by Elliott Morss, Morss Global Finance
1. The Ken Burns Promo
I have enjoyed Ken Burns’ TV series in the past, so I was looking forward to his “Cancer: The Emperor of All Maladies” recently shown on PBS. Given Burns’ historically accurate past work, I felt he would provide a balanced overview on the history of cancer and efforts to control it.
I did until I learned who paid for the series. The sponsors included Genentech (RHHGY), Cancer Treatment Centers of America, Siemens (SIEGY), Bristol-Myers Squibb (BMY), the American Association for Cancer Research, the American Cancer Society, the Leukemia and Lymphoma Society, and Stand Up To Cancer.
Despite the “feel-good” cases of cancer recoveries portrayed by Burns, the failures of the health industry have been well-documented by Clifton Leaf, Alexander Nazaryan and others. Nazaryan quotes the Lancet, a leading British medical journal “Has cancer medicine failed patients? In the words of cancer experts, the answer is yes.” Where are these failures in the Burns’ series? There is a fleeting cameo with Leaf, but mostly the series glamorizes the search for solutions.
So what is the reality? What progress has been made? We hear a lot about new discoveries, but should not the key success indicator be cancer death reductions? A significant decline in these numbers would mean progress. Table 1 provides data on deaths attributable to cancer for the 1969 to 21012 period plus what has happened since 1971, the year President Nixon launched the “war on cancer”. Progress? Since 1971, cancer deaths are up 73%, with lung cancer deaths up by much more (Table 1).
The only good news might be that deaths attributable to smoking, running at 480,000 every year, have started to fall. They are falling because the percent of Americans who smoke is down from 37% in 1975 to fewer than 20% today. And approximately 70% of lung cancer deaths, or about 100,000 deaths annually, are attributable to smoking. So these and other cancer deaths attributable to smoking have started to decline. But keep in mind; these declines are the result of policy-induced behavior change and not cancer research.
Quite surprisingly, with all the data available on cancer, it took some work to find these actual cancer death numbers. The cancer industry prefers “age adjusted deaths”. That is because 73 is the average age of people dying from cancer, and the number of people in the 65-75 age bracket has increased 39% since 1971. And consequently, “age adjusted” cancer deaths have fallen by 16%.
As a policy scientist, I take the unadjusted increase in cancer deaths as most relevant. The fact that 73% more people are dying from cancer now than in 1971 should be a cause for great concern.
Table 1. – Cancer Deaths by Type, 1969-2012
Source: Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov).
Surgery, Radiation, and Chemo are the three methods used to control cancer, and they all have been in use since the 1930s. Surgery is intended to remove the cancer cells while radiation and chemo are supposed to “kill” them. All three methods have serious side effects. And once any cancer has spread, there is very little that can be done to control it. This point is illustrated in Table 2 that gives cancer survival rates by stage. The stage measures the extent or spread of the cancer. It is clear that for all cancers, prevention methods are not effective once the spread has reached Stage IV.
Table 2. – 5 Year Survival Rates, Selected Cancers
Source: National Cancer Institute
One area where real progress can be seen is in how these cancer survival rates have changed over the years. Five-year relative survival rates describe the percentage of patients with a disease that are alive five years after their disease was discovered relative to the percentage of the general population alive five years later. Data on these survival rates for selected cancers are presented in Table 3. Overall, five year survival rates have almost doubled with childhood rates up from 20% in the earlier period to 81% more recently. This is certainly great news. However, the data also indicate just how deadly certain cancers are: for example, only 5% of people contracting pancreatic cancer are living five years later and the outcome is only slightly better for liver cancer. It is also worth remembering that extending some lives with treatments is not all good – suffice to say that chemo treatments are unpleasant.
Table 3. – Survival Rates, Selected Cancers
Source: National Cancer Institute
We learned from Siddhartha Mukherjee in the Burns’ series that cancer is very complex, there are different types of cancer and each has its own ways to hide and spread. But there is another side to this story that was not covered in the Burns series: treating cancer via surgery, radiation, and chemo has been a very lucrative business for all segments of the cancer industry: the hospitals, doctors, pharmaceutical companies, and equipment makers. It is hardly an overstatement to characterize this industry as a lumbering giant looking to perpetuate existing revenue sources.
Now, one might say that this is rubbish, that there is so much money to be made by anyone who finds a cancer cure. But against this, one has to recognize there is a lot of money to be made in the perpetuation of using surgery, radiation and chemo in cancer treatment.
Leaf points out that $15 billion is spent annually on cancer research. He is troubled that most of cancer research goes to the same large organizations year after year and how most of the individuals leading the research are “elderly”. Leaf also complains about how resistant the research community has become to new approaches.
Sustaining an industry year after year showing little progress requires considerable political support. Open Secrets reports that in 2014 the “health industry” – hospitals, pharmaceuticals, equipment makers, doctors, and nurses – spent $478 million on lobbying. Finance, insurance and real estate constitutes the only sector that spent more. Of course, most of the health lobbying money was used to keep the new health care law from cutting into the “stakeholders” profits.
However, plenty was spent keeping the “cancer train” going. Those active in cancer lobbying include: Siemens, Bristol Meyers Squibb, Genentec, Cancer Centers of America, American Association for Cancer Research, American Cancer Society, and the American Lymphoma and Leukemia Society.
One would like to think, as Leaf has suggested, that it is time for a cancer research reset:
- do an assessment of how the cancer research monies are currently being spent;
- cut off monies for initiatives not showing real potential, and
- launch new initiatives in the most promising areas with success indicators and deadlines.
Sadly, this will not happen. The current research engine has too much momentum and there is so much money being made. Perhaps a more productive question is to ask where, aside from finding better medical ways to treat cancer, we might find ways to reduce cancer deaths? Clearly, large inroads can be made with human behavior modification: we will see the benefits from fewer smokers in the coming decades. And as will be discussed in the next section, reducing overeating should cut cancer deaths dramatically as well.
In 2008, David Cutler wrote an interesting piece on this subject in which he tried to identify where death mortality rates actually came from. He concluded that 23% came from behavior modification (less smoking), 35% from improved screening, and 20% from improved treatment (mostly new chemotherapy agents. Cutler concludes:
“The relative importance of these different strategies seems surprising, but it is easily understandable. Despite the vast array of medical technologies, metastatic cancer remains incurable and fatal. The armamentarium of medicine can delay death, but cannot prevent it. Thus, technologies in metastatic settings have only limited effectiveness. Far more important is making sure that people do not get cancer in the first place (prevention) and that cancer is caught early (screening), when it can be successfully treated.”
There are other non-medical research initiatives that might bear fruit. For example, Table 4 provides data on average cancer incidence rates for top and bottom 5 states on selected cancers. The differences between the average 5 top and bottom states are far too great to be the result of chance alone. It is hardly unreasonable to ask why Kentucky, Delaware, Maine, New Hampshire and Rhode Island have the highest overall rates while Colorado, Hawaii, Utah, New Mexico, and
Arizona have the lowest rates. Certainly, smoking propensities have something to do with this. Utah has the lowest smoking propensity in the US while Kentucky and West Virginia have the highest. More work on finding the reasons for these spreads might yield to leads for lowering cancer rates separate from the medical research.
Table 4. – Cancer Incidence Rates for Top and Bottom 5 States, Selected Cancers
Source: Centers for Disease Control and Prevention
2. The Smoking/Obesity Connection
There are several interesting links between cancer, smoking, and obesity. As I have noted in an earlier piece, efforts to curtail smoking work against efforts to curb obesity. The New York Times reported: “Quitting smoking does increase the risk for weight gain, and may actually cause more weight gain than previously thought. One study found that the average weight gain among former smokers was about 21 lbs. rather than the 5 – 15 lbs. commonly cited.”
Results from a very large longitudinal study found a median 4-year weight gain for recent quitters without diabetes of 6.0lbs with an interquartile range (IQR) of −1.1lbs. to +14.1lbs. For those with diabetes, the average gain was 7.9 lbs., with an IQR of −3.1lbs to +18.1lbs.
The government, still focusing on getting people to stop smoking, was quick to add: “Our findings suggest that a modest weight gain, around 5-10 pounds, has a negligible effect on the net benefit of quitting smoking.” While the government downplays the weight gain, cigarette smokers do not. Most surveys find that smokers cite concerns about gaining weight as one of the most important reasons for not quitting.
Consider next the overweight/obesity link to cancer. The Centers for Disease Control and Prevention (CDC) report that an estimated 1 out of every 3 cancer deaths in the United States is linked to excess body weight, poor nutrition, and/or physical inactivity. Body weight seems to have the strongest evidence linking it to cancer: excess body weight contributes to as many as 1 out of 5 of all cancer-related deaths.
How does this compare with smoking as a killer? The American Cancer Society reports tobacco use accounts for at least 30% of all cancer deaths, causing 87% of lung cancer deaths in men, and 70% of lung cancer deaths in women. US tobacco use is responsible for nearly 1 in 5 deaths; this equals about 480,000 early deaths each year. Estimates on obesity-attributable deaths range from 280.000 to 324,000 annually.
Here is a quote from an academic piece written in 2003: “Although still viewed more as a cosmetic rather than a health problem by the general public, excess weight is a major risk factor for premature mortality, cardiovascular disease, type 2 diabetes mellitus, osteoarthritis, certain cancers, and other medical conditions. Obesity accounts for more than 280 000 deaths annually in the United States and will soon overtake smoking as the primary preventable cause of death if current trends continue. Indeed, obesity is already associated with greater morbidity and poorer health-related quality of life than smoking, problem drinking, or poverty.”
Eliminating cancer, like making batteries more efficient and ending sonic boom, has proven to be difficult. And the spread of cancer has resulted in a huge industry making good money off researching and treating the disease. Maybe the industry has become too comfortable. Maybe it is time to take stock, get rid of cancer research “dead wood” and refocus on initiatives showing the most promise.
And because it is uncertain whether medical researchers will ever find cancer cures, other approaches to reducing cancer deaths should be aggressively pursued.
One approach – government policies leading to behavior change – has proven very effective in reducing smoking and hence a large number of cancer deaths. Could government policies directed to the reduction of overeating result in similar behavior changes? Anti-smoking policies included a massive education effort, warning labels, and heavy taxes. Applying these measures to overeating will be tricky: unlike smoking where you had only the tobacco companies in opposition, efforts to reduce overeating would probably be opposed by the entire US food industry. And should obese people ostracized as smokers have been? And what will happen when the public learns just how large the share of our health bills is taken up treating overweight people?