As I write this, I am returning from a trip to Los Angeles where I participated yesterday in a panel discussion on the topic of cancer prevention and early detection. The occasion was the 2012 Global Conference sponsored by the Milken Institute. (If you are not familiar with this conference, it is probably one of the premier finance and investing conferences in the country, if not the world. And the luminaries in attendance--both as attendees and speakers--were a testament to the influence of the Institute and its founder, Michael Milken.)
I was on this panel through an invitation from the Melanoma Research Alliance and its chief executive, Wendy Selig, a former colleague of mine when she was at the American Cancer Society Cancer Action Network. Other participants included Dr. Stephen Gruber, who is the recently appointed director for the USC Norris Comprehensive Cancer Center in Los Angeles, Dr. Sancy Leachman who is the director of melanoma and cutaneous oncology at the Huntsman Cancer Institute in Salt Lake City, and Sherry Lansing who is the CEO of a foundation of the same name and a well-known cancer research advocate (she is very well known in the entertainment industry as the former head of Paramount Pictures and one of the people who conceived of Stand Up To Cancer which has done much to transform the landscape of cancer research in this country).
What made this event more interesting was that the audience was made up of those same financial and investing folks I mentioned above. As you might imagine, almost all the sessions were devoted to topics very relevant to their professional interests. The topic of the session I participated in was a bit off the usual target of the meeting. This session was not about investing--it was about health. I must admit that I was surprised at the number of attendees who joined us for our discussion, and even more pleasantly surprised that they remained engaged throughout our 90 minutes.
In what would have otherwise been a fairly typical recitation of facts about how cancer prevention and early detection can reduce the burden and suffering from cancer, a theme emerged: we as professionals are not doing our best in clarifying our advice about the prevention and early detection of cancer through cancer screening.
When you are sitting in a room with some very intelligent people realizing that our lack of clarity and conflicting recommendations on advising people what they need to do about their health, you begin to understand that we are facing a dilemma that could have a significant impact on how successful we are going to be in getting people to take action to reduce the risk of cancer or finding it early.
Ms. Lansing summed it up very nicely and succinctly on several occasions when she told the panel and the audience that as much as she respects the panel members and doctors in general, the messages we were sending did not make it easy for patients to decide what to do about cancer screening. And I could see in the expressions on the faces of those in attendance that she was not alone in her thoughts.
How does one respond to that cogent observation, especially from someone who is such a committed and passionate advocate in supporting cancer research and innovative cancer treatments?
The reality is you tell the truth: In some respects, our science has failed us. We have not done the best research in a timely fashion that provides clear answers to the questions that people have about their health. When it comes to cancer screening, there remains a lot of opinion, debate, advocacy and confusion. Sometimes the loudest voice becomes the message, and that voice may not necessarily be consistent with the science.
I wrote a blog last week about "data, data, data." I live in a data world where we want to be as evidence based as possible when we make recommendations to the public about cancer prevention and early detection. But on the other side of the data are people who look to us as professionals, scientists and experts on these topics to interpret that data and then tell them what they need to do. Instead, I fear, we are going in the opposite direction.
Let's take some research that was reported this week about breast cancer screening as an example:
For the past several years there has been a tug of war going on in this country about when women at average risk of breast cancer should get a mammogram. Start at age 40? Start at age 50? Every year? Every other year? The debate goes on and on and on and on.
This week studies were published in the Annals of Internal Medicine which suggested that we could be more "targeted" in our selection of women who would benefit from screening mammograms between 40 and 50 by considering their family history of breast cancer and their breast density. My colleague and friend Otis Brawley MD (who is the chief medical officer for the American Cancer Society) wrote an editorial accompanying the studies that supported them as a possible starting point for a discussion about who would benefit from screening in this age group. He also said that the concept was not ready for widespread application. But now that the studies have been published, there are those who will grab onto the results as "gospel," while ignoring the fact that no clinical trial has ever employed this strategy to answer the question whether or not this really has a significant impact on reducing deaths from breast cancer in this age group. The reality is that many women in this age group who develop breast cancer do not have one of these risk factors.
The easy answer to the dilemma is that women between 40 and 50 should have conversations with their health professionals about the benefits and risks of screening mammograms. But that implies that their health professionals have a very good grasp of the information and the debate, as well as all of the associated nuances. Unfortunately, other research suggests that simply is not the case.
The experts have drawn their scientific lines in the sand, and the women who depend on them are caught in the middle of this tug of war. So what happens to them? Where does this leave women in their 40's who have to make a decision whether or not to have a mammogram? Do they guess what they should do? Flip a coin? This isn't a game, my friends. These are lives we are talking about. And we don't have the answer. Even worse, it is likely that no study will ever be done anywhere in the world to definitively answer these questions.
I could make a similar comment about prostate cancer screening with the PSA test. After all these years, the experts are still disagreeing with one another whether or not prostate cancer screening really saves lives. The research is conflicting, the intellectual battles go on, and the patients are caught in the middle.
I have written before that our science is sometimes complicated, and not infrequently inconvenient. It doesn't always give us the answers we want or the answers we expect. Sometimes it doesn't give us the clear answers and directions that we need. Sometimes it is not that the research has not been done, but that the results are in conflict or are subject to interpretation or reinterpretation year after year after year, as has been the case with breast and prostate cancer screening.
I know there are experts out there who will disagree with me regarding some of the comments I have made in this blog. But sitting in front of that audience on that day brought home to me how serious a problem we have when it comes to giving consistent advice to the people we serve. After all, if we can't get the message right, why on earth should we expect people to do what we say (or for that matter, not do what we say they shouldn't be doing when we used to say they should be doing it in the first place)?
There is no ready answer to this dilemma. We need better screening tests, we need science to tell us which cancers are aggressive and which cancers if left alone may not require treatment. We will get there one day, but we are not there yet.
So we will continue to muddle through this morass of conflicting recommendations and information and try to get to health and try to get to truth. We will continue to hold opinions, and list all of the research that supports us in our particular beliefs as to whether or not a screening test works or doesn't work.
Our patients will talk to their doctors and their health professionals requesting advice and guidance, and the professionals will do their best to determine what course of action is in the best interests of their particular patients. And, as is frequently the case, those recommendations will be based in no small part on personal preferences, assumptions and beliefs based on experience ("remember the anecdote" is a theme that runs through medical practice) because the science and the experts are not sending clear messages.
This isn't the state of affairs that anyone predicted, and it isn't the state of affairs that anyone likes. But let's face it: it is our current state of affairs.
So what was the take home message for me as I left the stage yesterday after the panel was finished?
I must admit to a bit of discomfort as a result of our discussion. I had to admit to myself (and others) that in some respects our science has failed us regarding some aspects of the prevention and early detection of cancer. We clearly need better direction and better information when it comes to screening for certain cancers, in particular breast and prostate cancers. (Cervical cancer screening is a welcome exception where the evidence is strong that less frequent screening works. But try telling that to a medical and patient community that has been raised on the message that the annual Pap test is gospel.)
As we go forward, we must allow the lessons of the past to inform the research of the future, especially for the prevention and early detection of cancer. If we fail to heed that simple, straight forward message then we will have only ourselves to blame.