Hard Choices and Cancer Disparities

faststats1Covering 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.

But before cancer treatment comes cancer screening, another subject where Brawley had strong opinions. The best evidence for screening saving lives was found in colon cancer, he said, although effective fecal blood tests are underutilized in favor of more expensive colonscopies. On mammograms, he was a bit more lukewarm, saying (as he had in the New York Times that very day) that the procedure was effective and saved lives but “we expect more of mammography than it can actually give us.” Prostate cancer screening earned the brunt of Brawley’s criticism, in spite of statistics that show higher risk for the disease in African-American men – seemingly a simple route to reducing one type of cancer disparity. But in its current form, prostate cancer screening puts barely a dent in mortality rates while dramatically increasing costs for further testing and treatment, Brawley said.

That’s a controversial stance, but one that is built on evidence and numbers instead of emotions and hunches. As Brawley repeatedly emphasized throughout his talk, an evidence-based approach is the only way forward for American health care, whether the goal is reducing health disparities, reducing costs, or ideally, both.

“True health care reform is actually smarter and rational use of health care,” Brawley said, “and that’s one of the ways that we’re going to most effectively decrease the haves versus the have-nots and the disparities.”

UPDATE 9/28: The American Cancer Society has posted a video interview with Brawley where he expands upon his criticisms of prostate cancer screening. Gary Schwitzer at Health News Review discusses the comments briefly here.

About Rob Mitchum (525 Articles)
Rob Mitchum is communications manager at the Computation Institute, a joint initiative between The University of Chicago and Argonne National Laboratory.
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