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Continued Reduction in Cancer Mortality Requires Increasing Healthy Behaviors and Removing Inequities in Care



Screening and early detection activities, while important, have been overemphasized at the expense of tobacco cessation, healthy eating, and active living.
— Otis W. Brawley, MD, FACP

Many news reports about the latest cancer statistics released by the American Cancer Society (ACS) have focused on the 25% reduction in cancer mortality since 1991. Several reports quoted ACS Chief Medical Officer Otis W. Brawley, MD, FACP, who said in a statement1 announcing the publication of the statistics in CA: A Cancer Journal for Clinicians2 and Cancer Facts and Figures 20173: “The continuing drops in the cancer death rate are a powerful sign of the potential we have to reduce cancer’s deadly toll.”

In an interview with The ASCO Post, Dr. Brawley talked about the challenges to increasing healthy behaviors, the harms vs the benefits of cancer screening, overdiagnosis, equal treatment yielding equal outcomes, the “mini-epidemic” of liver cancer, among other issues.

Triad of Troublesome Behavior

“Screening and early detection activities, while important, have been overemphasized at the expense of tobacco cessation, healthy eating, and active living,” Dr. Brawley said.

As noted in Cancer Facts and Figures 2017: “A recent review conducted by scientists on behalf of the International Agency for Research on Cancer found that there is sufficient evidence to conclude that being overweight or obese increases the risk of developing 13 cancers.” In addition: “Accumulating evidence suggests that obesity also increases the risk of cancer recurrence and decreases survival for several cancers.”

Obesity among U.S. adults ages 20 to 74 more than doubled, from 15% in 1976 to 1980 to 38% in 2013 to 2014. Among children aged 6 to 12, there has been a fivefold increase in obesity, from 4% in 1970 to 20% in 2015. In fact, based on a recent ASCO position statement, obesity may overtake tobacco as the leading preventable cause of cancer in the United States in the near future.4

But obesity is just one part of a troublesome triad that also includes a high-caloric diet and lack of physical activity. “Indeed, we anticipate that that triad is going to become the leading cause of cancer in the United States, sometime in the next 20 years,” Dr. Brawley predicted.

Tobacco

In 1955, the percentage of adult males in the United States, who smoked cigarettes peaked at 55%, and in 1965, the percentage of adult females peaked at 35%. By 2015, the prevalence of current cigarette smoking was reported at 15%. “The issue is the people who are currently smoking are the hardcore smokers,” who find it more difficult to “get off” tobacco, he noted, adding that demographics show only 5% of college-educated people smoke compared with 30% of those with a high school diploma or less. Further, e-cigarette use is widespread in the United States and Europe, according to Cancer Facts and Figures 2017, which noted “there is growing concern that [e-cigarette use] will normalize cigarette smoking and lead to the use of other tobacco products with known health risks.”

Prostate Cancer Screening

The rate of new cancer diagnoses has been decreasing by about 2% per year in men. “Much of the overall decline in new cancer rates for men is because of the recent drop in prostate cancer diagnoses,” according to the ACS statement, because routine prostate-specific antigen (PSA) testing is no longer being recommended. Asked if that might augur an increase in the rate of advanced cancer at diagnosis, Dr. Brawley replied: “The papers that I have seen so far that indicate that there is an increase in metastatic disease at diagnosis have looked at the percentage of men and not the rates. The rate may be going up, but we don’t know that yet.”

Prostate cancer mortality has been decreasing since the early 1990s in men of all races/ethnicities, although the rate is twice as high among blacks than any other group. “The decline in prostate cancer mortality is actually quite complicated. Keep in mind that the decline in prostate cancer mortality has been picked up in 21 different countries. At least three-quarters of those countries don’t screen, and in several of them, it is illegal actually to accept payment for screening,” Dr. Brawley explained.

“That does not mean screening doesn’t work. The key to prostate screening is that we need to drive it back within the physician-patient relationship and get away from free screenings that are done at health fairs and malls,” he continued. “Men should be offered screening, but they should be told of the potential risks and benefits and allowed to make the decision,” suggested Dr. Brawley.

Active Surveillance

“One of the important things about prostate cancer is the Gleason scoring has been refined dramatically, and some elements of what used to be Gleason score 6 have been moved into Gleason score 7. As a result, people with Gleason score 6 disease, which is about half of all men with screen-detected cancer, have disease that rarely progresses,” Dr. Brawley noted. (For viewpoints on whether a Gleason 6 tumor should be treated or not, see the December 25, 2016, issue of The ASCO Post.)

Improvements in the Gleason scoring system mean that “men are feeling much more comfortable [with active surveillance],” Dr. Brawley added. “As I look at the treatment trends, there are a lot more men who are being watched as opposed to being treated aggressively. I think that the benefit/harm ratio of prostate cancer screening has actually changed because so many more men are choosing [active surveillance] after diagnosis.”

Blood Stool Testing

“Recent rapid declines in new colorectal cancers have been attributed in part to more people getting screened with tests such as colonoscopies, which can prevent cancer through the removal of precancerous growths,” according to the ACS statement. The use of colonoscopy among adults ages 50 and older nearly tripled since 2000, reaching 60% by 2015.

“We need to put a greater emphasis on stool blood testing,” Dr. Brawley said. “The data that show that stool blood testing saves lives are very strong. Results from the Minnesota Colon Cancer Control Study and follow-up reports5,6 “showed stool blood testing is associated with a 35% decrease in [colon cancer mortality] and a 20% decrease in the colon cancer rate,” Dr. Brawley reported. Further, fecal-occult blood testing is cost-effective. “Stool blood testing costs about $30 a year, whereas colonoscopy costs close to $2,000 per procedure,” Dr. Brawley said.

Disparities in Care

Racial disparities continue to decline, yet, in 2014, black men still had a 21% excess risk of cancer death compared to white men, and black women still had a 13% excess risk of cancer death. “A large part of the reason for this disparity,” Dr. Brawley explained, is, as “we have clearly shown that people who are black are less likely to get optimal care,” meaning timely care based on good science, “compared to people who are white.”

Dr. Brawley made a similar comment in an article in The New York Times7 concerning a study finding that the cervical cancer mortality rate was higher than a previous analysis of the data had shown and that the racial disparity was wider.8 The mortality rate for white women was 4.7 per 100,000 compared to 10.1 for black women. “When we look at the difference between black and white, and rich and poor, we find the same disparity,” Dr. Brawley commented. “The quality of assessment and follow-up can be different. The question becomes: how do we get adequate preventive care to all people.”

Zip Code vs Genetic Code

There are also state-by-state disparities in cancer mortality. “If you look at the state of Massachusetts, for example, you have a colon cancer death decline over 25 years of over 40%. If you look at Mississippi or Louisiana, the decline in death rate is not quite 10% for the same period of time. So we are moving from looking at racial disparities to looking at socioeconomic disparities, and now we are even starting to look at state-by-state disparities,” Dr. Brawley said.

“We are finding that one of the commonalities is that we have a group of people who are disenfranchised—we can define it by race, by socioeconomic status, or by state—and those people are not getting high-quality care. High-quality care starts with preventive services and goes on to screening and diagnostic services and on to treatment,” he explained.

There are “huge differences” in death rates for breast cancer, colon cancer, “and even to a certain extent, prostate cancer,” Dr. Brawley noted, among blacks in the military and military retirees vs blacks outside of the military. “Equal treatment yields equal outcome, and race is not a factor in outcome. The difference in incidence of prostate cancer between black men and white men doesn’t go away, but outcome certainly improves dramatically for black men in the military.”

Mini-epidemic in Liver Cancer

“We are in the midst of a mini-epidemic in liver cancer,” Dr. Brawley stated. According to Facts & Figures, the incidence of liver cancer has more than tripled since 1980. An estimated 40,710 new cases of liver cancer will be diagnosed in 2017 and an estimated 28,920 liver cancer deaths will occur.

Although liver cancer is about three times more common in men than in women, “the incidence rate for liver cancer is going up in both men and women,” Dr. Brawley noted. “That is because of hepatitis B and hepatitis C, drug exposures in the 1960s and 1970s, and the sexual revolution as well.” There is a vaccine against hepatitis B, but not for hepatitis C.

The Centers for Disease Control and Prevention (CDC) has an ongoing campaign to encourage that people born between 1945 and 1965 be tested once for hepatitis C.9 “So we are not screening for the liver cancer. We are screening for the cause of the liver cancer,” Dr. Brawley clarified. “Screening for hepatitis C has become very important,” he added, “because with about 6 months of therapy that costs between $50,000 and $70,000, we can cure hepatitis C in about 95% of people who have it.”

Survivors of Childhood Cancer

The 5-year survival rate for children with cancer rose to 83% for those diagnosed during 2006 to 2012, and while that is certainly good news, Dr. Brawley expressed concern remains about the effects of treatment, including second cancers, and the quality of life for these survivors.

“We are able to cure a lot of these diseases,” he said, “but cure for me is a four-letter word that I do not use lightly. I see a goodly number of women who end up with congestive heart failure because of the Adriamycin in their chemotherapy regimen. Survivors of childhood cancers may experience growth retardation and sexual development problems. Dr. Brawley added that survivors of childhood cancers may also experience problems with pulmonary function and cardiac function, and for those who received craniospinal radiation for leukemia and lymphoma, intellectual development issues.

“We need to worry much more about quality of life for the survivor. One quality of life issue that the Affordable Care Act took care of,” Dr. Brawley commented, was “pediatric cancer survivors who were in their 30s or 40s and were being told they were being kicked off their health insurance because they had spent a million or $2 million maximum. Before the Affordable Care Act, this was a common problem for people, especially people who got cured of their cancer at a young age,” he noted. Having no lifetime limit on health insurance would definitely be one of the features that Dr. Brawley would like to see continued in any replacement of the Affordable Care Act.

Dr. Brawley concluded that continuing success in reducing cancer incidence and cancer mortality will require not only more clinical and basic research, but “creative new strategies to increase healthy behaviors nationwide.” ■

Disclosure: Dr. Brawley reported no potential conflicts of interest.

References

1. Simon S: Cancer facts and figures: Death rate down 25% since 1991. American Cancer Society News Release, January 5, 2017. Available at https://www.cancer.org/latest-news/cancer-facts-and-figures-death-rate-down-25-since-1991.html. Accessed January 27, 2017.

2. Siegel RL, Miller KD, Jemal A: Cancer statistics, 2017. CA Cancer J Clin 67:7-30, 2017.

3. Cancer Facts & Figures 2017. American Cancer Society. January 5, 2017. Available at https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2017.html. Accessed January 27, 2017.

4. Castoro J: Obesity could soon be the leading preventable cause of cancer in the United States. Available at https://www.mskcc.org/blog/obesity-could-soon-be-leading-preventable-cause-united-states. Accessed January 27, 2017.

5. Mandel JS, Bond JH, Church TR, et al: Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med 328:1365-1371, 1993.

6. Mandel JS, Church TR, Bond JH, et al: The effect of fecal occult-blood screening on the incidence of colorectal cancer. N Engl J Med 343:1603-1607, 2000.

7. Hoffman J: Wider racial gap found in cervical cancer deaths. The New York Times, January 23, 2017. https://www.nytimes.com/2017/01/23/health/cervical-cancer-united-states-death-toll.html?_r=0. Accessed January 27, 2017.

8. Beavis AL, Gravitt PE, Rositch AF: Hysterectomy-corrected cervical cancer mortality rates reveal a larger racial disparity in the United States. Cancer. January 23, 2017 (early release online).

9. Centers for Disease Control and Prevention: Testing recommendations for hepatitis C virus infection. Last updated October 2015. Available at www.cdc.gov/hepatitis/hcv/guidelinesc.htm. Accessed January 27, 2017.


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