Monday, April 27, 2009

Is The Medical Community Complicit?

Gina Kolata wrote a fascinating piece this week on the subject of The War on Cancer, first declared by President Richard Nixon back in 1971. The main focus of her article is how elusive a “cure” is turning out to be, and how expensive the search has become.

As she points out, over the past 50 years the age-adjusted death rate from cancer has fallen a mere 5%, despite the federal government having spent well over $100 billion on cancer research. Details of cancer research funding can be found here.

What really caught my attention, though, was not the fact that a “cure for cancer” is so elusive, but rather her acknowledgement that the public believes that cancer is almost always preventable, and that failing prevention, if caught early enough it is almost always curable.

To some extent, these ideas are true. Quitting smoking clearly decreases a person’s risk of developing lung cancer. But does this mean all lung cancer is preventable? No. As discussed in this recent article in the Journal of Clinical Oncology, 10% of lung cancer patients in the US have never smoked a cigarette. Lung cancer in never smokers (LCINS) is a distinct entity, with its own epidemiology, risk factors, molecular biology, and treatment outcomes. A focus on cigarettes as the major cause of lung cancer is appropriate, because 90% of lung cancer is smoking-related, and lung cancer remains one of the most common types of cancer in the US (lung cancer causes more deaths in women than breast cancer), but by focusing on smoking almost exclusively, are we complicit in making the public believe that all lung cancer is preventable?

Numerous other interventions have been proposed to decrease the risk of cancer, including low fat diets, high fiber diets, the use of antioxidants, taking vitamins – but rigorous testing has rarely shown a benefit to these lifestyle changes when it comes to cancer.

What about early detection? Localized cancer is clearly easier to treat than metastatic cancer, and some cancers are readily detected by screening (including breast cancer, colon cancer, and prostate cancer). However, some types of cancer, such as pancreatic and ovarian cancer, remain difficult if not impossible to detect by a screening program.

Does early detection by screening actually save lives? On the surface, it seems the answer would have to be “Yes.” But in reality, not every screening program saves lives. Two very recently published articles failed to demonstrate a decrease in prostate cancer-related death in men randomized to an intensive screening program compared with “usual care.”

How is this possible? The benefit to screening and early detection of cancer is based on the idea that cancer progresses in an orderly fashion from a pre-cancerous lesion to a localized tumor and finally to metastatic disease.

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If a pre-cancerous lesion or a localized tumor is detected on a screening test and treatment is begun immediately, the belief is that metastatic disease can be prevented and lives will be saved. But what if some cancers are more aggressive than others and have already spread when the primary tumor is detected? Early detection of cancers like this will not change the disease-specific death rate (the death rate attributed specifically to cancer) because metastatic disease, which is what usually kills patients, will not be prevented from developing. What if the tumor that is detected is one that grows slowly and only rarely kills? Finding a tumor like this early may not save lives.

So does that mean screening programs don’t work? Not at all. But it does mean that such programs need to be rigorously tested. The introduction of Pap smears has had a profound impact on death from cervical cancer. Screening programs for breast and colon cancer have been shown to decrease cancer-related death from these diseases. However, screening for prostate cancer may not. Prostate cancer is a slow growing disease, and most tumors picked up by screening tests are small enough that they do not need to be treated – men with these tumors are more likely to die of something else (a heart attack or a stroke) rather than dying of prostate cancer. So finding this tumor early does not save lives. As future screening tests become available, they will need to be tested carefully to determine whether or not they should be widely applied.

What does all this mean? I think it means we as a medical community need to be very careful in how we discuss concepts like screening, prevention, and even treatment. Words are powerful. We need to choose ours carefully. We need to avoid complicity in misleading the public into believing that if they just eat right, exercise, and submit to a variety of screening procedures, they won’t die from cancer.

As Ms. Kolata also points out, “Research lurches from fad to fad — cancer viruses, immunology, genomics. Advocacy groups have lobbied and directed research in ways that have not always advanced science.”

Those of us involved in cancer research must continue to carry the fight forward, guided by science, so that one day cancer will be no more feared than high blood pressure.

Related Posts:
Does Vitamin D Help Prevent Breast Cancer?
HPV, STI’s and Teenaged Girls


Mary said...

Thank you for this very informative post! This is one of many reasons that I support private research funding for sarcomas. While some cancers may be preventable, the nature of most sarcomas makes prevention programs virtually useless. And who is going to spend money on early detection and education about sarcomas, since they are so rare? I don't know if a cure will ever be found, and I'm sure the research we need to do just to understand sarcomas will be incredibly expensive. But research has led to many, many advances in treatment of other cancers in the past 20 years. I just want sarcoma patients to get that too.

Elizabeth Munroz said...

This is very thought provoking and makes me realize how this fallacy of believing if caught early certain cancers can be prevented from proliferating. It has been a question on my mind often as I see chondrosarcoma patients with exactly the same primary diagnosis ending up with very different outcomes. Learning that we cannot predict the variability brings it all home to me. Thank you for bringing up this very important subject. I will be approaching the subject of early detection and preventability differently now, as I had believed the same.

Luke said...

I think the Health Care system has had a ongoing difficulty with the timely utilization of research and more so in disseminating relevant findings to impacted populations.

Last stat I recall was a general estimate of 17 years from publication of research to widespread utilization.

I believe there currently are many well meaning initiatives to shorten this gap such as the push for evidence based health care. Although, I don't know how PR Departments let that be the name for current practice improvements. Because it just begs the question of what health care practice was before we decided to use evidence to base practice on.

If health care providers have this much difficulty with the implementation of research then indeed guiding the public in prevention and screening will be difficult.

But regardless for better and worse change/newer fads are coming.

This past Thursday, Senators Edward Kennedy and Kay Bailey Hutchison introduced new landmark legislation to the U.S. Congress to develop new strategies and improve existing systems in fighting cancer. Entitled the 21st Century Cancer ALERT (Access to Life-saving Early detection, Research and Treatment) Act, the legislation intends to reevaluate our national cancer program and improve cancer research, prevention, detection, control and treatment. The legislation's reported aim is to increase the pace and effectiveness of cancer research, treatment and prevention.

Health care is changing especially in regards to the individuals increasing participation in their own health maintenance and in their access/bombardment of health-ish info.

Perhaps we need a lexicon for the "evidencity" of prevention, screening, and tx recommendations. How do we inform practitioners and particularly consumers what is substantiated by degrees of research or lack of research. How do you individualize evidence to the point of utilization by the individual. If evidence finds a more timely and clearer voice, how do you keep it from dilution by special interest miscommunication.

Does the health care system toss the individual a sack of oranges and ask, "How do you like dem apples." Because apples and oranges are close enough. Well I don't know about the last part. It just gave me giggles to write, "How do you like dem apples."

Hopefully greater access to information will lead to improvements.

If 50 years largely focused on tx has only dropped the age-adjusted death rate a mere 5% perhaps a reevaluation is inorder to include greater research on prevention, screening, quality of life issues, and ...

Doctor David said...

Thank you for your thoughtful, insightful comments. That's part of what I love about blogging... being able to provoke thoughts like these!

Michael Wilhelm said...

I am very impressed by your site and blog.
I am just beginning mine and among running a small public company (ImmuneRegen Biosciences) and other healthcare related companies, I don't get to the blog as often as I would like. I am impressed by your blog's upkeep.

I guess I would update more often if there was more traffic to my blog. Hopefully having Cadence for Cancer visible on your site will assist in this. I am a longtime advocate for cancer research as we ourselves are developing modalities for treating the disease. Additionally, I am new to charitable fundraising, and am quite committed to doing so for the rest of my life.

I will keep your blog in favorites and visit often.

enlarged prostate treatment said...

The fight to find a cure for cancer must move forward. There are too many people suffering from such illnesses and deserve a cure!

Telephone Triage said...

A very thought provoking site and blog...yes we need to care a little more for it is a human life and not just a toy.

Medical Billing Software said...

Yes the medical staff take it lying down and treat it just like a office days work...sometimes they refuse to come on Sunday and even not attend a serious patient on a holiday.

More Medical Travel Info said...

Yes they have become very professional and like a business organization.Complicit is an understatement they have become negligent actually.

Propecia said...

Complicit yes because there are diseases like HINI in this era of modern medical advancement and yet nothing to do about it.

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