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Avoiding the obvious while running in diminishing circles
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My colleague Mellisa Wheeler, MSW, director of outreach services at Levine Cancer Institute, ran an extraordinary meeting focused on disparities of cancer care.
She invited Otis Brawley, MD, MACP — chief medical officer of the American Cancer Society and a HemOnc Today Editorial Board member — as principal guest, supported by a faculty that included Dorothy Roberts, JD, professor at University of Pennsylvania.
Brawley spoke eloquently about the adverse impact of inequity of care, and Roberts reminded us that the issue of race and disparities of care is more complex than many recognize. Specifically, many of the shibboleths about worse outcomes of medical care for African Americans being racially or genetically determined are confounded by socioeconomic issues that lead to poor access and affordability as the primary determinants of these results.
What was unique was that there was a packed house of socially active clinical personnel, all working in the Carolinas to overcome disparities of care, under adverse circumstances with a chaotic and dysfunctional national system of health care — a federal government that is somewhat in disarray regarding the funding of health care and health insurance, state governments often without any clear plans of action, and a hardening of the national attitude to the underprivileged.
The participants were drawn from groups that actually do something to help the plight of the underserved, rather than spending all their time in analysis paralysis and planning exercises. Their work really matters.
Adverse outcomes for underserved
Those of you who read this column regularly know I believe that attention to the problems of inequity of health care could be the single biggest step toward reducing cancer deaths. This meeting emphasized that concept, and reminded me that our present society — and its approaches to inequity — probably will send us in the wrong direction.
There are clear data to show the adverse impacts of poor care for minorities and other underserved populations. We have previously shown there are significant differences in cure rates between well-insured patients and those on Medicaid, with a disproportionate population of black and Hispanic individuals receiving Medicaid. One important impact of the Affordable Care Act was that it reduced the number of uninsured black and Hispanic individuals by nearly 50%.
Pan and colleagues reported that there also are clearly defined differences in outcome between insured black individuals and their white counterparts. The uncertainty in government support for a health safety net for minorities and underserved populations easily could lead to an increase in cancer deaths similar to the one that occurred in the financial crash of 2008, when thousands lost health insurance.
PSA screening
Another example of this egregious national folly is covered in the excellent discussions of prostate screening in this issue of HemOnc Today. As seen in the cover story, there has been considerable controversy about the utility and effectiveness of PSA screening for asymptomatic men with prostate cancer.
I favor the view that random screening of asymptomatic white men, with no family history, has not been proven to save lives.
The majority of the randomized trials — if they have shown any survival difference — have only shown it to occur with respect to deaths from prostate cancer, but this has been offset by deaths from other causes. Most of the published studies have not yet reported an OS benefit from screening, despite nearly 2 decades of follow-up.
In my view, if there is no difference in live bodies at the end of a randomized trial of any screening and no evidence for improved quality of life, the exercise has failed to produce the desired result.
I emphasize that my view excludes black individuals and those with a family history. Sadly, as enunciated in the aforementioned articles, blacks were grossly underrepresented in the extant randomized trials of PSA screening, and little has been done to resolve the problem. Thus, we have no good information about whether this group will or will not benefit from prostate screening.
Although the NCI and other federal agencies require appropriate racial and ethnic representation in their funded studies, it is amazing how often that just does not occur, even though there has been some improvement in the past 2 decades. Perhaps a more stringent enforcement of the rules vis-à-vis funding of cancer centers and grants might improve the situation to an acceptable level.
We know black individuals have the highest incidence of prostate cancer, they may have more advanced prostate cancer at presentation, and there is a higher death rate from this disease than among white or Hispanic individuals.
Surely there should be greater focus on this problem, and it is a serious lapse that the U.S. Preventive Services Task Force neglected to emphasize the importance of completing relevant studies in its last report. The various Intergroup trial teams seem not to have placed this crucial issue on their research agendas, either.
Unfortunately, the U.S. Preventive Services Task Force encyclical is being applied to black individuals widely, without adequate data, and I fear that this will have devastating consequences.
Ignored opportunities
History will judge the physicians, politicians and health policy mavens of the present era harshly for their failure to tackle so many important and burgeoning public health issues. My list includes prostate cancer screening in black individuals, HPV vaccination, other measures to improve equity in cancer care, well-funded and definitive studies of cancer survivors, and the impact of increasing obesity on health outcomes, just to name a few.
Instead of focusing on these, the medical and political powers continue to focus on incremental improvements in treatment of advanced disease and pointless epidemiological studies focused on weak associations in cancer causation.
Potential quantum leaps are available for testing, but we continue to ignore them.
References:
Goss E, et al. J Clin Oncol. 2009;doi:10.1200/JCO.2008.21.1680.
Koroukian SM, et al. Cancer. 2012;doi:10.1002/cncr.27380.
Pan HY, et al. Cancer Epidemiol Biomarkers Prev. 2017;doi:10.1158/1055-9965.EPI-16-0976.
Raghavan D. Oncologist. 2011;doi:1634/theoncologist.2011-0233.
Siegel RL, et al. CA Cancer J Clin. 2017;doi:10.3322/caac.21387.
For more information:
Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, is HemOnc Today’s Chief Medical Editor for Oncology. He also is president of Levine Cancer Institute at Carolinas HealthCare System. He can be reached at derek.raghavan@carolinashealthcare.org.
Disclosure: Raghavan reports no relevant financial disclosures.