During the American Academy of Dermatology Annual Meeting in March 2022, Otis W. Brawley, MD, MACP, FRCP(L), Bloomberg Distinguished Professor of Oncology and Epidemiology at Johns Hopkins, spoke about the National Cancer Act under Richard Nixon and the impact that Act has had on modern medicine as we know it.
How Far We’ve Come
Dr. Brawley noted that first, the National Cancer Act established important pieces of our National Cancer Institute (NCI) Surveillance Epidemiology and End Results (SEER) Program, which helps us to figure out how we are doing. Dr. Brawley noted that we are able to know a “great deal” about incidence and five-year survival in infants because the National Cancer Act establishes registries. Previously, we had state by state numbers but didn’t know much about incidence. However, by looking at survivor rates and treating patterns, we have been able to reduce the number of Americans who died from cancer from 1991 to 2018, a roughly 31% drop. Dr. Brawley credits early detection, improvements in treatment, and the incorporation of prevention and risk reduction into healthcare.
The National Cancer Act also established various components of education for the population and, essentially revolutionized medicine by increasing the amount of money going into investigator-initiated basic research and clinic science. Dr. Brawley noted that it is because of investigator-initiated science that we have learned about molecular pathways, genetics, and genomics. It’s the reason we are able to recognize signatures of tumors and some important immunology components.
Disparities
Dr. Brawley pointed out, though, that with access to numbers, it became apparent that there were some disparities. Those disparities resulted in a “tremendous interest” in health disparities, health equity, health justice, etc. By studying populations, Dr. Brawley says we can identify interventions that need to be employed, identify interventions that have been employed have been useful, and identify where we need to go to efficiently target other efforts.
Some of the ways we can define (or categorize) populations includes by sex or gender, race, area of geographic origin, family/tribe, ethnicity and culture, area of residence, and socioeconomic status.
For example, Dr. Brawley pointed to cancer mortality by race/ethnicity from 1990 to 2017. He noted that while most races/ethnicities experienced a decline in cancer mortality rates during that period (American Indian/Alaska Native did not decrease), the degree to which they declined varied. Turning to breast cancer specifically, during the period from 1975 to 2015, he noted that there were no Black-white disparities in breast cancer mortality in 1975. However, as we learned to screen and treat the disease, white breast cancer mortality declined while Black breast cancer mortality rose for decades before slowly coming down. Disparities in breast cancer, Black versus white, are greater today than they’ve ever been before. From a Ronald Reagan executive order, we started collecting and publishing numbers for the other three racial and ethnic categories in 1990 (Hispanic, Native American/Alaska Native, and Asian/Pacific Islander), and that there are disparities between white and Native Americans, Hispanics, and Asians as well.
The Most Important Question
Dr. Brawley posited that the most important question in cancer control is how can we provide adequate high-quality care (including preventative services) to populations that so often do not receive it?
He notes that there are seven states where Black-White mortality differences are not statistically significant and that there are twelve states where White breast cancer mortality is higher than that of Black women in Massachusetts.
It’s Not Just About Race/Ethnicity
While race/ethnicity do play an important role in disparities, so does education. Dr. Brawley noted that patients who did not graduate from high school are far more likely to die from cancer than people who are college graduates.
Human Behavior
Dr. Brawley highlights the importance of preventative activities and getting patients the care they need. While screening is important, he notes that interventions of lower impact are frequently employed, which diverts limited resources from where they can have the greatest impact.
Dr. Brawley pointed to some of the most common causes of cancer that we know of, including tobacco, diet and lack of physical activity, alcohol, and UV radiation. He discussed how in 1964, we started learning about how bad smoking was and how important it was to cancer prevention. We have successfully reduced the number of smokers.
Now, he seems to indicate, we need to turn our attention to educating and focus on preventing obesity, as weight-related cancers are expected to increase 30 to 40% by 2030. He noted that many Americans are not meeting the CDC’s recommendation for physical activity (150 minutes of moderate intensity activity or 75 minutes of vigorous intensity activity each week) and that more than 25% of adults reported no leisure time physical activity in 2018.
Cancer Control
Dr. Brawley concluded by noting a handful of ways to control cancer, including vaccination (HPV and Hepatitis B), sun avoidance, safe sexual practices, pollution avoidance, and appropriate screening (including for Hepatitis C, breast cancer, colorectal cancer, cervical cancer, lung cancer, and prostate cancer).
He also noted that there are additional issues to address, including identifying those most in need and the importance of education. He also pointed to the role of culture and cultural change in practicing health behaviors. The United States leads the western world in preventable cancer deaths, the majority of which are among white Americans. Therefore, the issue of disparities in health care are not just a racial minority health issue.