How We Do Harm: A Webinar by SHARE with Dr. Otis Brawley

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Dr. Otis Brawley, author of How We Do Harm, pulls back the curtain on how health care is really practiced in American. Hosted by SHARE: Self-help for Women with Breast or Ovarian Cancer.. www.sharecancersupport.org. If you would like to watch the full webinar, visit www.sharecancersupport.org/brawley.

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How We Do Harm: A Webinar by SHARE with Dr. Otis Brawley

  1. 1. Presents“How We Do Harm” with Dr. Otis Brawley
  2. 2. Otis W. Brawley, MD, FACP, FASCO Chief Medical and Scientific Officer American Cancer SocietyProfessor of Hematology, Medical Oncology, Medicine and Epidemiology Emory University
  3. 3. Healthcare • An issue that must be approached ethically, logically and rationally • We must realize: – What we know. – What we do not know. – What we believe.
  4. 4. Disparities in HealthOf all the forms of inequality,injustice in health care is the mostshocking and inhumane• ML King, Jr. Presentation at: The Second National Convention of the Medical Committee for Human Rights; March 25, 1966; Chicago, IL.
  5. 5. Toward an Efficient Healthcare System• Some consume too much – (Unnecessary care given)• Some consume too little – (Necessary care not given)• We could decrease the waste and improve overall health!!!!
  6. 6. The American Healthcare System• Overconsumption of Healthcare• The Greedy Feeding the Gluttonous• A Subtle form of Corruption
  7. 7. Prostate Cancer Screening
  8. 8. Prostate Cancer and Chemoprevention• Pretend you are a 55 year old male and a preventive pill exists: – If you take the pill it will definitely double your risk of prostate cancer diagnosis from 10% lifetime to 20% lifetime. – It you take it, it may decrease your lifetime risk of prostate cancer death by 20% from 3% to 2.4%.• Would you take this pill?
  9. 9. Recommending for Informed Decision Making• American Cancer Society• National Comprehensive Cancer Network• American Society for Clinical Oncology• European Urology Association• American Urology Association
  10. 10. Recommending Against Routine Prostate Cancer Screening• U.S. Preventive Services Taskforce• Canadian Taskforce on the Periodic Health Examination• American College of Preventive Medicine• American College of Physicians
  11. 11. The American Cancer Society 2010Prostate Cancer Screening Guideline“Men should have an opportunity to make aninformed decision with their health care providerabout whether to be screened for prostatecancer, after receiving information about theuncertainties, risks, and potential benefits associatedwith prostate cancer screening.”
  12. 12. American Urological Association*Given the uncertainty that PSA testing results in morebenefit than harm, a thoughtful and broad approachto PSA is critical.Patients need to be informed of the risks and benefitsof testing before it is undertaken. The risks ofoverdetection and overtreatment should be includedin this discussion. *Taken from the AUA PSA Best Practice Statement 2009 and markedly different from statements made in press conferences
  13. 13. Recommending for Informed Decision Making• American Cancer Society• National Comprehensive Cancer Network• American Society for Clinical Oncology• European Urology Association• American Urology Association
  14. 14. Prostate Cancer and Chemoprevention• Pretend you are a 55 year old male and a preventive pill exists: – If you take the pill it will definitely double your risk of prostate cancer diagnosis from 10% lifetime to 20% lifetime. – It you take it, it may decrease your lifetime risk of prostate cancer death by 20% from 3% to 2.4%.• Would you take this pill?
  15. 15. Lung Cancer Screening
  16. 16. The National Lung Screening Trial• Nearly 54,000, age 55 and above• 30 pack year or greater history of smoking. If quit, did so less than 15 years prior to trial entry• Reasonable health• Prospectively randomized to PA Chest Xray or LD sprial CT yearly X3• Done at twelve sites with experts specializing in lung CT
  17. 17. The National Lung Screening Trial(one view of the 20 percent reduction in mortality)• At ten years from the start of screening about 27,000 at high risk, age 55 or over at the start of the trial. – 80 to 90 lives were saved of a lung cancer death – About 340 died of lung cancer – 16 died due to interventions caused by screening (six did not have cancer)
  18. 18. Lung Cancer ScreeningConsider spiral CT for those:• Healthy aged 55 years and above• H/0 30 pack years of smoking or more• If quit smoking did so less than 15 years ago• Who understand that there are risks of unnecessary diagnostic procedures and even death associated with screening.
  19. 19. Offers Low Dose Spiral CT of the Lung to those at risk forlung cancer. ($325 cash).“At risk for lung cancer,” according to St Joe’s, includes 40year old non-smoking women who have lived in anurban area for more than ten years.The business plan relies on insurance to pay for thefollow-up testing of the 25% or more abnormal screens.
  20. 20. Medical Gluttony • Screening tests of no proven value • Treatments of no proven value • Laboratory and radiologic imaging done for convenience. -Cannot find original. -Legal defense (real or imagined). -Tradition.
  21. 21. “It is difficult to get a man to understandsomething, when his salary depends on his notunderstanding it.” Upton SinclairA professional is someone who puts the interestsof his patients above his own. Hal Sox
  22. 22. Rational vs. Irrational Medicine • Rofecoxib (Vioxx) vs. Naproxen • Once a day vs. twice a day • $90 per month vs. $12 per month
  23. 23. Rational vs. Irrational Medicine Generic Omeprazole (Prilosec) vs. Esomeprazole (Nexium) 25 cents per day vs. six dollar per day Eight dollars per month vs. 180 dollars per month
  24. 24. True Healthcare ReformRequires:The use of “Evidence Based Care and Prevention”That is:  The rational use of medicine  Not the rationing of medicine
  25. 25. True Healthcare ReformRequires:The use of “Evidence Based Care and Prevention”That is:  We do what we know works, and often do not do!  We stop doing what we know does not work, and often do!
  26. 26. Breast Cancer Screening
  27. 27. Breast Cancer Screening in the U.S.The Ten Year Potential 64,673 deaths averted USPSTFAge Estimate of Lives Lost due Number in Number Needed Avertable to Non- Population to Screen Deaths Compliance40s 22,327,592 1,900 11,751 4,11350s 20,542,363 1,340 15,330 5,36660s 13,909,277 370 37,592 13,157
  28. 28. Breast Cancer Treatment
  29. 29. Adjusted Breast Cancer Survival by Stages andInsurance Status, among Patients Diagnosed in1999-2000 and Reported to the NCDB
  30. 30. Non-Standard CareOf 6,734 women treated for breastcancer in seven states, 35% did notreceive adjuvant chemotherapyconsistent with guidelines. Wu et al., J Clin Oncol 2012
  31. 31. Non-Standard CarePredictors of non-guideline adjuvantchemotherapy include: – Medicaid insurance (OR, 0.66; 95% CI, 0.50 to 0.86) – Lack of Insurance (OR, 0.69; 95% CI, 0.56 to 0.85) – High-poverty areas (OR, 0.71; 95% CI, 0.51 to 0.97) – Low education areas (OR, 0.65; 95% CI, 0.48 to 0.89) Wu et al., J Clin Oncol 2012
  32. 32. Non-Standard CareIn a prospective study of 957 patients receivingadjuvant breast cancer treatment in 101practices, factors associated with nonstandardregimens include: – Black race (p=.008) – Lower education level (p=.003) – Insurance type (P=0.48) – Employment status (p=.045) Griggs et al, J Clin Oncol. 2007
  33. 33. Clinical Lessons Learned LateMedicine without Wisdom!!!
  34. 34. Clinical Lessons Learned LateOverused Interventions• Hysterectomy• Caesarian section• Carotid endarterectomy• Coronary Artery Bypass Grafting• Tonsillectomy
  35. 35. Clinical Lessons Learned LateDrugs re-assessed after-marketing• Postmenopausal Hormone replacement therapy• Lidocaine after MI• Hyper-vitaminosis (vit E, Beta Carotene, Selenium)• Vioxx for arthritic pain• Erythropoetin to stimulate blood
  36. 36. Clinical Lessons Learned LateTreatments introduced without assessment• Halsted mastectomy• Cryotherapy for prostate cancer• Adjuvant bone marrow transplant for breast cancerScreening done before proven harmful• Chest Xray screening for lung cancer• Urine screening for neuroblastoma
  37. 37. U.S. Health Care SpendingIn 2010, the U.S. spent$2.6 TRILLION on Health Care
  38. 38. U.S. Health Care Spending•How Big is a Trillion? 1 million seconds Last week 1 billion seconds Richard Nixon’s Resignation 1 trillion seconds 30,000 BCE
  39. 39. Spending in Context2010 $2.6 trillion $1.4 trillion 17.9%$1.1 trillion Gross Domestic Product * Excludes alcoholic beverages ($150 billion) and tobacco products ($92 billion) Source: Bureau of Economic Analysis; National Bureau of Statistics of China, MGI analysis
  40. 40. Gross Domestic Product by Country, 2010Thrillion Dollars, at Official Exchange Rate • United States 14.45 • China 5.74 • Japan 5.46 • Germany 3.28 • France 2.56 • Brazil 2.09 CIA Fact Book, 2012
  41. 41. American Healthcare• 16.2% of GDP in 2008• 17.3% of GDP in 2009• 19.3% of GDP by 2019 (projected)• 25% of GDP by 2025 (projected)
  42. 42. Beyond Healthcare Reform• Medicare, Medicaid, and Social Security account for all of the projected increase in Federal spending over the next 40 years.• For the past 30 years, costs per person throughout the health care system have been growing approximately two percentage points faster per year than per-capita GDP.• Most projections assume this pattern will continue through 2050. Over time, the fiscal consequences of this rate of growth in health costs are massive.
  43. 43. Average Life Expectancy (years) S J 74 75 76 77 78 79 80 81 82 a n ap a M n a M rino S on w a itz co er A l an us d tr S alia w ed The Cost of a Long Life2006 CIA FACTBOOK Ic en el A and nd o C rra an a F r da an ce Ita A ly us tri S a pa N in S orw in a ga y po Lu I re x sr N em a e l ew bo Z u N ea rg et la he n rl d G and er s m Life Expectancy – Per Capita Spending a G ny re ec e M B alta el U gi u ni te Fin m d la Ki n ng d U e m D do ni nm te d ar St k United States Translate into Longer Life Expectancy at e C s ub C a yp r Ire us la Higher Per Capita Spending in the U.S. does not P nd or tu ga l 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 Per Capita Spending in USD
  44. 44. Healthcare in Three Countries (2010)• Canada Switzerland U.S.• Infant Mortality 5.04 4.53 6.22 per 1000 live births• White Male Life Exp 78.0 79.7 76.8 Years• Per Capita Costs 4445 5270 8233 US Dollars• Proportion of GDP 11.4% 11.4% 17.9%
  45. 45. Cigarette Smoking Prevalence* (%), by Sex, Adults 18 and Older, US, 1965-2008 Men Women*Redesign of survey in 1997 may affect trends. Estimates are age adjusted to the 2000 US standard population using five age groups: 18-24, 25-34 years, 35-44 years, 45-64 years, and 65 years and over.Source: National Health Interview Survey, 1965-2008, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.
  46. 46. Obesity in the United States 1970 and 2008 40 35 35 30 25Percent 20 20 15 15 10 5 4 0 1970 2008 1970 2008 American Adults American Children Aged 21 and above Aged 6 to 11
  47. 47. Obesity U.S. 2008 Women Men• Non-Hispanic Blacks 49.6% 37.3%• Mexican Americans 45.1% 35.9%• All Hispanics 43.0% 34.3%• Non-Hispanic Whites 33.0% 31.9% CDC MMWR, 2011
  48. 48. • Tsunami of Chronic Disease –Diabetes –Cardiovascular Disease –Orthopedic Disease –Cancer
  49. 49. • Tsunami of Chronic Disease• Will surpass tobacco as leading cause of cancer• Think of the number of people we could save from a cancer death if we did what we know we should do
  50. 50. True Healthcare Reform (An Efficient, Value Driven Health System)• Rational use of healthcare is necessary for the future of the U.S. economy (an issue of U.S. security)• It is possible to decrease costs and improve healthcare by using science to guide our policies
  51. 51. Otis W. Brawley, MD, FACP, FASCO Chief Medical and Scientific Officer American Cancer SocietyProfessor of Hematology, Medical Oncology, Medicine and Epidemiology Emory University
  52. 52. www.sharecancersupport.org Call Our Helplines: Breast Cancer: 866-891-2392Ovarian Cancer: 866-53-SHARE español: 866-891-2392

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