Diverse group people celebrating 1500 x 1003

Otis Webb Brawley, Chief Medical and Scientific Officer and Executive Vice President of the American Cancer Society (ACS) joined me on my bi-monthly podcast for the American Journal of Managed Care to talk about some good news when it comes to cancer. Recent statistics from ACS show that the death rate from cancer has been declining over the last two decades, and dropped another 1.7% last year. There has also been a 2% decline in the rate of new cancer diagnoses in the last decade for men, although not for women.

What follows is a condensed edited version of the transcript of the podcast. You can also listen to the conversation here:

 

The impact of smoking cessation

Pat: Otis, what’s going on? Why are death rates declining? And why are new diagnoses declining for men, but not for women?

Otis: The biggest reason for the decline in the death rate is that people have stopped smoking. Men stopped smoking in the late 1950s and continued to decrease the prevalence of smoking well into the 1980s. There was a leveling off of the decline but it started again in the last 15 years. When men stopped smoking, they stopped stop getting smoking-related cancers.

Women actually continued to increase their smoking rates throughout the 1960s and their declines have been slower than in men. So, we’ve seen less of a decline in cancer death rates in women because their decline in smoking was not nearly as steep as the decline that men had in the 1960s.

Pat: It’s really good news that people have quit smoking. I live in California and I just don’t see smokers anywhere anymore.

Otis: Yes, but there are huge geographical variations in smoking rates. In West Virginia and Kentucky, ~30% of adults still smoke. In Utah and California, it’s down to around 10%. I am a little worried that marijuana is going to increase some of our lung cancer rates because it is carcinogenic.

Pat: What about vaping? Is it safer?

Otis: Vaping is safer than combustible cigarettes but that does not mean that it is safe. There are a lot of things in the vaping solutions that we don’t know about and they have not been tested. So, I’m not an advocate for vaping at all. There is a group of individuals, smoking combustible cigarettes, who find that they can wean off with vaping. I’m fine with them doing that. But I would prefer that they do it by using other nicotine replacement products because vaping still is going to have some health risks that are undefined yet.

There’s also this concern that vaping is a gateway for children toward combustibles. They can vape up in their bedroom so their parents won’t smell it. They get hooked on nicotine and the next thing you know, they’re smoking combustibles when they’re out of the house.

 

Screening for lung cancer

Pat: Can you talk about the impact of advances in diagnostics that facilitate earlier detection of lung cancer?

Otis: There’s a great study that shows that lung CT screening decreases the risk of death by about 20%. That same study showed that it actually has some harms associated with it as well. In fact, for every 5.4 lives saved by lung cancer screening, one life is lost associated with biopsies and bronchoscopy that resulted from screening. So, there is the benefit and there is the risk.

Everyone who is considering getting screened needs to balance the benefit and risk and make a choice for themselves as to whether they want to be screened. Also, they need to be screened at a good place that is capable of evaluating the CTs and treating lung cancer if it’s diagnosed. That being said, in the U.S., very few people (maybe 3% to 4%) who are eligible for lung cancer screening (people in their mid-50s and older who have smoked more than a pack a day for 30 years and are still in good health) are actually getting it.

Pat: I recently spent time at Enlitic, a digital diagnostic startup, that that is using artificial intelligence and machine learning to improve the efficacy of lung-cancer CP screening. They showed me data that suggests it is much more sensitive than regular CT scanning and that it is particularly good at being able to calculate the three-dimensional volume of lesions. Are you familiar with this advance? Do you think that this could change the way we think about lung CT screening?

Otis: I think, first and foremost, we need to discourage smoking. We should consider lung CT screening, particularly for people who have extensive smoking histories. Over time, CT scanning for lung cancer will get better and more hospitals will offer it. We’ve actually done some mathematical modeling on lung CT screening as it exists now. If it was available throughout the entire United States in the way it was offered in the University Hospitals in the trial I described, we could save about 12,000 lives per year. But as it is offered now, it would actually cost us a little over 2,000 lives per year. Keep in mind that well over 150,000 people die every year from smoking-related diseases. So, we really need to focus on the anti-smoking message. But lung cancer screening is going to get better and it will be an option. We should mention that about 20% of lung cancer patients are non-smokers. Right now, unfortunately, we don’t have anything to offer them in terms of screening.

 

Targeted therapies for lung cancer

Pat: But there are new targeted therapies available for non-smokers with metastatic lung cancer, right?

Otis: That is right. This is really good news for someone like me, who is a medical oncologist. But for patients, this can still be somewhat dissatisfying. Many of our lung cancers—I say lung cancers (plural) because when I graduated from medical school, we only had two kinds of lung cancer: small cell and non-small-cell. Now, 30 years later, based on their molecular biology, non-small-cell lung cancer (NSCLC) is thought of as perhaps 80 different types of cancer. For some of those cancers, we have drugs that perform very well. For example, some patients with NSCLC that have the ALK gene rearrangement have been alive with metastatic disease for five and six years right now. This is a disease which 7-8 years ago had a life expectancy of a year or two. Unfortunately, these targeted therapies are only good for about 30% of the people who have non-small-cell lung cancer right now. But they are growing in number and they’re getting better.

 

What’s going on with breast cancer?

Pat: Breast cancer is still a scourge among women even though death rates have declined. How much of the progress that we’ve made in breast cancer is related to being better at diagnosis versus having more treatments including the new targeted therapies or is it a mixture of both?

Otis: We’ve had a 40% decline in breast cancer death rates over the last 30 or so years, much of it due to improvements in treatment. But nearly half of it is due to screening. I’m a big advocate for both because we’ve got a lot of good studies to show that there’s a substantial number of Americans who are diagnosed with breast cancer and then get less than adequate care for that breast cancer. So, we need to work on getting screening to people and making sure the screening is good. But, we also need to make sure that women get good treatment once the disease is diagnosed. We very frequently argue about whether we should start screening at age 50 or at age 40. As one who gets to look at the epidemiology, I know we could save more lives if we just correctly treated everyone that we are diagnosing now. That is not happening.

Pat: That’s a very good point and we’re going to come back to it at end of our conversation. Because this isn’t just a problem with breast cancer. There is a disparity in access to diagnosis and treatment with respect to all cancers. But first, let’s talk about the outcomes of some other common cancers.

 

Prostate cancer

Pat: Let’s start with PSA screening. We’ve been hearing for years that we shouldn’t order this test because there is morbidity associated with the workup that is triggered when a test returns positive. What’s the final word on that?

Otis: There is no final word yet. There’s been a decline in mortality that’s close to 50%. That decline started before we started screening in the United States. So, it’s hard to say that the whole thing is due to screening. That decline exists in 21 countries around the world—18 of which don’t screen, several of them actually have policies against screening that are really very harsh. Some of the decline that we’ve seen since 2000 might be due to screening but the decline that we saw in the 1990s is definitely not due to screening, rather it might be due to treatment. Also, there are some technical issues about changing the way death certificate data are interpreted. In 1991, the World Health Organization changed the algorithm raising questions about why we’ve seen a decline in prostate cancer? Some of the people who are dying are being categorized as having other diseases. Overall, it translates into “we still don’t know” whether we should be screening for prostate cancer with a PSA test.

What we do know is that in the 1990s in this country, every man who was diagnosed was told you need to be treated immediately. Many of them had a radical prostatectomy in the next week. Today, in 2018, more than half of all men who are diagnosed through screening are told we should watch your cancer. Many of those men will never be treated. We’ve gotten a lot better at being able to distinguish the cancers that need to be treated and the ones that can be watched.

The answer to the question of whether a man should be screened for prostate cancer has changed just in the last five to ten years. There’s a group of men who I would encourage to get screened knowing what their concerns are. These are men that I would have encouraged not to get screened just five years ago. I do think it’s still up to the man to decide once he understands the potential benefits and the potential risks of screening. He needs to know that there are harms associated with prostate cancer screening related to both diagnosis and treatment but there also may be benefits. The man needs to decide what he wants to do.

Pat: I think this whole discussion about prostate cancer shows us how very hard it is to get to the “truth”. From a consumer point of view, you want somebody to say, this is what you should do. But prostate cancer has shown us that you can’t always get there. There are still some very difficult decisions that have to be made by patients in conjunction with their family and healthcare providers.

 

Is colorectal cancer another good news story?

Otis: Yes! And there’s less controversy. We have had dramatic declines—well over 40% to 45%—in colorectal cancer death rates throughout the United States. Some of these declines started back in the 1970s. They are linked to screenings (stool blood screening, sigmoidoscopy, colonoscopy) that are all highly effective. Even stool blood testing that triggers a colonoscopy has been shown to find polyps that reduces the risk of colon cancer. So, we’re talking about a screening test that reduces the risk of death and reduces the risk of colon cancer.

Our ability to treat the disease, including stages 3 and 4, have improved dramatically. This, too, is a part of the reason for the decline in mortality. The sad thing is there is geographic variability in outcomes. This is a lot like what we discussed with smoking breast cancer. There are 12 states in the United States that have not had a 10% decline in colorectal cancer death rates even though the United States as a whole has had close to a 45% decline.

Pat: Do we know if that’s due to environmental factors, ability to get insurance coverage, or patient education? Are there any hints to why that disparity exists?

Otis: Yes. The declines are because people got adequate preventive diagnostic and therapeutic care. Preventative care can be related to diet (e.g., five to nine servings of fruits and vegetables per day), not being obese, exercising—all of those things prevent a number of cancers, not just colon cancer. It’s not just screening.

What we have found is the states that have had a very small decline in colorectal cancer death rates are the states that overwhelmingly have the highest proportion of people who have not graduated from high school or not graduated from college. They are some of the poorest states in the United States. They are also the states where people traditionally have difficulty getting healthcare once diagnosed. They also have difficulty with some of the preventative aspects, too. They are some of the states with the highest proportion of the population being obese.

The death rate for college-educated Americans in the United States is considerably different from that of non-college educated Americans for cancer. If all Americans had the death rate of college-educated Americans, 150,000 of the 620,000 people who are going to die from cancer this year would not die. They would have had all the preventative aspects over the last 10, 15, 20 years in terms of diet and exercise. They would have had all of the screening that college-educated Americans tend to have. And, they would have had access to better care. All of those things are important when it comes to lowering death rates. We spend a lot of time talking about race and racial disparities, but most of the racial disparities, are actually due to socioeconomic disparities.

Pat: It is completely unacceptable in a country as wealthy as ours that we have two Americas: an America that gets good healthcare and has good health outcomes and an America that doesn’t. Otis, I hope you will come back soon to talk to us about disparities in cancer outcomes.

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