Otis W. Brawley gave a presentation on the evolution of our concept of cancer and disparities in cancer outcomes. Some key points: - Our understanding of cancer has advanced from the 19th century definition to incorporating genomics and personalized medicine. Screening and diagnostic tools have also improved greatly over time. - However, an estimated 10-20% of cancers detected through screening are overdiagnosed and do not need treatment. Screening also has harms like unnecessary biopsies and treatments. - Disparities exist in cancer outcomes based on factors like race, income, education level, geography. An estimated 152,000 cancer deaths per year could be prevented in the US if all Americans

1. Otis W. Brawley, MD, MACP, FASCO, FACE
sss
Bloomberg Distinguished Professor
of Oncology and Epidemiology

2. Disclosures
• Employment:
• Johns Hopkins University
• Consulting
• National Institutes of Health
• Centers for Disease Control
• Department of Defense

4. What is Cancer
The Evolution of Our Concept of the Disease
• Moving from a 19th Century definition to a 21st Century definition
• Moving he biopsy to the biopsy and genomics
4

5. Rudolph Ludwig Karl Virchow
1821- 1902

6. Adenocarcinoma

7. Advances in cancer diagnosis:
– X-ray – 1890’s
– Mammogram - 1950’s
– Ultrasound – 1960’s
– Computerized Tomography (CT) - 1970’s
– Magnetic Resonance Imaging (MRI) - 1980’s
– PSA in the 1980’s
– Stereotactic biopsy – 2000’s to present

8. Bone Scan of Metastatic Adenocarcinoma

9. Mammogram with a Ductal Carcinoma

10. Adenocarcinoma

12. Overdiagnosis of Cancer
There are some small screen detected cancers that are not a clinical
threat to the patient.
– We cure some cancers that do not need to be cured!!!!
– How to determine that these tissues are non-threatening is a major area of
research.

13. Overdiagnosis of Cancer
(A Difficult Concept to Comprehend)
Cancers have varying biologic behaviors
Estimates:
– 10 to 20% of radiologically detected lung cancers
– 10 to 50% of mammographically detected invasive breast cancers
– Up to 80% of Ductal Carcinoma In Situ of the breast
– 40 to 60%% of ultrasound detected thyroid cancers
– 60% of PSA detected prostate cancers

14. Cancer Screening
• Can be beneficial! Can be harmful!
– Beneficial in that it can save lives
– Harmful in that it treats patients who do not need treatment
• Often both and only a good randomized clinical trial
can disclose the net benefit to the population
(risk/benefit ratio).
• Need to follow good science.

15. Cancer Screening
• Breast
• Cervix
• Colorectal
• Lung*
• Prostate*
* Informed decision recommended as harms
are significant
15

16. The National Lung Screening Trial
(one view of the 20 percent reduction in mortality)
Screening always has benefits and harms!
5.4 lives saved for:
• Every 2 people with a complication due to an
invasive procedure
• Every 1 life lost prematurely
*Note: those with greatest risk of cancer had greatest
benefit.
N Engl J Med. 2011 Aug 4;364(22):2148-54

17. Lung Cancer Screening Recommendations
• Some professional organizations “encourage” lung cancer screening
and some healthcare institutions have put lung screening in their
business plan as it can be a profit center.
• Some professional organizations recommend “informed decision
making” regarding lung cancer screening
“Encouraging” in light of the documented harms can be viewed as
paternalism, not respecting the individuals right to self determination.
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18. Prostate Cancer Screening
• 11 of 11 prospective randomized trials have shown the harms of prostate cancer
screening
– Considerable overdiagnosis.
– Overtreatment.
– Harms of treatment:
• Fever and sepsis associated with diagnostic biopsies.
• Mental anguish.
• Poor quality of life after diagnosis and treatment.
• 2 of 11 prospective randomized trials have claimed a small mortality reduction.
• All 11 trials have flaws.

19. Applying ERSPC to the Population
fourteen years of follow-up
Of 1000 men aged 55 to 69 screened
regularly over a twelve year period
– 100 will be diagnosed with prostate cancer
– The number treated is declining in recent years
– 4 will die of the disease

20. Applying ERSPC to the Population
fourteen years of follow-up
Of 1000 men aged 55 to 69 who
choose not to be screened over a
twelve year period
– 60 will be diagnosed with prostate cancer
– 5 will die of the disease

21. Applying ERSPC to the Population
fourteen years of follow-up
5 per 1000 dying going to 4 per 1000 is
the 20% reduction in relative risk of death
Screening saves 1 life in 1000 men screened regularly for 12 years,
but at what cost?
Of the 100 diagnosed through screening 96 think they are the 1 in
1000 whose life was saved.

22. Prostate Cancer Screening
A Complex Message
This is ripe for confusion and distrust
– Many (who mean well) promote screening and do not
understand the nuances.
– Many promote screening because it is money making!
Confusion and distrust can cause disparities in receipt of care
beyond prostate care.
22

23. Prostate Cancer Screening
Quality of Treatment is very important in outcomes.
– Surgery
– Radiation therapy
– Observation for low grade lesions
Increasing volumes due to screening can tax and
diminish the quality of a treatment program.
This can again cause distrust in a community

24. Breast Cancer Strategies to Reduce Cancer Mortality
CISNET Modeling of outcomes from 2013 to 2025
• With current breast cancer screening and treatment patterns, there will be
50,100 to 57,400 deaths in 2025
• With annual screening of all women 40 to 54 and biannual age 55 and
above and current treatment patterns there will be 5100 to 6100 fewer
deaths
• With all women receiving appropriate therapy and no change in screening
rates there would be 11,400 to 14,500 fewer deaths
• If all women received appropriate screening and treatment there would be
18,100 to 20,400 fewer deaths
24
Mandelblatt et al, Cancer, 2013

25. Cancer Demographics
• The American Cancer Society estimates that 1.76 million
Americans will be diagnosed with cancer in 2019.
• It is estimated that 607,000 will die of cancer in 2019.
• Age adjusted cancer mortality rates have declined 26% from
1991 to 2016.

26. 0
50
100
150
200
250
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010
Rateper100,000
US Cancer Death Rate
1900 to 2016
215
159
64
Age Adjusted to 2000 Standard
1900-1970, US Public Health Service, Vital Statistics of the US, Vol. 1 and Vol 2;
1971-2010, US National Center for Health Statistics, Vital Statistics of the U.S
A 26% decline
over 25 years

27. The 26% Decline
• Half of the decline is due to prevention of disease primarily due to
smoking cessation since the early 1960’s
• Half of the decline is due to improvements in screening and treatment.
27

28. Race
Defined by US Office of Management and Budget before every
decennial census.
– White
– Black
– Asian
– Pacific Islander
– Native American/Alaskan Native
In US population data Ethnicity is defined as Hispanic or non-Hispanic

29. Race
Defined by US Office of Management and Budget every ten years.
– Sociopolitical and not biologic according to OMB definition
– Rejected by Anthropological community as non-scientific
– Race changes over time*

30. Disparities by Location
• Region of the US
• Rural - Urban
• Neighborhood
30

31. Socioeconomic Status
• Personal Income
• Family Income
• Education
31

32. Cancer Mortality by Race/Ethnicity from 1990 to 2015
Siegel, et al. CA 2018;68:329-339

34. Breast Cancer
In 2019,
269,000 Diagnosed
42,300 Deaths
There has been a 40% decline in age-adjusted female
mortality from 1990 to 2016

35. 0
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45
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Breast Cancer Mortality 1975-2015
SEER Data, Age Adjusted to year 2000 Standard
White Black Hispanic NA/AN Asian/PI
Siegel, et al. CA 2018;68:329-339

36. Breast Cancer Mortality Decline
from 1988-90 to 2013-2015 by State

37. Breast Cancer
The Reality
DeSantis et al, CA, 2017
There are seven states where B-W
mortality differences are no longer
statistically significant.

38. Colon and Rectal Cancer
In 2019,
– Diagnosed: 101,400 colonic and 44,200 rectal
– 51,000 Americans will die of colon and rectal cancer.
– Among US Population as a whole, there has been a
50% decline in age-adjusted death rate since 1980.

39. 0
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Female Colorectal Cancer Mortality, 1975-2015
SEER, Age-Adjusted to year 2000 Standard
White Black NA/AN API Hispanic
Siegel, et al. CA 2018;68:329-339

40. 0
5
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Male Colorectal Cancer Mortality 1975-2015
SEER, Age-Adjusted to year 2000 Standard
White Black NA//AN API Asian
Siegel, et al. CA 2018;68:329-339

41. Colorectal Cancer Mortality Decline
from 1980-82 to 2013-2015 by State
Siegel, et al. CA 2018;68:329-339

42. Adjusted Colorectal Cancer Survival by Stage and Insurance
Status, among White Patients 18-64 years Diagnosed from
1999-2000, NCDB
Stage I, Privately Insured

43. Colon Cancer Quality of Surgery
A minimum of 12 lymph node should be examined in an adequate
colorectal cancer pathology specimen
-About half of all colorectal cancer patients have 12 or more LN examined.
-Hispanics, Blacks and the poor have higher odds of receiving an inadequate
dissection.
-Inadequate examination associated with hospital where care was received.
-Inadequate staging leads to some of the talk that colorectal cancer is more
aggressive among Blacks!!!
– Rhoads et al, Cancer 2012 Jan 15;118(2):469-77

44. Causes of Colorectal Cancer Disparities
Differences in:
– prevalence of screening
– in quality of screening
– in proportion treated
– Quality of treatment
• Differences by:
– Race
– Socioeconomic Status
– Region of Residence
44

45. Cancer Health Disparities
State by State
Age Adjusted Cancer Mortality Rate 2015
– 125 deaths per 100,000 in Utah
– 195 deaths per 100,000 in Kentucky
45

46. The Most Important Question in Cancer Control
How Can We Provide Adequate High Quality Care (to
Include Preventive Services) to Populations That So
Often Do Not Receive It?
Facts
Unnecessary care interferes with the provision of
necessary care
State by state disparities are increasing with the
Affordable Care Act!!

47. 47
State Medicaid Expansion Plans as of mid 2019

48. Scientific Progress
Population disparities always increase when there is scientific
progress in medicine.
– This was seen when there were improvements in screening and
treatment of breast and colorectal cancer
– It is occurring as we move into the era of precision medicine
and immunotherapy
– New preventive interventions are less likely to cause significant
disparate outcome.

49. THE IMPORTANCE OF ADEQUATE CARE
TO INCLUDE PREVENTIVE CARE
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50. Potential Number of Premature Cancer Deaths That Could be Averted
by Eliminating Educational vs. Racial Disparities in African Americans,
Aged 25 to 64 Years, 2007
Siegel et al. Cancer Statistics, 2011. CA: A Cancer Journal for Clinicians. 2011:61(4)212-236.
Males Females

51. Applying Known Science
(Prevention and Treatment)
• It is estimated that 607,000 Americans will die of
cancer this year.
• If all Americans had the cancer death rate of
college educated Americans, the number would be
455,000.
• Nearly one-fourth of cancer deaths (152,000
Americans) would not occur!
Siegel, et al. CA 2018;68:329-339

52. Applying Known Science
(Prevention and Treatment)
• At least 152,000 deaths per year are preventable if all Americans
received known medical prevention and treatment.
• The majority of those preventable deaths are in white Americans.
• The issue of disparities in health are not just a racial minority
health issue.
Siegel, et al. CA 2018;68:329-339

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54. The Johns Hopkins Medical Institutions
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