Print BCTV: Failing Patients -- American Cancer Society CMO Brawley on social disparities in cancer care

Failing Patients

Transcript of BioCentury This Week TV Episode 153




Dr. Otis Brawley, Chief Medical Officer, American Cancer Society




National Cancer Institute

Grady Memorial Hospital

Winship Cancer Institute, Emory University




Oncologic Drugs Advisory Committee

Halsted Mastectomy

Tuskegee Syphilis Study




Affordable Care Act


American Society Clinical Oncologists

American Heart Association

American Diabetes Association



Steve Usdin, Senior Editor




NARRATOR: Your trusted source for biotechnology information and analysis, BioCentury This Week.


STEVE USDIN: Has money corrupted medicine? What's behind the tremendous disparities in care? This week, a candid conversation with the Chief Medical Officer of the American Cancer Society, one of America's most outspoken physician scientists. Coming up, Otis Brawley's controversial views.


NARRATOR: Biotechnology is a complex world of passionate opinions and strong personalities. "Point of View" is a special BioCentury series, probing the thinking and experiences that have shaped some of biotech's most controversial and influential individuals.


STEVE USDIN: Otis Brawley grew up in a crime-infested Detroit neighborhood, determined to avoid the drugs and violence that surrounded his family. He beat the odds, graduating from the University of Chicago's School of Medicine and completing a prestigious fellowship at the National Cancer Institute. As head of cancer care at the nation's largest public hospital, Grady Memorial Hospital in Atlanta, and deputy director of the Winship Cancer Institute at Emory University, Dr. Brawley saw the good and bad of America's health care system.


He became convinced that money has corrupted medicine, that the pursuit of profits by insurance companies, pharmaceutical companies and physicians is causing unnecessary suffering. Brawley has spoken out in a controversial book, and his criticisms aren't easily dismissed. As Chief Medical Officer for the American Cancer Society and adviser to FDA, the CDC, and NIH, he's one of the most influential oncologists in America.


I'm pleased to be joined by Dr. Otis Brawley, Chief Medical Officer of the American Cancer Society. Dr. Brawley, there are tremendous disparities in the outcomes for cancer patients in the United States based on their race. Why is that? Is it rooted in culture, or is it biology, or some other reasons?


OTIS BRAWLEY: Overwhelmingly, the disparity is because of disparities in quality of care. When I say quality of care, I'm also talking about preventive care. People who are poor, people are less educated, people who are disenfranchised don't get a lot of the things that people who are middle class and within the system get. And overwhelmingly, when we look at black, white disparities, more than 70% of those disparities are due to logistical issues of just not getting the simple care that people ought to be getting.


STEVE USDIN: So can you give some examples? I'll start with a question: colorectal cancer -- the rates of colorectal cancer deaths between blacks and whites in America are hugely divergent. What are some of the reasons for that?


OTIS BRAWLEY: Well, that's a great example. Colorectal cancer is one of the diseases that there's no debate screening actually saves lives. And we've got great data to show that there are huge black, white differences in screening for colorectal cancer, number one. We've also got data to show that people who don't have insurance or don't have the ability to go to the doctor because they feel an abdominal symptom or a bowel problem put off going to the doctor and end up in an emergency room, because they've got an obstruction from an advanced colorectal cancer.


If that person were not poor or had insurance, had availability of physicians, they would've gotten diagnosed earlier when the disease was more treatable. Frequently, black is just a code word for poor. Or black is a code word for disenfranchised or without insurance or without access to care. And that overwhelmingly drives most of the disparities.


STEVE USDIN: So that makes me wonder, I used to watch you when you were a member of the Oncologic Drugs Advisory Committee for the FDA, the ODAC. Every ODAC meeting that I would go to, there was always somebody who would say, but there aren't enough black people in this clinical trial, or there aren't enough people of this racial minority in a clinical trial. If the differences are cultural or economic rather than biologic, does it make sense to say we need to get more African Americans in clinical trials.


OTIS BRAWLEY: Very rarely does it make sense to say we need to get more black Americans on clinical trials, from a scientific standpoint. Frequently, people are motivated by political ambitions when they say we need to get more blacks on the clinical trials. But from a scientific standpoint, what we need to be worried about is getting more blacks decent care.


The problem is not that that the drugs don't work in blacks. The problem is blacks don't get the drugs.


STEVE USDIN: So I want to switch to another topic and something you've written about, which is some of the causes for cancer. And one of the things I think that might surprise me -- it surprised me when I read it in your book -- is that obesity is one of the leading causes of cancer in the United States. And if you think about it, cigarette smoking is declining, obesity is going up. Where are we going with that?


OTIS BRAWLEY: Yeah. Actually, that's also a reason for some of the disparities, because obesity rates are higher, especially in black women in the United States, compared to white women. Smoking is the number one cause of cancer right now. In the last 20 to 30 years, epidemiology has shown that obesity -- it's really a triad. It's high caloric intake, lack of physical activity, and obesity, the three things combined actually is a huge cause of cancer.


It is causing more cancer, that triad. Smoking is causing less cancer. Within the next 10 to 20 years, it will be the number one cause of cancer, the triad of high caloric intake, lack of physical activity, and obesity. It will have surpassed tobacco.


STEVE USDIN: And another thing that's interesting and people have to think about is that there's a long time frame, there's a long onset. People think of you're having an exposure or something happening to you. And you get cancer. Actually, it's a lot more complicated long term than that, isn't it?


OTIS BRAWLEY: Absolutely. There's a lead time or a lag time. For example, when people stopped smoking in the 1960s and 1970s in large numbers, as they did after Luther Terry's announcement, people stopped dying from lung cancer in the 1990s and into 2000 to 2010. When people started getting cancer because of obesity, it actually was 10, 20, 30 years of obesity that led to the cancer.


A lot of people think that you do something and you get an end result of the cancer very quickly. There's usually a 20 to 40 year lag time in many of these things.


STEVE USDIN: Thanks. More of Dr. Brawley's point of view in just a moment. But first, some shocking data on cancer disparities.


NARRATOR: You're watching BioCentury This Week.




STEVE USDIN: We're talking about money and medicine with Dr. Otis Brawley. Dr. Brawley, in your book, you talk about how economic incentives for drug companies, for hospitals, for insurance companies, have distorted medical care. I want to take them apart, pick them apart. Let's start with drug companies. Of all the drugs that were approved for cancer last year, 11 of the 12 cost more than $100,000. Are they worth it?


DR. OTIS BRAWLEY: Yeah, that's a really good question. It literally is 11 out of 12 cost more are $100,000 a year for treatment. Most of those drugs only increase median survival by three to four months. I'm really worried about drug development. Perhaps the answer is that some of these drugs ought to be mixed together. There's some incentives for the drug companies to not try trials where one company's drug is mixed with another drug. This is a huge problem. Profit and desire for profit is actually holding us back. It's negatively affecting progress in cancer.


STEVE USDIN: In what way? Because the drug companies, of course, will say they need to make those profits -- they do say it -- in order to invest those into the best research itself.


DR. OTIS BRAWLEY: In order to protect someone's drug, they're not going to allow their drug to be compared with another drug or someone to take both drugs while they're being treated for cancer. And especially when we talk about these newer targeted drugs, having two or three targets being hit -- very much like we're doing now in treatment of HIV disease -- having two or three targets being hit at the same time might be the way to treat some of these cancers, but many of these drug companies don't want their drug to be used with other companies' drugs for fear that they might harm that drug's reputation and decrease their ability to charge for it.


STEVE USDIN: You've written in your book also, you're highly critical not only of drug companies, but also of physicians. And you suggested that in many instances, or in some instances, physicians' treatment decisions are motivated more by their pocketbook -- by the profits that they're going to make from delivering drugs -- than by what's best for their patients. Do you really believe that?


DR. OTIS BRAWLEY: Yes, I do. Actually, I've got numerous examples. Thankfully, the system is changing a little bit, but the way we have worked, especially in medical oncology and several other disease entities -- rheumatology -- is that doctors give drugs to patients in their office, and we literally sell the drugs to the patients with a mark-up. We buy wholesale, we sell retail.


In medical oncology, when there's a question as to whether someone should be getting a chemotherapy, the incentive is to the doctor to say, let's give the chemotherapy. Patients who want treatment, even though they may not necessarily need the treatment, they want to get the therapy, as well. So I really think that there's a lot of problems in the system. Some of them are with doctors. Some of them drug companies. Some of them with insurances and hospitals. Some with patients.


STEVE USDIN: So what's the solution when you're talking about doctors? Right now, they get a mark-up on the drugs that they give. What's a more rational way to do it?


DR. OTIS BRAWLEY: Well, first off, I don't want to condemn all doctors. I think there are a bunch of us in medicine who need to realize that the definition of a professional is someone who puts their patient or their client above their own interests. And some of us do need to be more professional. Some of us already are very professional, but I think when we practice medicine, there's a bunch of us who need to start realizing what the science actually says and actually be much more orthodox to the science.


I'm also very outspoken that we need to start looking at certain things that are unclear, and realize there are things that we know scientifically, things that we don't know scientifically, and things that we believe. And one of the great problems in medicine is a lot of doctors confuse what they believe with what they know.


STEVE USDIN: So in cancer, what are some examples, say from the last decade, of things that doctors believed but then turned out not to be true?


DR. OTIS BRAWLEY: There has been premature adaptation of a number of things in medicine over the last 100 years that we did. And we actually would tell people who questioned us -- we would put them down. Some doctors actually have lost their jobs because they question things. So first, let's start out with the Halsted mastectomy. Dr. Halsted said this is how you do a breast cancer surgery in 1903. We continued doing it well into the 1980s.


Anyone who asked, could we do a lesser surgery, a less morbid surgery, like lumpectomy and radiation, actually got criticized. Some people lost their jobs for that. Prostate cancer screening, which we adopted in the late 1980s without a single clinical trial that showed that it was beneficial. That's an example of doctors jumping to a conclusion.


You want to leave medical oncology? When I was a resident, we used to give people drugs to suppress arrhythmias when we thought that they were going to have an MI. 20 years later, the clinical trials show that those drugs cause harm.


STEVE USDIN: Well, we've been talking about money and medicine. Here's some facts about cancer drug prices.




NARRATOR: Now, back to BioCentury This Week.


STEVE USDIN: Dr. Otis Brawley is Chief Medical Officer at the American Cancer Society. We're talking with him about improving cancer care. Dr. Brawley, in your book, you talk about famine and gluttony in cancer care. The famine part, that's pretty obvious. People don't get access to care.


What's the gluttony part?


OTIS BRAWLEY: The gluttony is there's a whole bunch of people who get too much healthcare. And they actually get harmed because they get too much healthcare.


STEVE USDIN: How can you get too much of healthcare? Healthcare is a good thing.


OTIS BRAWLEY: There are certain things that people do, certain interventions that are not scientifically proven to be beneficial. And people get harmed because they get those things that have not been proven to be beneficial but are thought to be beneficial.


STEVE USDIN: So you've been at the center of a few firestorms over this. One of them is around mammography.




STEVE USDIN: What's your views about mammography?


OTIS BRAWLEY: My view of mammography is that mammography clearly saves lives. We've got eight clinical studies to show that it saves lives. However, mammography has some drawbacks and some limitations. I'm concerned that a lot of the emphasis has been on getting mammography but not informing women of the benefits as well as the risk. And I really would like people to realize mammography does save lives. I happen to believe that women should start mammography screening in their 40s.


Others believe it should start in the 50s. And we can have that disagreement. But what we don't talk about is mammography is going to miss a lot of cancers that we wish it would find. Mammography is going to find some things that look like cancer that turn out not to be cancer. And women are going to get needless biopsies and needless treatment because of that. But it does save lives.


STEVE USDIN: And what about prostate cancer? You mentioned that earlier, prostate cancer screening. That's another controversy.


OTIS BRAWLEY: Prostate cancer screening I got involved with because I was involved in the apology for the Tuskegee Syphilis Study. And I ultimately met a marketing guy from a major cancer center who showed me this amazing business plan on how much money they could make by offering free prostate cancer screening. And I ask them, how many lives will you save if you screen 1,000 men? And he looked at me like I was a fool, and he said, don't you know, there's never been a study to show this stuff saves lives.


I can't give you an estimate.


STEVE USDIN: What's the point of it?


OTIS BRAWLEY: The point of it was that the hospital made lots of money off of free prostate cancer screening. People thought it was a good thing.


STEVE USDIN: They didn't make the money off the screening. They get the money off of the results of what people get as a result of that.


OTIS BRAWLEY: The treatment. You offer the free screening, you end up bringing some people in for treatment for things that you found.


STEVE USDIN: Is that is a good thing because you found cancer and you're saving people's lives?


OTIS BRAWLEY: I know radical prostatectomy in the United States, one out of every 100 to 150 men getting radical prostatectomy, they die as a result of the surgery. I know that, but I don't know how many men's lives are saved because they get the radical prostatectomy. So there's a real problem here. And it's an ethical issue. It's people wanting to make money, wanting to do good, but not realizing scientifically they don't know if they're doing good.


STEVE USDIN: So what's your message then to men? Should they get PSA tests?


OTIS BRAWLEY: I think that men, if you look at what all the major organizations say about prostate cancer screening and have been saying for some time is, men need to look at the possible unproven but possible benefits. Men need to look at the proven harms associated with screening. And men need to make a decision that they are comfortable with. I'm not saying men should not get screened.


I'm not saying men should get screened. They should realize there's a controversy. They should realize that there's a potential for benefit. There's a potential for harm. And they should do what they feel is appropriate for them.


STEVE USDIN: So another thing that's in the news now, very quickly, is the idea that some things that are being called cancer in the past shouldn't be anymore.


OTIS BRAWLEY: That's right. Our definitions of cancer come from German pathologists in the 1850s. And they did autopsy studies, and they look at a biopsy, and they'd say this is what prostate or breast cancer looks like. Now, 160 years later, with all our new technologies, we can biopsy a five millimeter lesion in a woman's breast and say it looks like the same thing that killed a woman 160 years ago. We don't know if that five millimeter lesion is genomically programmed to grow, spread, and kill, or if it's genomically programmed to stay five millimeters for 50 years.


STEVE USDIN: So what a difference if we call a cancer or if we call it something else?


OTIS BRAWLEY: If we start doing the studies to be able to figure out what needs to be treated and what needs not be treated, we can save a lot of people from the harshness of treatment.


STEVE USDIN: So Dr. Brawley, we've been talking about screening. Another kind of screening is screen for cervical cancer. What are your views about cervical cancer screening?


OTIS BRAWLEY: Cervical cancer screening in the United States is oftentimes an example of the overuse of technology. Everybody, the obstetrician, gynecologist groups, the American Cancer Society, all the major organizations recommend cervical cancer screening for adult women every three years. Many women get it every year.


If you look at the 4,000 or so women who die from cervical cancer every year in the United States and look at their medical histories, most of them never got screened ever. Those who did usually got a pap smear greater than 10 years before the diagnosis. So here you got a group of people who get screened too much and a group of people who don't get screened enough.


Those are the folks who die, the disparate people who have the disparities. I think pap smears are important. Women should be getting them every three years. Try to get a high quality pap smear. I'm a little bit worried that the people who read pap smears are disappearing, and a lot of this is becoming instrumented and mechanical.


I am worried about quality in the future.


STEVE USDIN: We've been talking about overuse of medicine and not getting enough access to the other kinds of treatment. Have you had to talk about some of the advances, though, of the last few years, what are the highlights, things where we really made some solid advances against cancer?


OTIS BRAWLEY: There's about a 20% decline in cancer mortality in the United States. Overwhelmingly, that decline in mortality has been brought about by prevention efforts, especially smoking cessation. Colorectal cancer screening is responsible for a 35% drop in colorectal cancer death rates. Breast cancer screening is responsible for about a 30% to 35% decline in breast cancer death rates.


So there's been some real impressive advances over the last 20 to 30 years, especially over the last 15 years. If we look at drugs, certainly the targeted therapies for a couple of diseases have been really, really important. Rituximab and the treatment of some of the lymphomas has been a godsend, Gleevec for the treatment of CML, Chronic Myelogenous Leukemia, as well as a few other diseases, even gastrointestinal stromal tumors has been a godsend.


We unfortunately have a lot of drugs that only prolong life for three to four months, but we've got a few areas where we've actually done wonderful. Crizotinib in ALK-positive, ALK-mutated lung cancer is actually something just in the last year or so that has come to fruition. We actually have drugs that are actually holding lung cancer in check. Unfortunately, it's only 2% or 3% of people who have lung cancer who have that.


But we are making some advances.


STEVE USDIN: Well, thanks. Coming up, a conversation you want to hear. Dr. Brawley's thoughts on preventing cancer.


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STEVE USDIN: Now, Dr. Brawley, prescriptions -- what can individuals and society do to improve cancer prevention? Dr. Brawley, besides the obvious, stop smoking, what are the things that people themselves can do and that we should do as a society we should do better prevent cancer?


OTIS BRAWLEY: Number one, we need to do things to promote physical activity and exercise and decrease obesity. We have become a culture over the last 40 or 50 years that actually consumes a lot more calories on a daily basis than we did, say, in 1970. The built environment, the lack of sidewalks in suburbs, our reliance on driving everywhere has actually caused us to get more obese and actually is increasing our cancer rate.


So try to be thin, try to exercise, try to eat five to nine servings of fruits and vegetables per day. I prefer sun avoidance. Wear long sleeves when going out into the sun, much more effective than even sunscreen.


Those are the major things.


STEVE USDIN: And if we're talking about it as a society, one of the things -- I think you've written about this also -- is what would be the difference in cancer outcomes if everybody got what we know is the best care for cancer?


OTIS BRAWLEY: If everybody got what we know is the best care for cancer I would estimate that somewhere between 8,000 to 12,000 Americans would not die every year right now. We are leaving a large number of people behind, because they get less than optimal care for cancer. That's just for cancer.


STEVE USDIN: And what do you think, the Affordable Care Act, is that going to make a dent in that?


OTIS BRAWLEY: The Affordable Care Act, in my mind, is more insurance payment reform than anything else. I see it as an improvement over our old system. But it's not as good as I wish it could be. The old system desperately needed to be changed, and I look forward to the Affordable Care Act, because it is an improvement. But it's not the improvement I would like to see.


STEVE USDIN: We've had people on the show also have talked about cancer and particular about Medicaid. And expanding Medicaid is one of the big things in the Affordable Care Act. The president of American Society of Clinical Oncologists said on this show that having Medicaid for a cancer patient, the outcome is the same as if they don't have any insurance at all.


OTIS BRAWLEY: In the past, that has been very true. But the average person who has Medicaid and is being treated for cancer got that Medicaid at the time they were diagnosed with cancer. If we can give people Medicaid and give them the education on how to use it for prevention, how they should be using their Medicaid to get colon cancer screening if they're over the age of 50, breast cancer screening if they're over the age of 40, we're actually going to end up diagnosing a bunch of these people with cancer earlier when we can actually treat them, when we can actually cure them.


STEVE USDIN: And getting then back to what we started to show with, which is disparities -- do you think that the Affordable Care Act is going to help much and in reducing disparities, or does something else need to be done?


OTIS BRAWLEY: The Affordable Care Act is clearly going to help reduce cancer disparities. It's going to reduce disparities in other healthcare areas. It is not going to be the answer to all of our problems. I believe that voluntary health organizations like the American Cancer Society, American Heart Association, American Diabetes Association, and others are going to need to step up and help people learn how to utilize the insurance that they all of a sudden have gotten. They're going to have to step up and help to promote healthy lifestyles still.


I do believe the Affordable Care Act is going to help save some lives. But it is not the answer to all of our problems.


STEVE USDIN: Thanks. That's this week's show. I'd like to thank my guest, Dr. Otis Brawley. Remember to share your thoughts about today's show on Twitter. Join the conversation using the hashtag #biocenturytv. I'm Steve Usdin. Thanks for watching.