, having a scale in a visible location, to name a few—and commit to them for 20 weeks. The coach made three home visits during that time, as well as contacted them by phone several times. Compared to households in the control group, the intervention households reported larger decreases in daily calorie consumption than the control group and fewer had gained weight.

Kegler and her team are now rolling out the intervention, called Healthy Homes/Healthy Families, in Albany, Columbus, Macon, and Atlanta in partnership with Horizons Community Solutions and four United Way 2-1-1 agencies. Coaches will check in over a 12-week period via phone and text rather than in person. “We were pleased with the results of our first study,” says Kegler, who is a professor of behavioral, social, and health education sciences. “We want to see if it can be just as effective if it’s shorter and less labor-intensive.”

Cancer prevention research at Rollins has long been a strength, and it seems poised to do nothing but grow. “Our school is in the enviable position of being housed in a major research university and having strong affiliations with the National Cancer Institute,” says Lash. “Our researchers are working to prevent cancer here in Georgia and beyond.”

Bolstering ovarian cancer research

Joellen Schildkraut joins Rollins

Dr. Joellen Schildkraut joined the Rollins team in January as the Jules and Uldeen Terry Distinguished Professor of Women’s Health. One of the pioneers in ovarian cancer genetics, Schildkraut is widely recognized as a preeminent scholar in her area.

“When you think about ovarian cancer epidemiology, Joellen Schildkraut is the first name that comes to mind,” says Dr. Timothy Lash, Rollins professor and chair of the epidemiology department. “She is a leader in the study of ovarian cancer.”

Ovarian cancer is relatively rare—with about 22,000 new cases in the US each year compared with more than 330,000 cases of breast cancer— but it is often deadly. That’s because there is no effective screening, and it produces no tell-tale symptoms until its advanced stage. As a result, rather than being diagnosed in its early stage, when the five-year survival rate is 93 percent, ovarian cancer is often not diagnosed until it has spread, when that survival rate drops to 27 percent.

The outlook is even worse for black women. While white women are more likely to be diagnosed with ovarian cancer, black women are more likely to die from it, regardless of the stage or subtype. Schildkraut has been trying to find the reasons behind these disparities.

“If you ask me, Joellen’s most significant work is her study of disparities in ovarian cancer survival,” says Jen Doherty, an endowed chair in cancer research at the University of Utah Huntsman Cancer Institute and a longtime collaborator with Schildkraut. “She has taken it from zero to 100.”

Schildkraut was instrumental in forming the Ovarian Cancer in Women of African Ancestry (OCWAA) consortium, which draws together disparate studies to allow researchers to access enough data to draw meaningful conclusions.

“In order to study a rare disease in a minority population in the US, you need to be able to bring a lot of people together, which is what Joellen has done with OCWAA,” says Doherty. “She has contributed behind the scenes to progress in ovarian cancer research and to the success of a lot of researchers because they could leverage this data for their studies.”

For her own research, Schildkraut is still trying to answer the big question behind mortality disparities—why? “Many people think access to care explains a lot of the differences, but ovarian cancer does not have symptoms or early detection screening, so I think other, perhaps biological factors, are more important factors,” says Schildkraut.

For example, Schildkraut has found that body mass index seems to be more of an ovarian cancer risk factor for black women than for white. In addition, her studies have shown that a family history of breast cancer seems to be more predictive of ovarian cancer in black women than in white women. “I’m surprised by that, and I don’t understand it,” she says.

Schildkraut is also working to identify a genetic overlap between breast and ovarian cancers. She was among the many researchers who linked mutations in the BRCA gene to breast and ovarian cancers, and she is continuing to search for other genetic predictors.

Schildkraut came to Rollins from the University of Virginia School of Medicine, where she was a professor. “Emory’s world-class reputation, its strong epidemiology department, and its affiliation with a comprehensive cancer center made it an ideal place for me to continue my work,” she says. “The research and educational environments here are amazing.”