One of the most common questions I am asked is whether we are really making progress in our efforts to reduce the suffering and death from cancer.
There are many ways of saying “yes” in response to this question.
Probably the simplest answer is to comment on the increase in the 5 year survival of people diagnosed with invasive cancers from 50% in 1974-76 to 65% for those folks diagnosed between 1995 and 2001.
However a better and more detailed examination of how effective our cancer control and treatment efforts have been over the past 15 years or so recently appeared in an article and accompanying editorial in the American Cancer Society’s journal Cancer.
The net result of the discussion was not a simple pat on the back. The authors concluded that we have made progress; but we could do much better.
As noted in the article, in 1996 the board of directors of the American Cancer Society set a challenge goal for this country to reduce by half the number of deaths related to cancer between 1990 and 2015.
One important caveat that is often forgotten when our “2015 goals” are discussed is the fact that this goal was not a goal for the American Cancer Society alone. It was a goal for this country.
By challenging the country to reduce the suffering and death from cancer, the Society was exhorting all of us to apply the information we already knew about the early detection and prevention of cancer, about the treatment of cancer, and about the causes of cancer to every aspect of our society and our health care system. And, it presumed there would be continued research progress in each of these areas that, when applied, would contribute to achieving what was clearly an ambitious goal.
We are now at about the mid-point in the period of time allotted to make the goal. So the natural question is, “How are we doing?”
The question was examined in detail by a committee of the Society, and that review formed the basis for the article.
Several themes emerged:
- Overall, there has been a sustained reduction in cancer deaths of about 1% each year
- Most of the progress has been made in the most common cancers that contribute to about half of all deaths from cancer (lung, prostate, breast, colon)
- Underlying health factors that affect the incidence of cancer have been addressed to some degree (for example, tobacco use), in other cases become more of a problem (obesity), and in other cases have had mixed effects (reduction in the use of hormone replacement therapy in post-menopausal women)
- We really could do a much better job of applying the knowledge we already know
The authors point out several interesting findings.
In addition to the sustained, steady decrease in cancer deaths noted above, they also comment that the annual death rate from cancer has decreased by 23% from what would have been expected when comparing rates from 1990 to 2001. That translates into more than 315,000 deaths that were either prevented or delayed as a result of everyone’s efforts.
To meet our 50% goal, however, at the present rate will take until 2040. That is another 34 years instead of being achieved in 2015 as had been hoped for when the goals were set.
What do we need to do to improve this rate of decrease in deaths?
Tobacco is the single most important contributor to deaths from cancer. Cancer of the lung and many other forms of cancer are caused by tobacco in both men and women.
Even though we know this, we haven’t been as vigorous nationwide as we might have been with respect to tobacco control.
Increased taxes, smoke-free environments, advertising and telephonic smoking cessation support services are but a few examples of what works in tobacco control. Improve tobacco control, and deaths from lung cancer and other tobacco-related illnesses decline significantly, although perhaps over a longer time than we would like.
But budget cutbacks and other political considerations have prevented the progress we could achieve in these areas.
There is hope that some of the current prevention and early detection trials may provide some indications of benefit, and that could accelerate the decrease in lung cancer deaths. But those trials remain “in progress,” and it will be several years before the results are known.
There are some interesting observations regarding colorectal cancer in the article.
For example, the authors note that deaths from colorectal cancer have been declining for some years, in part because of screening but also for reasons that suggest there may be factors other than screening that account for the decrease.
They provide the example of obesity, which has increased dramatically over the time period we are discussing.
We know that obesity is an accepted risk factor for colorectal cancer. Imagine that if we had not had the obesity epidemic, then perhaps the rate of colorectal cancer deaths would have declined even more than it has.
On the other hand, we also have known that hormone replacement therapy (HRT) is associated with a decreased rate of colorectal cancer in women. But in 2001, HRT was found to have several harmful side effects and the use of hormones dramatically decreased in post-menopausal women.
As the authors note, we are still waiting to see the expected increase in the rate of colorectal cancer in women as a result of large numbers of them no longer taking HRT.
But the major issue with colorectal cancer isn’t HRT or the fact that anti-inflammatory drug use has decreased since the Vioxx scare (these drugs are associated with a decreased rate of colon cancer).
The major issue in this disease is that so many people don’t get properly and regularly screened.
If we did screen as recommended for colorectal cancer, there is one estimate I have seen that says we could save 35,000 lives a year. That is more than half of the expected 55.000 deaths from this cancer in the United States this year.
In breast cancer, we need to dramatically increase our rates of screening if we are to improve our rate of death from this disease more than we have to date. If anything, the data are suggesting that women are beginning to become somewhat more complacent about mammography as time goes on. That is not a good thing.
The outlook for other cancers is not as good as it is for the four most common cancers (colon, lung, breast and prostate) according to the researchers.
For many of them, we don’t know their risk factors as well as we do for the more common cancers, we do not have particularly effective early detection methods, and our treatments are not as successful.
And we can’t forget that as our country gets ages, older people tend to put less emphasis on prevention and early detection, and that many cancer treatments are considered too toxic and unsafe for the elderly (although that opinion has been questioned by many, especially for those older folks who are still reasonably healthy and active).
One of the biggest challenges we face is how we make certain that everyone in this country has access to the information, the medical care and the support they require to either prevent cancer or find it at its earliest stage.
The authors note that we do not do a particularly good job of extending the benefits of our knowledge to all of our citizens, particularly those who live in poverty and have limited access to health care.
The report concludes:
“Just how much steeper the future downward slope in cancer death rates can be will depend on the extent to which policy makers and the American public can join together to create systems and incentives to reduce several behavioral risk factors for cancer (especially tobacco use and obesity), to facilitate early cancer detection (especially for colorectal cancer), and to assure that state-of-the-art treatment is available for all Americans who are affected by cancer.”
The editorial which accompanied the article applauded the progress described above, but notes that “we must accelerate greatly our current rate of progress.”
The editorialists go on to say that what we need to do now is not to so much worry what they describe as “headline-grabbing scientific and technologic breakthroughs,” but to figure out how to get what we already know into the places where that knowledge needs to be applied.
One of the questions they posed was, in my opinion, a key to understanding what is happening:
“If we cannot deliver what we discover and develop, then, as a nation, should we have spent the resources to discover and develop?”
We have spent immense amounts of public and private funds on research into cancer treatments and cancer prevention. Yet, despite all we have learned, there remains a considerable chasm between what we know and what we do.
If you spent a substantial amount of your money to build a house, wouldn’t you want to live in it?
That is basically what is happening in this country today when it comes to many aspects of the cancer prevention, cancer detection and cancer treatment. We simply aren’t creating the networks and applying the knowledge in an effective manner that would provide many of our fellow citizens the benefits of what we already know.
If we could solve that puzzle through a better understanding of social, political and medical systems, we could do great things not only for cancer, but for many aspects of our health and economy as well.
We have the knowledge and have gone a long way to create the infrastructure to effectively reduce the burden of cancer in this country, as the editorial’s authors note.
In their words:
“The stage is set for significant reductions in cancer death rates, and the urgency has never been greater as we face the aging of the population and daunting increases in health care costs. But realizing the promise depends enormously on how we apply the fruits of scientific inquiry to close the gaps between ‘what we know’ and ‘what we do’ to eliminate preventable cancer deaths; and ‘what we do’ depends fundamentally on effective, concerted will, advocacy, and leadership and on the power of broad societal alliances—among public health and health care leaders, policy advocates and policy makers, researchers, and the public.”
So we find ourselves at a crossroads.
Are the ambitious goals the Society set for this country a decade ago just that—ambitious and unachievable—or are they goals that (with some concerted efforts) we can meet by the target date or close to it?
To me, the answer is obvious.
2040 is simply too far away, especially when one considers that we already know much of what we need to know to make those goals close to a reality.
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