Latest / CareTalk: Healthcare. Unfiltered. / Dr. Otis Brawley on Cancer Screening and Health Disparities

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Dr. Otis Brawley on Cancer Screening and Health Disparities · CareTalk: Healthcare. Unfiltered.

• 0:00
  David: When it comes to cancer screening, it is possible to have too much of a good thing.
• 0:04
  David: Today's guest, Dr.
• 0:05
  David: Otis Brawley, is the global expert on cancer prevention and control.
• 0:09
  David: He's focused on reducing overscreening of medical conditions to increase quality of life and reduce racial, economic and social disparities.
• 0:17
  David: He leads research efforts at the Bloomberg School of Public Health and the Johns Hopkins Kimmel Cancer Center and more.
• 0:24
  David: Welcome to Care Talk America's home for incisive debate about healthcare, business, and policy.
• 0:29
  David: I'm David Williams, president of Health Business Group.
• 0:33
  John: And I'm John Driscoll, the president of Walgreens Health.
• 0:35
  John: Dr.
• 0:36
  John: Braley, thank you so much for joining us and, and for helping update us on kind of where we are in terms of cancer care and cancer screening.
• 0:44
  John: Um, thank people.
• 0:45
  John: Thank you.
• 0:46
  John: Often talk about the how, well, how poorly we're doing on every health statistic.
• 0:52
  John: Globally, you know, where I think like we're the lowest in the industrialized country on so many different public health measures, but on cancer cancer's usually held out as an example to the contrary.
• 1:03
  John: So as the person who's probably done more research on this than anyone we could find, how are we doing on cancer care in the us, particularly against the rest of the.
• 1:14
  Otis: Yeah, it's interesting.
• 1:15
  Otis: Uh, if you look at survival statistics or five year survival statistics, we do very well, but that's cause we screen a lot and we screen more than anyone else.
• 1:24
  Otis: If you look at mortality, that is our people not dying from cancer.
• 1:30
  Otis: We don't do as well.
• 1:33
  David: Well, gee, I was hoping for a better answer than that, but I guess if you're speaking to an oncologist, you'd, you know that if that's the worst news you get, you're probably okay.
• 1:41
  David: So what's so, so, so what's the problem?
• 1:43
  David: We're just, um, what's, and what's going on with screening?
• 1:46
  David: You know, I alluded it to in the, in the, in the intro,
• 1:48
  Otis: but, well, in the United States we don't spend much time thinking about risk behaviors that prevent cancer and risk behaviors that, uh, cause us to live longer.
• 2:01
  Otis: We spend an awful lot of time obsessed with screening, and I'm not against screening, it's just that there is wise use of screening and then there is overscreening.
• 2:12
  Otis: Uh, lemme give you some examples.
• 2:14
  Otis: The easiest one is in cervical cancer.
• 2:17
  Otis: Uh, There are about 4,000 women who are gonna die from cervical cancer this year, and this study has been done time and time again.
• 2:26
  Otis: Uh, 95% of those women got no screening for cervical cancer within the 10 years of their diagnosis of cervical cancer.
• 2:36
  Otis: Most of them had never gotten cervical cancer screening at all.
• 2:41
  Otis: , but there's a host of women in the United States, the majority of women in the United States who are getting cervical cancer every year, cervical cancer screening every year.
• 2:53
  Otis: There is not a single organization, professional organization in the United States.
• 2:59
  Otis: They recommend cervical cancer screening every year.
• 3:02
  Otis: Some tests you should get every three years if you choose to get them.
• 3:06
  Otis: And other tests, you should get every five.
• 3:09
  Otis: Okay.
• 3:09
  Otis: I've just told you that the majority of women in the United States who are adults are getting regular screening too often, and yet 4,000 women die every year and they never get screened.
• 3:24
  Otis: That's an example of overscreening in our society at large, leading to under screening in the poor women who died from cervical.
• 3:34
  Otis: Uh, in the issue of, uh, uh, prostate cancer screening, we don't have good studies to tell us that prostate cancer screening definitively saves lives.
• 3:48
  Otis: Uh, all the major organizations in the United States, Canada and Europe don't say men should be screened for prostate cancer.
• 3:57
  Otis: They say men should be informed of the potential.
• 4:00
  Otis: And the potential benefits associated with prostate cancer screening, and then men should be encouraged to make a choice for themselves.
• 4:10
  Otis: I hear a lot of folks encouraging them to get screened for prostate cancer and not respecting a man's right to make that decision for himself.
• 4:19
  Otis: I hear a lot of folks promising the prostate cancer screening definitely saves lives when the National Cancer Institute says it's one of the important questions in American medicine today.
• 4:34
  Otis: These are some so is.
• 4:36
  John: Is the problem incentives, Otis?
• 4:39
  John: Is it, is it that we're, we're paying more for an incentive, more screens and we should be investing more in healthier behaviors?
• 4:48
  John: Is that at the bottom
• 4:49
  Otis: of what we're, that's part of it.
• 4:51
  Otis: You know, it's hard to, uh, make a living off of prevention unless you're selling vitamins that don't.
• 4:58
  Otis: Uh, and that, that's a real problem to begin with.
• 5:01
  Otis: Yeah.
• 5:02
  Otis: Uh, the, the other issue is ever since we were all at our mother's knee, we were told the way to deal with cancers to find it early and cut it out.
• 5:12
  Otis: That was a fine message in the 1920s, perhaps into the 19.
• 5:17
  Otis: Fifties and sixties.
• 5:18
  Otis: But the one thing that has happened in this medical revolution that we have is our screening tests are getting better and better, and we're starting to be able to identify a lot more cancer than we used to be able to identify, and we've not been able to reconcile this following fact.
• 5:39
  Otis: There are a ti, there are some cancers that God never intended for them to grow.
• 5:47
  Otis: and kill.
• 5:48
  Otis: Yes, I can find a prostate cancer in a man, but many of those prostate cancers we now know are never destined to harm that man.
• 5:59
  Otis: And the greatest harm I can do is tell him he has prostate cancer and then go cure him.
• 6:05
  Otis: And the concept that there is a type of cancer that doesn't need to be cured, it's very hard for people to accept.
• 6:14
  Otis: You know, one of the things we should do more is define the molecular test that are better going to be able to identify the cancers that need to be treated and the cancers that need to be watched.
• 6:28
  Otis: Uh, by the way, this overtreatment, this type of cancer that doesn't need to be treated.
• 6:34
  Otis: It exists in prostate cancer.
• 6:36
  Otis: It exists in breast cancer.
• 6:38
  Otis: It exists in thyroid cancer.
• 6:41
  Otis: I'm not saying if you have a breast cancer, don't get it treated.
• 6:44
  Otis: I'm saying that the future of medicine is going to lead us to Mrs.
• 6:51
  Otis: Smith.
• 6:52
  Otis: You have a breast cancer, but it needs to be lodged.
• 6:56
  Otis: Mrs.
• 6:56
  Otis: Jones, you have a breast cancer that needs to be treated.
• 7:00
  Otis: That's the future and we need to realize and invest in doing the research to get to that.
• 7:08
  John: does the grail test, I mean, these, these, these, these, these, these liquid biopsy tests that are emerging from Illumina and others where they're looking at creating probabilistic models around at, at, uh, based on what they see at a molecular, is that the kind of promise that you're, that, that you're, that you're hoping to see delivered from a, from a sort of te basically what you're saying, screen test, treat, not treat, it's that kind of a if then.
• 7:36
  Otis: Yeah, well this is where I have to tell you, I'm a consultant to Grail As they're trying to develop their tests.
• 7:41
  Otis: Uh, there are a number of these blood tests, we call them ceeds, or multi early detection tests that are being developed right now.
• 7:51
  Otis: And, uh, these tests may have a number of different uses in the.
• 7:56
  Otis: We're not exactly ready to say what all of those uses could be.
• 8:01
  Otis: Some of them are gonna be useful to assess people after treatment to make sure they have not relapsed.
• 8:07
  Otis: Some of them may used in addition to normal screening.
• 8:14
  Otis: As an adjuvant.
• 8:15
  Otis: You know, the grail test is actually being marketed right now in some countries, but they very carefully say, continue doing colon cancer screening with stool blood testing or colonoscopy.
• 8:28
  Otis: Continue doing mammography screening.
• 8:31
  Otis: Uh, those are the tests that we know.
• 8:33
  Otis: Save lives.
• 8:34
  Otis: If you're going to do prostate cancer screening, continue doing it and use the grail test in addition.
• 8:41
  Otis: I think several other companies are going to be very much like that in the near future, but this is a huge area of, uh, research.
• 8:50
  Otis: And yes, those tests may ultimately, in five or 10 years, be able to identify the cancers that need to be watched versus the cancers that need to be.
• 9:02
  Otis: .
• 9:02
  Otis: David: I wanna go back to your point, the sounds like there's plenty of screening and aggregate, but it's not necessarily reaching the people that that need it.
• 9:10
  Otis: And I wanna overlay that on the, with the public policy side and ask you about Medicaid expansion, which is a big part of the Affordable Care Act.
• 9:19
  Otis: Has that had an impact on cancer screening?
• 9:21
  Otis: Has it helped to reduce some of these disparities that you're talking about?
• 9:24
  Otis: Or is it, or they not really?
• 9:26
  Otis: Yes, yes.
• 9:27
  Otis: Uh, the, the Affordable Care Act has done some wonderful things.
• 9:31
  Otis: Uh, we're only going to start sending the expansion of the Affordable Care Act, start decreasing mortality in the next year or two.
• 9:39
  Otis: Remember, a cancer diagnosis this year, uh, early is going to prevent a death intend to 12 years from now at, at the very earlie.
• 9:50
  Otis: What we have seen is states, uh, like in Ohio, uh, that have expanded the Affordable Care Act so that everyone who's an adult has insurance.
• 10:00
  Otis: We're seeing women who have that cervical cancer, uh, being treated with the more advanced treatments that preserve fertility.
• 10:11
  Otis: Uh, compared to women who might be in Mississippi or Alabama that have not, or, or Georgia, which is not expanding, uh, Medicaid so that all people who are adults in those states are around.
• 10:24
  Otis: Are are insured, uh, we are definitely starting to see state by state disparities.
• 10:30
  Otis: You know, when I started my work 30 odd years ago, uh, we used to talk about minority health and health disparities.
• 10:37
  Otis: We're now starting to talk about Mississippi versus Massachusetts.
• 10:42
  Otis: When we start talking about disparities, uh, cause states that have not expanded.
• 10:48
  Otis: Uh, clearly have all the indicators to show that they're gonna have higher mortality from cancer from a number of cancers than states that have expanded Medicaid.
• 11:00
  Otis: And is
• 11:01
  John: that being driven ironically, because people are getting screened.
• 11:05
  John: Or screened and treated earlier.
• 11:07
  John: Is it this that is the positive.
• 11:09
  John: So you're basically not anti screening, you're for appropriate care.
• 11:14
  Otis: That's exactly right.
• 11:15
  Otis: I very frequently am, uh, accused of being against screening.
• 11:19
  Otis: I'm against inappropriate screening.
• 11:22
  Otis: I'm.
• 11:22
  Otis: For appropriate screening.
• 11:24
  Otis: And you bring up another really good point.
• 11:27
  Otis: Uh, one of the early papers that made my career was a paper that, uh, showed that 7% of black women in, 2% of white women in metropolitan Atlanta who were diagnosed with localized, curable breast cancer, got no treatment in the first year after diagnosis.
• 11:46
  Otis: So we, we focus a lot on screen, screen screen.
• 11:50
  Otis: We don't focus enough.
• 11:52
  Otis: Diagnosis and treatment after the screening.
• 11:55
  Otis: Uh, and you know that 7% of black women with a curable breast cancer not getting the cure within a year of diagnosis, I think says it all about the United States.
• 12:10
  Otis: So,
• 12:10
  John: so what can we do about that?
• 12:12
  John: Obviously that's an outrageous number.
• 12:14
  John: It's an not ra 1% is an outrageous.
• 12:17
  John: But that differential is
• 12:18
  Otis: crazy.
• 12:19
  Otis: Percent of white women.
• 12:20
  Otis: Yeah.
• 12:20
  Otis: The 2% of white women is 7% of black women who got no treatment after they heard those commercials about get a mammogram, and then had enough access to care that they got a biopsy and a pathologist ready as being cancer.
• 12:35
  Otis: The issue for those women.
• 12:37
  Otis: Uh, is they are not really in the medical system or they don't feel comfortable in the medical system.
• 12:45
  Otis: We spend a lot of time on making sure people can afford care and making sure that people have the care available to them, but not can they utilize the care.
• 12:56
  Otis: Some people have tried to overcome this issue with navigators.
• 13:01
  Otis: Friends or buddies to carry people through the healthcare system and help them get the services that they need.
• 13:09
  Otis: Those things can be very important.
• 13:11
  Otis: We need social workers who have access to programs to help women get the care that they need.
• 13:18
  Otis: Some of these women did not get treated because they didn't have transportation, uh, for regular, regularly going to the doctor.
• 13:27
  Otis: Mm-hmm.
• 13:28
  Otis: . Going to the clinic.
• 13:29
  Otis: Some didn't get treated cause they didn't have childcare.
• 13:33
  Otis: Uh, there were some who didn't get treated cause they had a job.
• 13:37
  Otis: But if they took time off from their job, they would lose it.
• 13:40
  Otis: They didn't get sick leave.
• 13:42
  Otis: You know, these are all social issues that lead to people dying, things that really ought to be overcomeable in the wealthiest country in the.
• 13:51
  Otis: Country that spends 18% of its gross domestic product on healthcare when the number two country, Germany spends 11% on healthcare.
• 14:02
  David: So speaking of, uh, spending money, one place that we spend a lot of money is on, on drugs, including on drugs for cancer.
• 14:09
  David: What do oncologists think about drug price?
• 14:15
  Otis: Drug pricing is a double edge sword.
• 14:20
  Otis: Uh, drug pricing.
• 14:23
  Otis: Uh, If it is low, many companies will lose the incentive to develop new treatments.
• 14:30
  Otis: Uh, but yes, I have patients who are faced with a $3,000 deductible for, uh, a particular oral medication,$3,000 a month in deductible for a particular oral medication.
• 14:44
  Otis: They just cannot.
• 14:46
  Otis: This is actually very common now in American medicine.
• 14:50
  Otis: Uh, one issue is maybe these folks need to have better insurance and there are some really bad insurances out there.
• 15:00
  Otis: You know, the affordable care.
• 15:02
  Otis: Act says you have to have an insurance.
• 15:04
  Otis: It doesn't say you have to have a good insurance.
• 15:06
  Otis: And many people don't realize how bad their insurance is until they get faced with $3,000 per month deductibles for a particular drug.
• 15:16
  Otis: Uh, so I, I would fix that.
• 15:18
  Otis: And the other issue, uh, when we talk about drug prices and the drug companies making lots of money, I would wanna point out nobody ever points out that, uh, The insurance industry, the health insurance industry is making an awful lot of money.
• 15:36
  Otis: Actually, if you were going to invest in, uh, the drug industry or the insurance industry, uh, you would go with the insurance industry cause their profits are much better right now.
• 15:48
  David: Sounds good.
• 15:49
  David: John, last question to you.
• 15:52
  Otis: I,
• 15:52
  John: I, I guess Otis, what I always find interesting about your work and our conversations, I learn more about what I thought I knew regarding whether it's cancer or data or what's actually going on.
• 16:04
  John: So, and I love your theme about ingesting, reminding people that care needs to be part of healthcare.
• 16:09
  John: It shouldn't just be costs and infrastructure, but.
• 16:12
  John: Caring through caregivers and navigators and thinking about the whole person.
• 16:16
  John: But what's your advice to consumers?
• 16:18
  John: Because I think the, the statistics are, you know, um, you know, a one out of every, I forget how many Americans will get cancer in their lifetime.
• 16:27
  John: It's
• 16:27
  Otis: somewhere around one out of every 2.7 or so.
• 16:31
  Otis: It's, it's
• 16:32
  John: what's.
• 16:34
  John: So what's your advice to, to, to, what's your, what's your, what's your final advice to our, our, our, our, our population?
• 16:41
  John: That if they don't get cancer, they'll know someone close who has
• 16:45
  Otis: Yeah.
• 16:45
  Otis: Well, we need to be, we need to be literate about all the aspects of cancer from prevention and risk reduction through screening, diagnosis, and.
• 16:55
  Otis: Uh, when I say prevention and risk reduction, uh, one of the things that I published a few years ago is the death rate for, uh, college educated women in the United States is 60 100,000 per year.
• 17:09
  Otis: The death rate for high school educated women is exactly twice that.
• 17:14
  Otis: 120 per 100,000 per year.
• 17:18
  Otis: Uh, now what is it about education that lowers the risk of death?
• 17:23
  Otis: It's actually the fact that you could get into college.
• 17:26
  Otis: Cause women who do one year of college are closer to the college graduates than they are to the high school graduates.
• 17:33
  Otis: And this is getting to cancer Prevention is a pediatric.
• 17:38
  Otis: The most common age that people start smoking is 16.
• 17:42
  Otis: The second most common age is 15.
• 17:45
  Otis: We have data to show that weight gain from birth to the age of 15 increases a woman's risk of getting breast cancer when she's 60 years old.
• 17:56
  Otis: We need to focus on, uh, the adult and.
• 18:00
  Otis: The pediatric obesity problem in the United States, you know, 40% of adults are obese among black women, 60%.
• 18:09
  Otis: By the way, there is another category called overweight I haven't talked about.
• 18:13
  Otis: Obesity is worse.
• 18:15
  Otis: 40% of adults are obese among children.
• 18:19
  Otis: It was 4% in 1970, and now it's 20 plus percent of kids are obese.
• 18:26
  Otis: We need to focus on.
• 18:28
  Otis: Okay.
• 18:29
  Otis: Then we need to, those of us who are adults, we need to focus on the appropriate screening that we all should get, which is colon cancer screening every 10 years, if it's colonoscopy every year, if it's stool blood testing every three years, if it's stool dna.
• 18:47
  Otis: Starting at 45 for people at normal rest cervical cancer screening among women who are adults every three years or every five years, depending on the test that you decide to get.
• 19:00
  Otis: Men need to make the decision about prostate cancer at about the age of 50, and they need to get it every one to two yards.
• 19:09
  Otis: Those of us who smoke, please.
• 19:11
  Otis: If we smoked, uh, more than 30 a pack a day for more than 30 years, talk to your doctor about the pros and cons of lung cancer screening and go get your lung cancer screening at a good place.
• 19:24
  Otis: That's another problem we in America have.
• 19:27
  Otis: Sometimes we go get our treatment.
• 19:29
  Otis: At the wrong places.
• 19:30
  Otis: There's certain things that need to be done in the big major hospitals.
• 19:34
  Otis: Certain things that can be done in the community.
• 19:37
  Otis: Hospitals try to think about these things.
• 19:40
  Otis: By the way, last thing I'll say, in addition to Don't smoke.
• 19:43
  Otis: Everybody should try to eat five to nine servings of fruits and vegetables per day.
• 19:48
  Otis: Everybody should try to get some exercise on a daily basis.
• 19:53
  Otis: The American Heart Association of American Cancer Society of Great Publications on that.
• 19:58
  Otis: We need to, we're gonna have to
• 19:59
  John: get David out of that office.
• 20:01
  John: That's why he looks so pale Lotus.
• 20:02
  John: I mean, he's not looking good.
• 20:04
  John: We gotta get him out.
• 20:05
  John: Yeah.
• 20:05
  John: We gotta,
• 20:05
  Otis: we need to start thinking about health.
• 20:08
  Otis: Yes,
• 20:08
  David: John, I was trying to emulate, you know, uh, the leaders.
• 20:12
  David: Putting on the right headphones, but I guess it's not, that's it's, that's not gonna be enough . Let's just to start in any case.
• 20:17
  David: That's it for yet.
• 20:18
  David: Another episode of Care Talk.
• 20:20
  David: Our guest today has been Dr.
• 20:21
  David: Otis Brawley.
• 20:22
  David: He's a leading expert on cancer prevention and control.
• 20:25
  David: I'm David Williams, president of Health Business Group,
• 20:29
  John: and I'm John Driscoll, the president of Walgreens Health.
• 20:32
  John: If you like what you heard, you didn't, please subscribe.
• 20:35
  John: Otis, thank you for joining us.
• 20:37
  John: It's my
• 20:38
  Otis: pleasure.
• 20:38
  Otis: Thanks for having me.