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July 29, 2016
Despite Progress in War on Cancer, Access to Care Complicates Efforts

The ongoing war on cancer has made some inroads, but certain factors, especially disparities in access to care, have tempered our success, according to Dr. Otis Brawley, chief medical and scientific officer for the American Cancer Society. Also an epidemiologist and practicing oncologist, he spoke about the last 50 years of efforts to defeat cancer at the recent NIAMS intramural research program annual scientific training event.

In the mid-20th century, the push to enhance cancer research culminated in enactment of the National Cancer Act of 1971. The law allowed for a significant boost in cancer research spending, better coordination among researchers and improved cancer control and prevention efforts. Brawley explained that cancer-related deaths peaked in 1991 at 215 per 100,000 people. By 2012, cancer deaths had declined by 23 percent. The reduction is largely related to smoking and tobacco use cessation efforts, but it is also correlated with better prevention and early screening efforts, increased cancer awareness and improved treatments. Still, even as the death rate declines, some populations aren’t experiencing the same benefits. Why are certain groups doing worse than others?

In public health, stratifying ourselves by race or ethnicity is inherently problematic, because “race does not define biology,” Brawley said. Rather, racial constructs are sociopolitical and heterogeneous and their definitions change over the years. The reason that some populations have fared better than others, he said, is because of unequal access to adequate care.

Dr. Otis Brawley (l), chief medical and scientific officer for the American Cancer Society, and Dr. John O’Shea, scientific director at NIAMS
Dr. Otis Brawley (l), chief medical and scientific officer for the American Cancer Society, and Dr. John O’Shea, scientific director at NIAMS

PHOTO: RICH CLARK

Looking at different types of cancer helps illustrate the access-to-care issue. For instance, in the 1970s, there were no racial differences in deaths among women due to breast cancer. Since 1981, breast cancer deaths have been declining overall. However, mortality rates among white women are dropping more quickly than among black women, presumably due to differences in access to care.

Population differences are seen in deaths associated with colon cancer, as well. The death rate from colon cancer overall has been cut nearly in half since 1975, largely due to early screening, awareness and better treatments. But some states have higher rates of death due to colon cancer than others. “I don’t think people in one state are biologically different from those in another state,” Brawley said. In addition, when comparing colon cancer patients who have private insurance to patients with Medicaid or no insurance, those with private insurance were more likely to be alive 5 years after diagnosis than those without.

Education can also reduce cancer deaths—people with college degrees are more likely to do better after being diagnosed than those without degrees. Education may also help lessen the coming “tsunami of chronic disease.” Obesity and other chronic conditions, said Brawley, will surpass tobacco use as the leading causes of cancer over the next two decades.

Even as we grapple with disparities in access to adequate care, we are in the midst of change involving how we treat cancer—changes that are and will continue to lead to newer and better treatments. We are shifting away from the traditional definition of cancer as a disease involving uncontrolled cell growth and moving toward a better understanding of cancer’s molecular basis and genetic influences. This has led to innovative treatment ideas. For instance, we know that cancer cells can evade our typical immune system response by sending a misleading signal and we are learning that certain drugs can override that signal and trigger our immune cells to attack the cancer.

Overall, we have been effective in reducing cancer deaths, but we need to turn our attention to other factors that are complicating our efforts, said Brawley. We need to focus on preventing chronic diseases and “we need to realize that adequate health care is a human right,” he concluded.

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