1. Presents
“How We Do Harm”
with Dr. Otis Brawley

2. Otis W. Brawley, MD, FACP, FASCO
Chief Medical and Scientific Officer
American Cancer Society
Professor of Hematology, Medical Oncology,
Medicine and Epidemiology
Emory University

4. 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.

5. Disparities in Health
Of all the forms of inequality,
injustice in health care is the most
shocking and inhumane
• ML King, Jr. Presentation at: The Second National Convention of the
Medical Committee for Human Rights; March 25, 1966; Chicago, IL.

6. 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!!!!

7. The American Healthcare System
• Overconsumption of Healthcare
• The Greedy Feeding the Gluttonous
• A Subtle form of Corruption

12. Prostate Cancer Screening

13. 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?

14. Recommending for Informed
Decision Making
• American Cancer Society
• National Comprehensive Cancer Network
• American Society for Clinical Oncology
• European Urology Association
• American Urology Association

15. 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

16. The American Cancer Society 2010
Prostate Cancer Screening Guideline
“Men should have an opportunity to make an
informed decision with their health care provider
about whether to be screened for prostate
cancer, after receiving information about the
uncertainties, risks, and potential benefits associated
with prostate cancer screening.”

17. American Urological Association*
Given the uncertainty that PSA testing results in more
benefit than harm, a thoughtful and broad approach
to PSA is critical.
Patients need to be informed of the risks and benefits
of testing before it is undertaken. The risks of
overdetection and overtreatment should be included
in this discussion.
*Taken from the AUA PSA Best Practice Statement 2009 and
markedly different from statements made in press conferences

18. Recommending for Informed
Decision Making
• American Cancer Society
• National Comprehensive Cancer Network
• American Society for Clinical Oncology
• European Urology Association
• American Urology Association

20. 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?

21. Lung Cancer Screening

22. 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

23. 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)

24. Lung Cancer Screening
Consider 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.

25. Offers Low Dose Spiral CT of the Lung to those at risk for
lung cancer. ($325 cash).
“At risk for lung cancer,” according to St Joe’s, includes 40
year old non-smoking women who have lived in an
urban area for more than ten years.
The business plan relies on insurance to pay for the
follow-up testing of the 25% or more abnormal screens.

26. 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.

27. “It is difficult to get a man to understand
something, when his salary depends on his not
understanding it.”
Upton Sinclair
A professional is someone who puts the interests
of his patients above his own.
Hal Sox

28. Rational vs. Irrational Medicine
• Rofecoxib (Vioxx) vs. Naproxen
• Once a day vs. twice a day
• $90 per month vs. $12 per month

29. 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

30. True Healthcare Reform
Requires:
The use of “Evidence Based Care and Prevention”
That is:
 The rational use of medicine
 Not the rationing of medicine

31. True Healthcare Reform
Requires:
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!

32. Breast Cancer Screening

33. Breast Cancer Screening in the U.S.
The Ten Year Potential 64,673 deaths averted
USPSTF
Age Estimate of Lives Lost due
Number in Number Needed Avertable to Non-
Population to Screen Deaths Compliance
40's 22,327,592 1,900 11,751 4,113
50's 20,542,363 1,340 15,330 5,366
60's 13,909,277 370 37,592 13,157

34. Breast Cancer Treatment

35. Adjusted Breast Cancer Survival by Stages and
Insurance Status, among Patients Diagnosed in
1999-2000 and Reported to the NCDB

36. Non-Standard Care
Of 6,734 women treated for breast
cancer in seven states, 35% did not
receive adjuvant chemotherapy
consistent with guidelines.
Wu et al., J Clin Oncol 2012

37. Non-Standard Care
Predictors of non-guideline adjuvant
chemotherapy 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

38. Non-Standard Care
In a prospective study of 957 patients receiving
adjuvant breast cancer treatment in 101
practices, factors associated with nonstandard
regimens 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

39. Clinical Lessons Learned Late
Medicine without Wisdom!!!

40. Clinical Lessons Learned Late
Overused Interventions
• Hysterectomy
• Caesarian section
• Carotid endarterectomy
• Coronary Artery Bypass Grafting
• Tonsillectomy

41. Clinical Lessons Learned Late
Drugs 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

42. Clinical Lessons Learned Late
Treatments introduced without assessment
• Halsted mastectomy
• Cryotherapy for prostate cancer
• Adjuvant bone marrow transplant for breast
cancer
Screening done before proven harmful
• Chest Xray screening for lung cancer
• Urine screening for neuroblastoma

43. U.S. Health Care Spending
In 2010, the U.S. spent
$2.6 TRILLION
on Health Care

44. 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

45. Spending in Context
2010
$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

46. Gross Domestic Product by Country, 2010
Thrillion 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

47. 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)

48. 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.

49. Average Life Expectancy (years)
S J
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1000
1500
2000
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3000
3500
4000
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50. 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%

51. 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.

52. Obesity in the United States 1970 and 2008
40
35
35
30
25
Percent
20
20
15
15
10
5 4
0
1970 2008 1970 2008
American Adults American Children
Aged 21 and above Aged 6 to 11

53. 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

54. • Tsunami of Chronic Disease
–Diabetes
–Cardiovascular Disease
–Orthopedic Disease
–Cancer

55. • 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

56. 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

57. Otis W. Brawley, MD, FACP, FASCO
Chief Medical and Scientific Officer
American Cancer Society
Professor of Hematology, Medical Oncology,
Medicine and Epidemiology
Emory University

58. www.sharecancersupport.org
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