Covering medical research for the University of Chicago, one hears a lot about racial health disparities and the efforts to narrow those gaps. But some statistics still pack a punch, and Otis Webb Brawley’s talk at the University of Chicago last Thursday contained several left hooks. The five-year risk of death after diagnosis with breast cancer is almost twice as high for black women as for white women - but 30 years ago, the risk was nearly equal. An uninsured patient with stage 1 colon cancer is more likely to die from their disease than an insured patient with the more-dangerous stage 2 colon cancer. Obesity in children has risen five-fold since 1970, and obesity is expected to pass cancer as the #1 cause of cancer by the year 2030…if it hasn’t already.

In Brawley’s role as chief medical and scientific officer for the American Cancer Society, it’s his job to use these statistics to make clear arguments to scientists, physicians, politicians, and laypeople about what must be done to reduce cancer disparities. But Brawley’s talk for the Bowman Society Lecture Series (named for retired professor, and former teacher of Brawley at the Pritzker School of Medicine, James Bowman), was distinctly not about just throwing money at the problem. His central philosophy was “equal treatment yields equal outcomes among equal patients” - but sometimes, deciding what that equal treatment should be is the hard part.

Brawley took care to set his talk in the context of spiraling health care costs in the United States, showing the now-familiar graph plotting our highest-in-the-world health care spending against the country’s mediocre life expectancy. Racial disparities could explain part of those poor returns on US health care spending, but Brawley put the focus on “faith-based medicine” - not health care based on religion, but care (and associated spending) based on assumptions about what works rather than hard evidence. As an example, Brawley cited the practice of chest X-ray screening, considered by physicians in the 1960’s to be a necessary routine procedure for the detection of cardiopulmonary disease. But clinical trials found that these screens caused more harm than good, through increased rates of lung cancer and over-diagnosis.

“We did all those things because we thought we were doing the right thing, but we didn’t do rigorous assessment before we started doing them,” Brawley said. “So I ask the question: are we willing to be scientific and accept scientific realities? There are things that we do that add to the incredible cost of health care, but make no difference in outcome.”

That tough talk should apply equally to the problem of reducing health disparities in minority populations, Brawley emphasized. While some pursue the genetic risk factors that may explain disparate rates of disease in minorities, Brawley argued that socioeconomic factors were a much bigger target for intervention. A 1998 study that compared the breast cancer mortality gap in the general population versus women in the U.S. military medical system (who receive free health insurance and easier access to hospital care) found that the gap was still there, but almost two-thirds smaller. The other third could be genetics, Brawley conceded, but the more significant - and, in his view, easier to fix - factors were social and economic.

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Inside a ballroom of the Chicago Sheraton Wednesday morning, an unusual live event was taking place. As a few dozen people looked on with intent interest, an abstract mix of watery reds, fluffy yellows and pulsating browns filled a giant projection screen. Swooping above and into this mixture were what looked like two metallic alligator heads, joined occasionally by various other silver creatures to help lift, cut and suction the material below. Through the whole process, the operator of these tools offered audio narration from halfway across the country, conversing casually with a panel of experts in the ballroom.

The strange screening was a live surgical broadcast, one of many offered at the 2010 World Congress on Endourology held last week. Dr. Steven Shichman, a urologic surgeon from Connecticut, was performing a robotic partial nephrectomy - removing a tumorous mass from the top of a 70-year-old man’s kidney. Despite the large remote audience, Shichman went about his work with calm professionalism, slowly and methodically clearing tissue until the kidney, tumor, and important blood vessels took shape within what looked like (to the non-surgical observer) an impossible mess. After carefully clamping the major blood vessels to the kidney, Shichman deftly removed the bulbous tumor and sutured the organ surface, completing those time-sensitive tasks in a brisk 11 minutes. Hundreds of miles away from his operating room, he received a round of applause.

Endourologists concern themselves with fixing or removing the kidney, prostate, and bladder, but the live surgery revealed the meeting’s emphasis on a different organ: the eyes. Like any medical conference, there were plenty of data, numbers, and graphs to pore over about the effectiveness of established and experimental surgeries. But the main purpose of the meeting, which attracted over 900 urologists from 50 different countries, was the sharing of surgical techniques and strategies, an information exchange of a sort that would be familiar to craftsmen of any field.

“We will cover 1,300 abstracts, and I am sure that all of us can learn from each other,” said Arieh Shalhav, professor of surgery at the University of Chicago Medical Center and the President of this year’s World Congress.

Sharing knowledge is essential in a field that has advanced quickly over the last two decades, first with the introduction of laparoscopic, minimally-invasive procedures in the 1990’s and lately with the use of surgical robots such as the da Vinci system. The new technology and methods have changed major surgeries requiring large abdominal incisions to intricate procedures that leave behind only a few marks mere millimeters in diameter. The role that urologic surgeons have played in pushing forward the boundaries of minimally-invasive surgery was underlined by Jeffrey Matthews, professor and chair of surgery at the Medical Center, in his welcoming remarks.

“We’re looking to you not only for leadership in urology and urological disease, but also leading all of surgery in your approaches to innovation and minimally invasive techniques and other advances,” Matthews said.

Interestingly, some of the discussion Wednesday at the conference engaged over just how hard to keep pushing the boundaries of minimally-invasive surgeries given the field’s recent successes. A new technique known as LESS - Laparoendoscopic Single Site Surgery - was the floor topic for one such debate, between Matthew Gettman of Mayo Clinic and Stuart Wolf from the University of Michigan.

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On the grim top 10 list of the most common cancers in the United States, familiar faces sit at the top of the charts. Prostate cancer for men, breast cancer for women, lung and colon cancer for both sexes - all are diseases that have inspired massive awareness and fundraising efforts to inform patients and bolster scientific research. But the #5 cancer on the list (the #4 most commonly diagnosed cancer in men) has not gotten nearly as much attention as the Big Four. Bladder cancer was diagnosed in an estimated 71,000 people last year, according to the Bladder Cancer Advocacy Network, but does not have the high profile of its kin.

Bladder cancer survivors and physicians hope to change that with the first Bladder Cancer Awareness Day, to be held this Saturday, July 17 with events around the country. It seemed like a good opportunity to sit down with our resident expert on bladder cancer, Dr. Gary Steinberg, for a comprehensive overview of the disease. Steinberg, the Bruce and Beth White Family Professor at the University of Chicago Medical Center, is a surgeon that specializes in the treatment of bladder cancer - both the removal of tumors and the bladder reconstruction that sometimes follows.

The risk factors for bladder cancer are not unique - smokers are twice as likely to develop the disease, while several industrial chemicals have been linked with tumors of the bladder, Steinberg says. As with many cancers, it’s a misnomer to think of bladder cancer as just one disease. Steinberg talks about the different types or “grades” of bladder cancer, and the range of treatment options available to patients with those diagnoses. He also describes ongoing research efforts to improve those treatments, from work with the Cancer Genome Atlas to find novel therapeutic targets for chemotherapy drugs to trials using stem cells to construct new urethras and bladders.

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