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On killing innocents: Anzac Day revisited
April 25 is known in Australia and New Zealand as “Anzac Day,” commemorating the immense foolishness of a set of British generals at Gallipoli in World War I.
For reasons that have never made sense, they sacrificed thousands of Australian, New Zealand and British troops in a pointless assault on Turkish forces embedded atop cliffs in an impenetrable physical target. Had the British allowed these troops to land less than two miles downstream, at a beach leading to flat terrain, lives would have been saved by a forced march and an attack with even odds, and victory might well have occurred.
Anzac Day commemorates the only military loss sustained by Australian and New Zealand troops and reminds us of the impact of a bad decision process that overlaps with plain stupidity.
The report describing the presentation of Korenaga and colleagues in this edition of HemOnc Today reminds us of the folly of bad policy and poor planning (see related article).
‘Disturbing’ study data
Sadly, we have often covered the vast discrepancies of medical outcome endured by the underserved populations of the world.
This is not just a North American issue, but reflects the fate of some immigrant groups, those who are impoverished, people of color in white (and sometimes black) society, the elderly, those who are geographically isolated, indigenous populations, minorities, those with severe mental impairment and the LGBTQ community.
Some years ago, Siran M. Koroukian, PhD, Paul M. Bataki, MS, MD, and I showed that patients covered by Medicaid had significantly impaired survival outcomes compared with those with private insurance when treated for curable malignancies. Many studies have confirmed this type of discrepancy, and it has even been shown that cancer death rates worldwide increased in association with the international economic downturn in 2008, presumably because increased unemployment and poverty were associated with delay of potentially curative cancer screening and a concomitant shift of treatment from early-stage to more advanced disease.
At the Society of Gynecologic Oncology Annual Meeting on Women’s Cancer, Korenaga and colleagues reported data from the National Cancer Database for more than 10,000 women treated between 2004 to 2015, showing elegantly that the addition of brachytherapy improved outcomes for chemoradiation treatment of locally advanced cervical cancer, and that optimal outcomes were achieved when brachytherapy was delivered in a timely fashion (within 8 weeks).
They also noted that outcomes were improved even if brachytherapy was delivered in a delayed time frame, compared with no use of brachytherapy as part of definitive treatment (ie, when patients are treated only with chemotherapy and external beam radiation). These figures, if confirmed in a peer-reviewed paper, are quite astonishing, with nearly a 25% difference in survival beyond 10 years.
What is very disturbing, given this substantial difference, is that this study demonstrated clearly that minority and underserved patients were much less likely to receive brachytherapy, based on these national figures. Korenaga and colleagues noted that women were less likely to receive standard-of-care brachytherapy within the recommended 8 weeks of therapy if they were black, low income, on government insurance or uninsured, or treated at more than one location for their radiation.
These data were amplified by a second report at the same meeting — from Alimena and King, in which 15,000 patients were reviewed — also showing reduced use of standard brachytherapy and timely treatment among African-American women (compared with white women), the elderly, and the uninsured or underinsured.
Taking a proactive approach
This phenomenon is not restricted to cervix cancer.
The paradigm-shifting studies of the National Lung Screening Trial, although demonstrating that low-dose CT scanning is associated with early detection and reduced mortality from lung cancer, also showed low representation of African-Americans — less than 5% — and lower numbers of rural poor, confirming the same pattern of disparity of care.
The oncology (and medical) literature is replete with examples of dramatically worse outcomes, across the board, in the care of the impoverished and underserved compared with the wealthy and well-insured.
Our national strategy is frightening.
Recently we heard our national leaders again discussing the replacement of Obamacare with an unformed and undefined plan ... political expediency and fear of losing votes has pushed the launch date of that foolishness backward, but it is still sad to think that there is so little insight into workable health care strategy among our leaders.
One might hope that, while expounding on “curve 2” health care economics — which emphasizes a value-based approach — they might understand that delay of diagnosis and expensive treatment for advanced cancer — or any other disease — in association with an absent health care funding safety net just does not make sense.
It would make so much sense to take a proactive approach to education, screening, diagnosis and treatment of the whole domain of the medically underserved, with a focus on integration of care, a separation of immigration policing from delivery of health care, and a greater focus on widespread application of best medical practices and evidence-based medicine, with optimal use of navigation, genetic counseling, survivorship care and supportive care.
Apart from being the right thing to do, the actual fiscal return on investment among under-resourced and undereducated populations is likely to be much greater than among the well-resourced and health-educated end of the community.
However, like the aforementioned British generals, some of our national leaders seem intent on sacrificing thousands on a rocky cliff, to absolutely no purpose, and with little chance of success.
References:
Alimena S and King MTH. Abstract 11. Presented at: Society of Gynecologic Oncology Annual Meeting on Women’s Cancer; March 16-19, 2019; Honolulu.
Korenaga TRK, et al. Abstract 10. Presented at: Society of Gynecologic Oncology Annual Meeting on Women’s Cancer; March 16-19, 2019; Honolulu.
Koroukian SM, et al. Cancer. 2012;doi:10.1002/cncr.27380.
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 Atrium Health. He can be reached at derek.raghavan@atriumhealth.org.
Disclosure: Raghavan reports no relevant financial disclosures.