American Cancer Society: Dr. Brawley and Dr. Len, Chief Medical Officer and Deputy Chief Medical Officer, on Sequenced
On this special episode of Sequenced, Dr. Brawley and Dr. Len, Chief Medical Officer and Deputy Chief Medical Officer, of the American Cancer Society join us to discuss the newsworthiness of cancer research, cancer prevention strategies, and the future of healthcare. Our moderator is Leena Rao, a technology reporter based in San Francisco.
The American Cancer Society is committed to freeing the world from cancer and is focused on cancer research, sharing expert perspectives, and increasing awareness for cancer prevention.
Leena: I want to get into actually something that pretty time-sensitive. It’s a new study that was released from the American Cancer Society around the death rate for colorectal cancer. Basically, what it said was among adults ages 20 to 54 the rate of colorectal cancer has been increasing actually since the mid-2000s. Which is kind of surprising because you think, considering all the testing and the advancements that we have, that potentially that rate would go down as it has with some other cancers. What should we take away from that study?
Dr. Brawley: Well, there actually were two studies. One looked at incidence rising in this group and the other looked at mortality rising in this group. It was actually from age 20 to 54 among white Americans. We don’t know why just among white Americans and we don’t know why it’s rising at all. The studies I think actually helped define scientific questions that we need to look into. The one thing that we can take from that is we know that screening is very effective in saving lives from age 50 and above, and we know that a substantial proportion of Americans over 50 don’t get colorectal cancer screening especially a substantial proportion of Americans age 50 to 55. And so, that’s one thing that we can act on right now. We’re looking into the question of should our screening age go down? It certainly can’t go down much below 45, but what can we do for people in their 30s or even in their 20s? And then why is this? I can tell you some of it seems to be driven by colon cancers that are in the rectum and in the sigmoid. These cancers are biologically a little bit different from some of the cancers that are in the middle of the colon or in the very proximal part of the colon. And so, the studies actually help define what we should be studying.
Dr. Len: There are a couple of interesting additional points. Number one, I think it’s important to bear in mind as Otis mentioned that these really are two different studies. They look at different elements. But the headline was how much of an increase there was in people in their 20s and 30s. The reality is those numbers are still very small but they reflect a trend and that trend is important. But the chances of someone getting a colon cancer at a very young age still remains a remote possibility. I’ve been a primary care physician at some point of my career. The reality is when somebody walks in your office and they may be 20 or 30 and they said, “I’ve had blood in my stool. It’s been going off for a period of time.” Our natural tendency is to say, “Ah, it’s hemorrhoids. Don’t worry about it.” Well, maybe sometimes you do have to worry about it. Now, clearly and some young people have what we call inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis. They are at a higher risk of getting cancer but some of these folks may have a family history you don’t know about or they may not have a family history and they could have colon cancer. So it’s important to listen, the person who’s a physician or a health professional clinician, it’s important to listen to what that person is telling you and not just routinely dismiss it. That’s point number one.
Point number two is in the study that was most recently reported where they saw this increase among white Americans who are in their 50s, and the question was about screening. The reality is that mortality rate has gone up even in the face of screening. So the increase if we hadn’t had any screening probably would have been even worse than it was. What that says to some of us and for many of us actually is that we have to really be concerned about what has changed. Is it our diet? Are we eating too much red meat, for example? We keep talking about exercise or physical activity. We’re spending a lot more time on the couch, we’re spending more time in front of the computers, we’re spending more time listening to podcasts. We’re not that active as we used to be. Some people do or they’re active when they listen to a podcast but a lot of people are sitting around, right? But the point is that we need to understand this better because what we’re seeing as trends today could become even more serious problems in the future. We have to look at the screening and the age when we start screening to see if there’s anything we could do to modify or change the outcomes. But we also have to pay attention to what we already know. What we already know is when you turn 50, you should get screened. Don’t do what I did. I always tell stories about myself. I waited until I was 55 to get my first screen and what the study is saying is when you turn 50, get screened. You could save your life.
Leena: Those are really important points to think about. So I’m 36 now but let’s say I’m around the age of like 40, 45. What should I be thinking about or thinking about in terms of warning signs of this particular cancer? You mentioned bleeding but are there other things someone who’s approaching that 50 mark should be considering as they are looking for some of these signs?
Dr. Len: When you’re 40 or 50, it’s not just colon cancer you should be concerned about. So you’re a young lady and if you have a change and let’s say a change in bowel habits, it may be blood in the stool or may be a change in the frequency of how often you go to the bathroom or maybe the change in the size of stool or severe constipation suddenly when you didn’t have that problem before. That’s one thing to worry about, but there are other things that happen. If you notice unusual swelling in the abdomen or pain in the abdomen, unfortunately these are not early signs. We used to call them the early signs of cancer. That’d be back in the 70s. But then we learned unfortunately that these are the late signs of cancer. So a good rule of thumb is if you notice a change that’s of concern to you. You know your body and this is applicable to everybody. You know your body better than anybody else. And I don’t care if we’re talking about your abdomen, I don’t care if we’re talking about the breast, I don’t care if we’re talking about breathing, if you see a change or feel a change, you know, on your skin, you see a mole change, get it checked. What’s the worst thing that could happen? A health professional looks at you and says, “I don’t think it’s anything but let’s keep track of it and if it continues then maybe some other studies are necessary.” Now, I think it’s also important to bear in mind that we’re talking about people at average risk. You don’t have a family history of colon cancer, you don’t have a family history of ovarian cancer, you don’t have a family history of cancer of the uterus. So if you’re at average risk and don’t have those, and most people don’t have any of those factors, they don’t have a family history, and you notice a change, get it checked. Fortunately, most of the time it turns out not to be anything serious, but don’t walk around wondering, “What do I do?” Do it. Find out.
Dr. Brawley: Actually, one thing that I would point out is that most people are never gonna have colon cancer. So if you’re 40 or 45, think about colon cancer, think about breast cancer, think about all these other diseases but remember you’re very likely never going have any of them. And if I were the Czar of the United States, I could do one thing to help with health care. I would get everybody a good relationship with a primary care doctor and make sure that everyone felt that they had the freedom to have conversations with that primary care doctor. So that people who have an abdominal complaint could go say, “Hey, doc. I got this problem. Let’s talk about it. Hey, doc. I feel this in my breasts can we talk about it?” I think we would get rid of a lot of the concerns that people have if they were able to have these conversations freely with a primary care doc.
Dr. Len: That’s an incredibly important point because it underlies a fundamental fact of healthcare that most people aren’t aware. Having a relationship with the clinician, somebody you can identify as being your primary source of care is the first and most important indicator of good health. You can do a lot of things for yourself when it comes to actually having a relationship with somebody who knows you. The sad fact is that today, and as we have this discussion, more people are losing that relationship. They may have a system of care, they may have a place, a building they go to, but they don’t know who their healthcare professional is who knows them or the healthcare professional may be there for a short period of time and goes on. That’s something we don’t pay a lot of attention to.
Leena: I think that’s such an important point. Everyone should have some kind of an advocate or someone who is their counselor, who they can go to. But what you said is that that’s just not happening and it’s probably one of the challenges that both of you have described a lot and that Americans experience when trying to get quality health care. How do we change this? Or what do you think is going to be the thing that’s able to solve this one problem?
Dr. Brawley: Well I spend an awful lot of time thinking about medical costs and medical economics. The fact that the United States has the most expensive medical care system in the world. It’s three and a half trillion dollars a year. The U.S. healthcare system is more expensive than the entire economy of France, the fifth largest economy of the world. We spend $10,000 per person on health care now in the United States. The second most expensive country, by the way, is Switzerland at about $6,000 per person. We spend a lot of money on things that don’t matter and then we don’t spend much money on things that do matter. Some of the high-end diagnostics and high-end screening tests that we’re spending a lot of money on don’t really help us. Some of the very expensive drugs that we spend a lot of money on, we could actually either do without those drugs or actually use much less expensive drugs. I think the first thing we need to do is try to truly transform our medical system such there’s much more efficient and we get things of value. Then after we start doing that, we need to start moving toward a system where every human being has access to a primary care physician who they can have a good working relationship to. That’s not, “You are assigned to Dr. X.” It is, “You know Dr. X, Dr. X knows you and you feel comfortable having conversations with him or her.”
Dr. Len: The point that Otis ranked as number two, I would rank is number one.
Dr. Brawley: You think costs will go down if number two happens?
Dr. Len: Yes. So the argument is I’ve been both a primary care physician and a specialist. I’ve been an oncologist throughout my professional career. And I’ve been in situations where I am a strong advocate for primary care medicine. When I say primary care medicine I mean primary care clinicians. A team of people who is going to be available to help take care of you and guide you through this morass. Fortunately, most of us don’t need fancy specialists. Sometimes we do and we’re grateful they’re there when they have to be, but we have so underfunded our primary care health teams that we can’t get people to go do that work anymore. Frankly, we don’t pay them enough in the scale when you look at physicians. I mean I’m not that I’d like to talk about money is the only motivator, but the reality is that they’re undercompensated compared to their professional colleagues. They graduate from school, these kids come out of school with $200,000, $300,000 in debt. It’s not uncommon. Tthen they go and as a primary care physician. You can’t repay that debt. You know, you can’t do it. So I mean that’s just one aspect, but it’s the most critical. And it doesn’t happen, it can be a physician, it can be nurse practitioners, it can be physician’s assistants, it can be a team-based care. It’s making sure you know somebody.
I can speak from personal experience. I’ve had some skin cancers but I’ve not had major cancer. But having had a life-threatening illness. I will tell you that having that person who knows you by your bedside was perhaps the most important thing to me when I was lying in that hospital bed when I was as sick as I was. Now, maybe that person didn’t have all the answers. But having that person there was so critically important to my well-being, my ability to recover. And helping me, and me being me, leading the conversation that took me out of that illness together with me being part of my team meant the difference for me at that most serious moment of my life.
Leena: It’s so true. I just had a baby a few months ago and she was born and there was a complication. And thankfully, my dad is a doctor. My husband and I were obviously very traumatized by what was going on with our newborn child who had just been born days before and couldn’t really understand what the doctors were saying. But having my dad there as a translator even or to say like, “Did you do this test? Or what do you think about this?” It was invaluable. You’re right. There’s a time where everyone has one of those people in their lives that can do that. But what role do you guys think employers have in subsidizing some of these costs or actually reducing health care costs here in the U.S.?
Dr. Brawley: I would like to see employers provide gyms, look at what’s being served in the cafeterias in terms of food, provide some counseling in terms of health education. One of the great downfalls in the United States is health care literacy even among college-educated Americans is very low. I actually think that we need to look very hard at what we’re putting into the education in third and fourth grade and then do some remedial work for the parents and grandparents right now in terms of health care.
Some of the things that I think about not just companies but zoning regulations. I mean one of the reasons why we’ve gotten into the problems that we have now regards to health. And our biggest assaults to health is smoking. Keep in mind we still have somewhere between 15% and 20% of adult smoking and in certain states, it’s up to 30% of adults still smoke. The next big assault for both cardiovascular disease and cancer, it’s the second leading risk factor for cancer, is the combination of obesity, lack of physical activity, and high caloric intake. Think of them as a three-legged stool. It’s not just obesity, it’s too many calories and not enough exercise. Zoning regulations over the last 40 years have moved a lot of the population away from sidewalks or areas where there are sidewalks and think about our building environment. In the 1950s we used to walk to the grocery store every other day or every third day, buy some fresh fruit, fresh vegetables, fresh meat, bring it home, put it in an icebox, and cook it. Today, we live in a suburb and we drive a car on a Saturday morning to the grocery store, fill up the trunk with all kinds of processed foods, and bring it back to our beautiful refrigerator/freezer where we microwave it all week. When we don’t microwave it all week, we go to fast food restaurants that specialize in giving us lots of cheap calories. Our environment has changed dramatically and that’s why in the United States we went from 15% of the population being obese in 1970 to well over 35% today. And in certain sub-populations, like black women, we’re well over 50% obese today. That’s driving a lot of disease. I would look at what government’s doing, what companies are doing. I’d look at what everybody is doing to try to create a more healthier environment where we increase the number of fruits and vegetables consumed, increase the amount of exercise and make smoking as difficult to do as possible.
Dr. Len: I’m sitting here as I’ve listened to Otis’s response which I thought, as usual, was excellent, but I’m smiling a little bit because he still lives in an age when he gets in a car on Saturday and goes to the grocery store. He has not heard about the revolution of how we shop for our groceries and have them delivered to our house.
Dr. Brawley: Even less exercise.
Dr. Len: In addition to which we have these companies now that advertise healthy foods but they are having a little bit of a hiccup in getting people to actually engage with them because people are more interested in getting some of those, as you say, cheap calories, which is a real problem. But as Americans, we spend most of our time with our employers. We don’t spend it at home, or we spend it sleeping. Our employers occupy good portions of our waking hours. So they have incredible influence. But they have not only influence on what the benefits are they offer. They also have the opportunity to influence our politics. I mean sometimes they don’t like to get into it. Maybe if the employers understood that the tobacco taxes were the key to reducing smoking and a proven key. Maybe if they got behind in some states like our own state of Georgia and they said, “This is something we think is important as a health measure.” Well, we’d be better off. Some people say, “Well, employers don’t have a role in that,” but they’re responsible. One of the issues surrounding employers that they’ve always dealt with, it’s not a new issue, is that some employers are very responsible in terms of the benefits they offer and they set. For example, some employers have very effective policies to help support patients with cancer during treatment, during disability, during family leave, whatever the issue may be and other employers don’t. And the sad reality is that some employers don’t want to have sick people working there because it cost too much money. Well, we understand that this is all of our problem, to make sure that everybody has access to care, to high-quality care. When they need specialized care, super specialized care that they can get that care and not have to meet that barrier where the person can’t get to where they need to be because of an internal policy, that’s an important role that employers can play, particularly large employers as we talk about the care of people with cancer.
Leena: How do you fundamentally change an attitude of an employer like that? There are some employers who are great and have a really, a great view of who their employees are and how they treat them. Then for some, it really is a financial decision and that’s all it is. How are you trying to educate employers to kind of cross the chasm there?
Dr. Brawley: Well, you’re actually make it a financial decision. You show them that by being interested in your employee’s health, you can actually reduce your cost. The average cost of a family health care plan in the United States right now is $19,000 a family. Now that’s a cost that in most employment situations is shared by the employer and the employee. But you can actually reduce healthcare costs, you can increase the number of days per year that people actually come to work, decrease sick time by stressing some of these health promotion activities. And I think that many companies that have the long term in mind, they’re actually starting to realize that they need to be stressing health promotion. Some of my doctor friends who are involved in health promotion activities, they’re not just doctors but they’re other health practitioners, are actually finding jobs nowadays as consultants to these companies especially large employers on “How do you promote a healthy workforce?” Better than that, “How do you promote health in the workforce and in the families of the workforce?”
Dr. Len: Let back up for a moment. The short answer is you lead by example. And I always mention some large employers who really do have good policies. A couple of years ago I was involved with the committee that was brought together by the National Business Group on Health and the National Comprehensive Cancer Network. The business group happens to be leading Fortune 100 to 500 companies to come together to establish health policy. And the National Comprehensive Cancer Network is a highly regarded collaboration of major cancer centers around the country that help guide cancer treatment and knowledge about cancer treatment. And those two organizations came together and we spent close to two years putting together a roadmap for companies on policies all the way from prevention and early detection through treatment, through employee assistance, through disability. We looked at everything in great detail, put an incredible book together that outlined the policies that an enlightened employer could put into place. Sitting around that table were large employers. I won’t mention any names. You can go look at the little list that’s on the internet, but there were some really major employers who were willing to stand up and lead by example saying, “We think this is important.”
The follow-on to that was, I was subsequently involved in the local community effort here in Atlanta, where they brought together a group of major employers that had a major presence in Atlanta, to figure out how they could take that plan and actually put into action in their own businesses. But another example is that I still remember I went and visited a large insurance company in western Massachusetts a couple of years ago. The CEO had a gym in the building. The CEO said, “My employees know if they want to meet me, to see me at 5:30. I’ll be on the treadmill. They come by and say, ‘Hello’” And the other thing he did that was interesting was that underneath this building was a very long tunnel where the mail guy would go back and forth. Ine of the mail people said, “Can I get a bike to do this because I’d rather bicycle back and forth as an exercise as opposed to standing.” And the guy said, “Sure.” They got the bike and they started a whole new example.
It’s those little examples over time that send a message to people, “We care about your health in a meaningful way.” On the other hand, there’s a large hospital in Chicago. There’s a doughnut shop right outside the door of its medical clinic. So people go get their diabetes checked then while I watched them, they came out the door of the medical clinic and one of the big hospital right downtown and walk right into the doughnut shop. And that doughnut shop was a busy place.
Dr. Brawley: That’s not the school that I went to. That’s right.
Dr. Len: No, they’re different. Another large Chicago school.
Dr. Brawley: Now, one of the things that I would point out is there’s a pressing need to really address this issue. If the last 30 years of rise in healthcare costs predict what the next 25 years are going to be, and I mentioned $19,000 is the average cost of a healthcare plan for a family in the United States. In the next 20 to 25 years, the average cost of a healthcare plan will be about the median family income in the United States. That’s not going to happen. If the last 30 years predict the next 25 years, we’ve got 20 to 25 years before the average family health care plan is equal to the median family income in the U.S. Our economy will collapse because of the cost of medical care before that happens. So it’s up to us now to change this.
Leena: That’s a great point. I would love to end our conversation with something that our audience could take with them for the future which is as we think about some of these recent advancements in cancer… If each of you could share maybe one advancement that you’re particularly excited about that could be game-changing for Americans.
Dr. Brawley: Well, things that I’m really hot on are actually cancer prevention activities. I think what we’ve done in smoking is amazing. There’s still work to be done there. Most of us don’t smoke now so that’s wonderful. We still need to work on diet, physical activity, and obesity. That issue is actually gonna become the leading risk factor for cancer over the next 10 to 15 years. So I really would like to focus there. On the screening side, I’m very excited about what we’ve been doing in colorectal cancer. We’ve had a 35% to 40% decrease in colorectal cancer death rates over the last 25 to 30 years. Much of it because of screening and improvements in treatment and that’s the one area that I’m really really excited about.
Dr. Len: I’ve been around oncology and cancer for close to 45 years. That’s a long time. And seen a lot of things to come and a lot of things go. You see a lot of what I call the hope and the hype, the over promise and an under deliver. Having said that, we say what gets me excited is the fact that we are where we are today. I have to always pinch myself because I don’t want to get into that hope and hype and over sell stuff. But the reality is I think we’re at an incredible point right now where our research has taken us to a place where we can now understand genomics, the genetics of cancer so much better. We understand immunotherapy. I fact, I did clinical trials in immunotherapy back in the early 1970s. It’s now 2017 and we’re just now getting the drugs that actually do something for people. So that’s very exciting. But I think looking into the future, what we’re going to have to wrestle with, it was back in 2009 I was on one of these morning TV shows and I was asked the question, “Tell our viewers something that they don’t know.” And I said, “In a period of time not too distant from now, we’re gonna be able to draw a blood test and tell whether or not you have cancer.” And Susan Love happened to be sitting next to me, and she got mock horror on her face and said, “My god, they’re gonna make everybody a cancer survivor.” And I sort of looked at Dr. Love and I said, “Well, you’re interfering with my moment on TV,” but then I went up to her later and I said, “Susan,” I saw her at a thing more recently. I said, “You were absolutely right.”
That’s both the excitement, the promise of what the opportunity is, at the same time that the balance of understanding what the risks are. We will be able to find, and we are finding, there’s research coming out even as we speak. We are finding cancer cells and we’re gonna find cancer earlier and earlier and earlier. We’ll do blood tests. We’re doing blood tests now and finding it. It’s only a matter of time. I don’t know what it’s gonna be. Six months or two years or five years, but we’re gonna get to that point. The question is, number one, are we going to be able to distinguish those cancers, those cancer cells we find that are really important? Will we be able to tell what to really do? Or are we going to then, in fact, make everybody scared and turn everybody into a cancer patient? Which would not be the right outcome. So that we need not only the wisdom of our technology and our science to lead us down this road, but also the wisdom to understand how to make a difference that is a meaningful difference and not just do science for the sake of science. I think the challenges are many, I think the opportunities are many, but I think that we have to have the wisdom to tell the difference of what’s really beneficial and what’s not. And that’s all. And I think Otis and I talked about this frequently. This has always been the real question. We can have a lot of fancy things to do. We really need to understand what makes a difference and we need to concentrate on making that difference for everyone.
Leena: Well, Dr. Brawley and Dr. Len, that’s a really hopefully positive and optimistic view of what’s gonna happen in the future. And we really appreciate you taking the time to explain about cancer prevention and how we can improve our healthcare system. Thank you so much for your time.