Cancer: Otis Brawley talk to Health Journalists 2012
April 23, 2012
Anyone going to hear a speech by Dr. Otis Brawley might think he or she could easily predict what Brawley will say. Since he’s the chief medical officer and executive vice president of the American Cancer Society, you might expect him to urge doctors to aggressively screen all their patients for cancer, and to aggressively treat them as well.
You’d be wrong.
At a recent Association of Health Care Journalists meeting in Atlanta (where Dr. Brawley also serves as a professor at Emory University), he slammed everyone in the health care system for overuse of under-proven treatments. These themes are also in his new book, How We Do Harm: A Doctor Breaks Ranks About Being Sick In America
I spend a lot of time as chief medical officer at the American Cancer Society worried about where trends are going and what’s happening and trying to make sure that people actually focus on relevant pertinent things. So first thing I’m going to say is always keep in mind that the leading cause of cancer and indeed the leading cause of heart disease is tobacco usage. Also please keep in mind that the second leading cause of cancer is the combination of very little physical activity, bad diet, which usually means high caloric intake and obesity.
At some point in time health care is going to so dominate commerce and so dominate costs in the United States, so dominate our economy it’s going to cause our economy to collapse. What we’ve gone through in the last couple of years is going to be nothing compared to what we will go through when health care is 25 to 30 percent of every dollar spent in the United States. And that’s only going to be in the next 10 to 15 years.
We have an amazing health care system. Or I should say a health care system with amazing potential that it is not meeting. When we had the conversation about health care reform, I can remember some of the politicians talked about how great our health care system is. And I was thinking ‘gee, we’re 50th in life expectancy. We’re 47th in infant mortality right. Countries such as Cuba do better than the United States in those.’
There really is a subtle form of corruption in American health care. Who is at fault for this corruption? Quite honestly it’s the doctors, it’s the hospitals, it’s the hospital systems, it’s the insurers. It’s the drug companies, it’s the lawyers and it’s even the patients. Everyone is at fault for the fact that the system really is not failing. Quite honestly, failure is the system.
We have doctors who want money. We have companies that want money, they give — those doctors give unnecessary chemotherapy. In my business those doctors give unnecessary surgeries and treatments, unnecessary imaging. They make promises about screening tests that we don’t know.
Then we have patients who consume too much health care. Patients who want things. We have patient families who are unable to accept that fact their comatose father with stage four, widely-metastatic prostate cancer, widely-metastatic lung cancer is dying. And they insist that everything be done.
Actually in my book I talk about how I still think I have post-traumatic stress disorder from what I did as a 28-year-old second-year resident to a man who had widely metastatic lung cancer for whom the answer was: ‘We need to try to keep him comfortable because he’s dying.’
But we kept him alive for an additional six weeks. And finally on the day that he died I was sitting at his bed — at the foot of his bed and I realized that he was on a ventilator. [I]t would be interesting to know what this guy would have thought of this, had he been able to think, because he was probably a redneck and I was this poor kid from Detroit sitting at the foot of his bed deciding how much air he would breathe in with every breath, how often he would breathe it, what his respiratory rate would be.
[H]is family could not accept the fact that he was dying and what we should do is try to keep him comfortable. They continuously said we need to give this guy everything possible. We would say: ‘Do you mean everything reasonable?’ And they would say: ‘Everything reasonable is everything possible.’
That happens all the time. … [P]eople cannot accept that death is a part of life. Death is an imminent part of life. And so let’s get back to how doctors promise people and indeed many of these people can’t accept that folks die because we in medicine have subtly lied to them over the years and thought that we can do much more in medicine than we actually can do.
We started widespread prostate cancer screening in the United States in 1990. It was 2010 that the first study actually was recorded that told us that prostate cancer screening might save lives.
So we did it for 20 years because some people thought it might save lives. [W]e in medicine told people it does save lives and you should get it. My own American Cancer Society recommended every man over 50 get prostate cancer screening, every black man over 40 back in 1992, without adequate scientific data.
Of course the study in 2010, which is still questionable as to whether it saves lives, but the study actually suggests that it might, which was published with the study that suggests that prostate cancer screening actually increases the risk of death, by the way. The one study that suggests that it might save lives said that we had to treat 48 men in order to save one life.
Prostate cancer treatment with radical prostatectomy in the United States has a one percent risk of death. You can kind of start doing the math. There’s not a lot of people saved.
[When I became] an assistant director at the National Cancer Institute and I have to go out [to a hospital] that is an NCI-designated cancer center. And there is the whole dog and pony show where they tell you how great the hospital is and how much service they do.
This [hospital marketing] guy explained to me how if his hospital announced they were going to do free prostate cancer screening in six weeks at a particular mall, and they would screen the first 1,000 men who rolled up their sleeve and said ‘please screen me’ – men over 50. He explained to me how much free publicity they would get off of that announcement. And how much increased business their chest pain center would get off that announcement. How much increased business their breast screening service, their women’s center would get off that announcement.
If they screen 1,000 men, they’ll have 145 abnormal. They’re going to charge about $3,000 to figure out why each of the 145 abnormals is abnormal and that’s how they charge for the free screening.
Now with this mall about 10 of that 145 won’t come to this hospital … Now the 135 that they have, 45 will die of prostate cancer and the other percentage they’re going to get radical prostatectomy at about $30,000 to $40,000 per case. With a percentage they’re going to get [radioactive] seeds and about $30,000 a case. IMRT radiation therapy at the time was about $60,000 to $70,000.
And then his business plan goes further. He knew how many guys are going to have so much incontinence that diapers don’t do it so he had in his business plan how many artificial sphincters the urologists were going to implant. And then he was a little apologetic because there is this new thing called Viagra on the market and that screwed up his estimate about how many penile implants he was going to sell because of guys who were upset about impotence due to prostate cancer treatment.
This is 1998. [I said] if you screen 1,000 people how many lives are you going to save. He took his glasses off, looked at me like I was fool and he said ‘Don’t you know nobody has ever shown that prostate cancer screening saves lives. I can’t give you an estimate on that.’
Quite honestly, a whole bunch of doctors have drunk the Kool-Aid. They don’t actually understand that prostate cancer screening may not save lives. The fact that some of them make money off them helps them to not understand, of course.
And unfortunately doctors tend to confuse what they believe with what they know. That’s actually something that we docs need to work on. We also need to realize that a profession is a group of people who puts its customers and the welfare of its customers above the welfare of members of the profession. A profession is a group of people who polices itself.
That’s one of the reasons why when a group of doctor professional organizations a couple of weeks ago announced these are tests that we are overdoing and we need to stop doing so often. I actually thought that was a good thing. We’re starting to finally realize what the real meaning of the profession is.
When I hear the politicians talk about death panels and rationing, we need to be talking about rational use of medicine. Not rationing but rational. And unfortunately that is not happening in the United States.
There is this drug called Prilosec. Suppresses acid in the stomach. Great drug. AstraZeneca only had one problem. Eighteen-year patent. Four years left on the patent.
Five billion dollar a year drug. Lots of money made off of Prilosec. ‘What’s going to be our next multibillion dollar drug?’ Well they started this thing called ‘operation shark fin,’ the search for the next multibillion dollar drug.
They couldn’t find a new drug but they found a very smart chemist who knew a little bit of patent law. You see Prilosec when it was made is a big molecule and – not to get too much into the chemistry – there is really two chemicals there and they’re mirror image isomers.
Well, you have the pill Prilosec – the left suppresses acid, the right [side of the pill] your liver takes out sends it to the kidney and you urinate it out. But it’s the left [side] that’s active.
Well the smart chemist realized it’s just one quick easy chemical step in the lab to do what your liver does for you. Separate left from right. And so they separated left from right, they did a series of studies that they sent to the FDA arguing that this new drug, which we have patented called Esomeprazole is equivalent to the old drug.
And the FDA agreed that the new drug was equivalent to the old drug so the FDA approved it. It’s equivalent in side effects, its equivalent in efficacy. And then they went to their marketing guys and they said how are we going to market this drug, the next multibillion dollar drug for AstraZeneca? And the marketing guy said ‘we’re going to package it as a big purple pill and then they said what are we going to call our next multibillion dollar drug? Let’s screw them, let’s call it Nexium.’
Okay, now I happen to go to Costco yesterday. A pill of Nexium is $6. A pill of Prilosec is $1 and a pill of generic Prilosec is 35 cents. Okay. Now one of the ten most prescribed drugs in the United States today is Nexium. At $6 a day. But, all the science tells us it was FDA approved because it was equivalent to something that costs 35 cents a day.
And we wonder why we have 18 percent of our GDP going towards health care.
By the way, about $8,000 per man, woman and child is what health care costs in the United States today. The number two country, which is Switzerland, is a little less than $4,000. Switzerland is fourth among UN countries in life expectancy and we’re 50th. I don’t think we get what we pay for.
You see, what we need to do and what we desperately need to do is not reform health care. We need to transform how we view health care. We need to become much more appreciative of prevention efforts. We need to reimburse doctors who coach and talk to patients far better than we are.
Today we give doctors who do interventions in patients a lot more money than they should be getting and doctors who talk to patients very little money. The incentive on the doctor today is to not talk to patients, just move them in, move them out and get volume.
We need to understand and appreciate science. We’re not going to have improvements in our healthcare system until the mass population demands that doctors appreciate science, demands and asks doctors to justify their reputations and justify their decisions. We need the skeptical, educated consumer. We need people who consume medicine to think about health care the same way they think about buying a television set at a Best Buy. We need people to actually stop just accepting things and start being skeptical.
By KHN Staff
This article was reprinted from Kaiser Health News with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.
- Q — Reporter from Oregon. I am a 16-year breast cancer survivor. I understand the ACS is responsible to promoting cancer prevention. Why has the ACS been so reluctant to acknowledge documented environmental exposures?
A — The biggest environmental promoter of cancer has been diet and lack of exercise. I think we need to spend most our efforts on that. Some of the data on environmental causes of cancer, when you start peering through it, doesn’t pass a bunch of tests. For example, I am still convinced that DDT causes some cancers. But truth be told, every time we have done a study to prove it, we have been unable to prove it. I struggle on a daily basis with environmental causes of cancer. I struggle against some of the garbage, for example, cell phones: much of the data about cell phones causing brain cancer is generated by about 8 people who really believe it. That doesn’t mean cell phones don’t cause brain tumors but growing up where I did, that increases my scrutiny of the literature. I don’t know. When you start changing an industry, you can’t turn it on a dime. It’s not even like changing the direction of an aircraft carrier. We will get a little more open and honest about the science, but we are also going to get more rigorous about the science.
- Q — What about Avastin covered by health care?
A — There is a group of women it is very good for, and there is a group it kills. I think we desperately need a maker or a way to say this is a woman who will benefit and a woman who won’t. I’ve seen a case in the past where a drug company tried to suppress a test because they knew it was only good for 30 percent, but they wanted the whole market of lung cancer patients. I have tremendous difficulty in telling a woman who truly understands the risk… That is not the reason for health care costs.
- Q — There are up to 70 percent of tests we do not need. There are doctors, nurses etc who provide these tests and if you cut the tests, you cut their jobs. So if we move in a more “rational” direction, what do we do about the body of people who will lose good paying jobs?
A — They will find other things to do and we will become a more productive society.
- Q — Oncology Times reporter. You mean the Choosing Wisely campaign. How is that going to affect oncology care in America?
A — It is going to decrease some oncologists’ income which may be appropriate. When we talk about imaging in the U.S. on a per 100,000 person basis, we have 3 times as many CT scanners and 5 times as many MRI scanners as in Canada. Canada is 10th in life expectancy and we are 50th in spite of the fact we criticize Canadian health care all the time. I’ll go on the record and say people in the United States may not live longer but we sure as hell take much better pictures of them dying.
- Q — NY independent journalist. Bone marrow transplant for women. Was covering a case of a woman dying in a sealed unit in a major teaching hospital and her insurance company would not pay for it. Moved by her plight. Yet the scientific evidence was not persuasive. So what do you think about the role of insurance companies today, an attempt to communicate more directly with the patient?
A — Insurance companies are interesting. Their 20 percent profits disturb me a bit. They do have some ability to make us better at practicing medicine. In my book, I actually talk about a lady in Atlanta whose cousin got me involved in her health care. This lady was convinced that even though she had stage one colon cancer, she needed adjuvant chemotherapy. Despite the fact every medical oncologist she went to told her there were no signs that showed it would help her, there was science to show it would help somebody who was 2 stages higher than her, and her risk of side effects now and later would be greater, she wanted the chemo to the point one of the oncologists eventually gave it to her. He of course got about $6000 – 10,000 for the 6 months of chemotherapy and she ended up raising her risk of leukemia and got no cancer therapy. Why did her insurance company pay for it? Turns out, the HIPPA law allows the insurance company to know she had colon cancer, but does not allow the insurance company to know she had stage one colon cancer. I think that is stupid.
- Q — Bob R, freelance writer. Do you think Warren Buffet, who is 81, got bad medical advice when he was told to get radiation for his stage one prostate cancer?
A — I’ll back up a little bit. No organization currently recommends that men just get screened for prostate cancer. The U.S. Taskforce has floated a proposed recommendation … The American Urological Association and the ACS say if a man has a 10-year life expectancy and understands the potential risks and benefits of screening, and wants screening, he should get screening. For men who are 82 who have stage one prostate cancer, most of those men in my mind should be observed. There are a few of those men who have high Gleason Score who I would recommend get radiation.
- Q — Sacramento Bee. Did a story about the HPV vaccine and got the usual emails from vaccine haters which I usually ignore. But I got one from a man who read the Merck study…
A — I do think it is appropriate to be giving the vaccine widely. I think we have overstated the case. We are assuming all cancers come through these ( ) lesions.
- Q — Mare Stonem, Daily Rx.com. What do you think about the problems found with various standard of care therapies including radiation and its promotion of stem cells, and chemo actually damaging healthy DNA which could promote later cancers?
A — I think all the more reason that all these things need to be done through very good clinical trials. The chemotherapy stuff, we need to do long term follow up. It is very important and have to be cautious in our use of chemotherapy drugs. By the way, one of things to be concerned about is nurses and pharmacists who mix these drugs developing cancer because of their exposures.
- Q — Matt Perry, freelancer in Sacramento. I sat through a similar conference where Peter Lee said if you don’t think this is one of the best times to revolutionize health care, you should think of another profession. The rest of the day was devoted to same old, same old. So I am wondering when the healthiest people in the country would be involved in revolutionizing health care — the fitness instructors, the dieticians, the environmental causes.
A — One of the things we are privileged to do is to help out the First Lady with her campaign. She deserves applause. You would be amazed how much criticism she has gotten. There is a group of people on both sides of the isle: one will say the sun is shining and it is 12 noon, and the other side will argue that fact. That is so detrimental, especially when talking about kids and obesity. By the way, I will tell you the greatest problem with obesity is 4 percent of America’s kids were obese in 1980 and in 2008, it was 20 percent. Had increased by a factor of five among kids aged 6 to 11 between 1970 and 2008. That is important because – I am an orthodox, conservative scientist – I have studies that tell me hidden fat causes cancer. The smart thing to do is to prevent kids from getting fat as opposed to putting 50-year-olds on Weight Watchers.