How are we doing since President Nixon declared war on cancer by signing the National Cancer Act in 1971?
While the cancer death rate is on the decline, the economic burden of cancer care, coupled with an unsustainable rate of health care consumption, spells trouble for the future.According to American Cancer Society’s chief medical and scientific officer, Otis Brawley, AB’81, MD’85, if we want to save lives, we need to adopt a new definition of cancer for the 21st century, one that will allow us to identify and treat the cancers that threatens us and not waste money on treatments for a disease that will not take our lives.
In a lecture Brawley recently gave as part of the Committee on Cancer Biology Seminar Series at the University of Chicago, he analyzed emerging trends in cancer incidence and mortality in the U.S., as well as the barriers that must be overcome in order to adequately fund needed research and treatment.
From an economic standpoint, the current health care system in place is inefficient and unsustainable, he said.
In 2010, the government spent $2.6 trillion dollars on healthcare – or 18% of the value of all goods and services the U.S. economy produces. That figure is expected to rise to 30% by 2030.
That level will collapse the U.S. economy, Brawley said.
“It’ll be 1929 all over again,” Brawley said. “Health care is already negatively affecting our economy.”
The Affordable Care Act was an attempt to address problems with health care insurance payment practices, but for true health care reform, Brawley said, change is needed in the way health care is consumed.
And that calls for the adoption of more evidence-based medicine, noting that society needs to focus on the rational use of health care, which he favors, rather than the rationing of health care.
He provided several examples of times across history when medical practice did not respect science, creating an inefficient and often harmful way of treating cancer patients.
The most notable is the Halsted radical mastectomy, which involved removing a woman’s breast, underlying chest muscle, and lymph nodes.
This was a standard breast cancer treatment for nearly a century into the 1970s until a scientist showed it did not improve survival outcomes and was morbidly disfiguring women. Brawley said the procedure had lost relevancy in the 1920s, but was still performed showing how slow the medical profession can be to adapt to new evidence.
Now, women safely undergo lumpectomies, partial mastectomies, or other breast-conserving surgeries.
He also cited the use of a type of bone marrow transplant to help treat breast cancer. For at least 20 years, this was being done without any significant evidence that it was effective. Insurance companies, citing a lack of evidence, refused to pay for it until ordered by Congress in the mid-1990s to cover the procedure. It was abandoned in the 2000s.
Brawley is also concerned about overdiagnosis and overtreatment of cancer in our country.
It is expected soon there will be 14 million cancer survivors in the United States. He suggests that one-third of them didn’t need to be called “survivors” since the cancer they had treated would not have killed them.
Diagnoses of cancer are still being based on the same morphological characteristics that Rudolf Virchow (1921-1902) and colleagues first defined in 1853.
Brawley believes a 21st century definition of cancer must include genomics analysis tools that will improve our ability to predict which cancers will go on to cause symptoms or death, and which won’t, in order to avoid unnecessary, expensive treatment.
To that end, he believes screening is a double-edged sword.
While there is evidence to support screening’s life-saving benefit for some cancers, such as colon cancer, for other cancers, such as prostate, many groups disagree about what is best.
Overall, the medical field needs to become much better at first understanding the benefits and risks of screening and then explaining it to patients, Brawley said.
Another problem lies in the logistics of disseminating evidence-based medicine information to the people that it could most help. For example, between 40% and 45% of the U.S. population aged 50-75 are not getting regular colon cancer screenings. If this group did, 15,000 lives could be saved a year.
Brawley, who is a leader in health disparities research, cited racial disparities in cancer care as another troubling issue that needs to be addressed.
In breast cancer, for example, as we learned how to treat the disease a trend emerged showing that black women suffered from higher death rates than white women. Access to quality care was the difference, not any physiological differences among the races. Other cancers show this same divergence, where the survival rate starts out the same for all races but then trails off for minority groups.
A significant reason why cancer death rates are on the decline is because the 1964 report linking smoking to lung cancer sparked subsequent efforts to curb smoking. But Brawley said more can be done to improve smoking cessation rates, particularly among minority groups.
He is alarmed that our nation’s growing obesity epidemic will bring about a tsunami of chronic diseases, including diabetes, cardiovascular disease, and cancer. In fact, obesity and physical inactivity are about to surpass tobacco as the leading cause of cancer in the next decade.
How does Brawley suggest we address this problem? He advocates for a more European view on health care.
“We need to spend more time preventing illness not treating disease,” he said.
Over the next several years, groups such as the American Cancer Society will increasingly emphasize the role of nutrition and physical activity in preventing cancer.
This is a large shift in thinking from the “find it early and cut it out” mentality, which Brawley said does not work anymore. For the 21st century definition of cancer, he advocates for evidence-based medicine, science to guide policies, and more efforts on primary care and prevention.
In addition to his role with ACS, Otis Brawley, MD, is a professor of hematology, medical oncology, medicine, and epidemiology at Emory University in Atlanta. He has also held leadership roles at the National Cancer Institute and serves as a medical consultant for CNN. Brawley earned his medical degree from the University of Chicago Pritzker School of Medicine in 1985, and his undergraduate degree in 1981 from University of Chicago.