Interview Transcript:

Otis W. Brawley, M.D., Chief Medical Officer, The American Cancer Society

1. Are we adequately addressing the cancer pandemic in Africa and why? We are addressing the cancer pandemic, but we all need to focus more. We need to bring politicians, we need to bring non-governmental organizations into the fold to further address the cancer problem in Africa. I found the AORTIC meeting when 700 cancer specialists gathered this past fall to be incredibly valuable. I think it’€™s a wonderful step toward addressing the cancer problem in Africa. Cervical cancer is highly treatable in many areas of the world. We need to bring some of these abilities to detect and treat it and prevent it to Africa. Smoking, which is not very common in Africa but is growing, has got to be stopped or else we are going to end up with an epidemic of lung cancer. So while I’€™m very optimistic and I’€™m very happy with what we are doing in Africa, I feel that we need to do more.

2. What role will tobacco control play in cancer control in Africa? I can tell you that the Africa Tobacco Control Regional Initiative, Africa Tobacco Control Alliance, and Framework Convention Alliance have already been instrumental in helping establish an agenda for cancer control in Africa. You know, we have really played the tobacco companies to a stall or to a draw in the United States and now tobacco companies are looking to other countries. They are especially looking to Africa as being an area of growth. I think we have a moral obligation to help our African counterparts to combat tobacco in Africa and prevent what could be a tremendous epidemic of lung cancer, cardiac disease, and other diseases.

3. According to cancer associations screening is the best way for tracking cancers such as prostate cancer. Over 4000 men are diagnosed with prostate cancer annually in South Africa and most of times it’€™s too late to effectively treat the cancer.   How can we address the problem of men being tested for prostate cancer only once it is too late? You know the American Cancer Society and a number of other organizations have looked long and hard at the prostate cancer issue. I think it’€™s very important right now that everyone realize that there are significant uncertainties about whether early detection actually works for prostate cancer. Indeed, every organization that I know of that has made a statement about prostate cancer screening right now has said that men should be aware of the uncertainties and the potential benefits and need to make a choice as to whether they even get screened.

4. Which cancers are most successfully prevented or detected by regular screenings? There are wonderful clinical trials that demonstrate that breast cancer screening with mammography and clinical breast exam, or, when it’€™s not available, clinical breast exam alone actually decreases the risk of death. Breast self exam, that is telling women to screen themselves on a once a month basis, has not been shown to work but telling women ‘€œif you feel something in your breast, go get help’€ does seem to be beneficial. So again mammography screening or mammography screening with clinical breast exam and what I prefer to call ‘€œbreast awareness’€, if you feel a mass go get it evaluated, has clearly been shown to be beneficial and that’€™s the message that I believe we should be giving women.

Colorectal cancer screening has also, in clinical study, been shown to be beneficial in terms of decreasing risk of death in the case of stool blood testing by 35%. Indeed, perhaps the best screening test that’€™s ever been evaluated for any cancer is stool blood testing for colon cancer. Colonoscopy, sigmoidoscopy and other ways of imaging the colon and testing for cancer are all useful and we actually recommend that people get a screening test, not necessarily colonoscopy or stool blood testing, but any of the screening tests that have been used and advocated. They all work; the problem is people get them.

Cervical cancer screening, either the pap test or visual inspection with acetic acid, can save lives. We have a wonderful randomized study in India looking at visualization of the cervix and treating any area of the cervix that actually shows high polysaccharide content when it’€™s painted with vinegar, those all have been shown to save lives. So screening for breast, colon, and cervix cancer clearly saves lives.

We don’€™t have good evidence yet on screening for prostate cancer. We have one European study that suggests a small advantage to screening. The American study that was done at the same time did not suggest an advantage to screening. We don’€™t have good screening for lung cancer. So right now the three cancers that I encourage people to get screened for are colorectal cancer after the age of fifty, breast cancer after the age of forty, and for sexually active women, cervix cancer.

5. There is little information being kept on the progress or regress in cancer treatment in Africa -why is this so? How does this lack of information in Africa impact the fight against cancer and why is having information about cancer an important tool to fight it? It’€™s always nice to know what the incidence and mortality rates are in an area for cancer so that you can figure out if your cancer control efforts are even preventing cancer or preventing cancer deaths. We don’€™t have very many cancer registries in Africa. We need to support those registries that do exist and support the establishment of more. Indeed, the lack of cancer registries is a significant problem, but still the messages in terms of cancer control are really universal messages. Not smoking for example. A diet of five to nine servings of fruits and vegetables per day. Exercise. People trying to maintain an ideal body weight. Those things are universal. So we don’€™t really need a registry to advocate those sorts of things, but a registry or more registries would help us.

Myths about cancer and tobacco have been around for years, can you comment on the some of the myths listed below: All the data that we have so far actually does not really tell us that cell phones cause cancer. We have a small number of case control studies that suggest that it might, but some larger, better designed studies that suggest that it does not. You have the fact that over the last thirty years that we’€™ve had cell phones there has not been a dramatic rise in the number of brain tumors. Truth be told, only time will tell, but for now I think the most important thing to realize is the greatest danger from cell phones is actually distraction while people are driving and doing other things. We don’€™t have good data to show that cell phones cause brain tumors.

(b) Hair dye causes cancer You know, there are some good, well-designed case control studies that do suggest that certain hair dyes especially lighter-toned hair dyes, blonde-colored, red hair dyes, do increase risk of lymphomas by a small amount. The risk does not seem to be huge, but there does seem to be some increase risk of lymphomas, a special kind of lymph gland cancer, with certain hair dyes. We have not been able to follow that up further, but there are some studies that suggest it might be true.

(c) Only women get breast cancer In the United States, we have about 180,000 women or so diagnosed with breast cancer and about 1800 to 2000 men per year. Essentially one out every 100 people diagnosed with breast cancer in the United States is a man. So it’€™s important that we all realize that men can get breast cancer. If a man detects a mass in his breast, he needs to get it evaluated just as I suggest a woman who detects a mass in her breast should get it evaluated.

(d) Some antiperspirants cause breast cancer. I get asked a lot about antiperspirants and breast cancer. The truth is it’€™s been looked at and we have no evidence that there is a correlation between the use of antiperspirants and breast cancer.

(e) Cancer causes hair loss. Cancer in itself rarely causes hair loss. There are a number of diseases that can cause hair loss by the way: thyroid disease, malnutrition, genetics is perhaps the most common cause of hair loss, that’€™s why I’€™m balding. Now clearly some treatments that we have for cancer, especially chemotherapy which uses radiation to the head, can cause hair loss, but cancer in itself does not cause hair loss usually.

(f) There is a cure for cancer but pharmaceutical companies are hiding it. I can assure you that if there was a conspiracy to keep the cure for cancer away from people, the companies that I’€™ve seen and the governments I’€™ve seen are so inept, they couldn’€™t keep it secret.

(g) Cancer is contagious. One of the greatest things that concern me is how cancer patients are treated and many people think that cancers are contagious. Truth be told, no cancer patient can actually give you their cancer. There are infectious diseases that can be passed from one person to another that can cause cancer, but generally the patient who has cancer is already so sick that they can’€™t infect another person. The cancers that are virally mediated, the hepatitis can cause liver cancer, human papillomavirus can cause cervical cancers as well as some cancers of the head and neck, HIV is associated with some lymphomas. But cancer patients themselves, someone who has lung cancer or breast cancer or colon cancer, they’€™re not able to pass that on to someone else and it’€™s important that we realize that because it’€™s important that those patients not be stigmatized, ostracized, or isolated from their loved ones.

(h) Some people may be too old for cancer treatment to be effective. I am very concerned about people being prejudiced against folks because of their age. When I’€™m looking at a patient and trying to figure out how to treat them, I take into account their performance status and their quality of life but I don’€™t take into account their age. There are some people who are forty years old who are so sick that I would not treat and there are people who are eighty or eighty-five years old who are actually in pretty good health except for their cancer, who I would treat and I would treat very aggressively. So you need to look at what kind of cancer the individual has, what treatments you have available as well as look at the patient and look at the patient’€™s physical abilities. I don’€™t look at their age, I look at their performance status.

(i) A positive attitude is all you need to defeat cancer. Well positive attitude is certainly incredibly important to defeat cancer but it is not the only thing. I have seen patients who decide to rely purely on prayer, purely on ‘€œI’€™m just going to think positively and the cancer will go away.’€ That doesn’€™t work by itself, but a positive attitude and good treatment rooted in science can help.

(j) If you contract cancer you will most probably die. In the United States 100 years ago, most people who got cancer died. Today in the United States, two out of three people who get cancer are successfully treated for that cancer. In African nations and other third-world countries, there are people who are treated successfully. We need to do better, we need to get better treatment available to them. And ultimately we can get to a point where at least two-thirds of all Africans who are diagnosed are actually cured and survive their cancer to do very well after surviving their cancer.

(k) People with cancer can’€™t continue to work since it cannot be cured. I have had personally among patients that I take care of, people who were cured and returned to the workforce or people who battle their disease over a long period of time. I have one patient that I’€™m thinking of right now who has had breast cancer for 10 years. She still goes to work. She has active disease and we treat her for that disease. We have actually been able to arrest the growth of the tumor. If you do a chest x-ray, you can still see that she has breast cancer which is spread to the lungs, she has breast cancer which is spread to bone and liver, but she is still able to go to work. She is still able to drive a car. She has a family and several children and is doing quite well. She has very good performance status and is dealing with her cancer with both a positive attitude and some fortunes in terms of some of the treatments have been very successful.

(l) Second hand smoking does not cause cancer. I can tell you that secondhand smoke is both a cause of lung cancer, head/neck cancer, even bladder cancer has been linked to secondhand smoke. Worst yet, more people die or are affected with coronary artery disease because of secondhand smoke. We have several studies to show that cities that enacted legislation that said people cannot smoke in bars, in restaurants, in indoor environments, those cities, within 6 months of enacting that legislation, see a decrease in their heart attack rates. This is purely because of secondhand smoke’€™s ability to cause heart disease and it can cause cancer among a number of other diseases.

What are some of the ways to debunk these cancer myths? You know the best way to debunk cancer myths is with education. If you can get the news media to actually focus on cancer and tell stories about cancer, write stories about cancer, interview cancer survivors. When I was running a cancer center in Atlanta, I actually found that a large number of people thought that everybody died from cancer because they had never met a cancer survivor. So we actually got cancer survivors to go out and tell their story. If the news media carries those stories people actually get to see an individual who had the disease, who dealt with it, someone who can become a role model. We actually used to have people who would say ‘€œI felt this mass in my breast and I wasn’€™t going to come in and get it treated because I knew I was going to die. But I saw all of these breast cancer survivors on television and I realized that one could have that mass, get it treated and survive.’€ So giving good accurate information is important.   Now, the ACS recently had a meeting with AORTIC in Tanzania with news media from nine countries in Africa. And I think as the African press corps starts looking at chronic disease, especially cancer, writing more stories about cancer survivors, writing stories about what cancer is, what causes it, and what prevents it, I think people will get the message and people will actually start talking about it.

6. How does the ACS see its role in the fight against Cancer in Africa? The ACS sees itself as a catalyst for change, helping spread the message about the cancer problem. Our epidemiologists are world-renowned and have been working on defining what the problem is in all areas of the world, including Africa. We think that we can go to Africa and work with healthcare officials, making cancer much more of a public health priority, especially making things like tobacco control a public health priority. We think we can work with the new media to make cancer a public health priority for the news media as well. So we think we can do a lot of good, primarily through affirmation, primarily through education.

7. Does cancer compete with HIV for resources? Can this be overcome and what can be learned from the way Africa and the world has responded to the HIV/AIDS crisis? HIV/AIDS crisis. We can learn the importance of having a comprehensive plan, the importance of addressing key, critical questions as you try to combat a disease. Does cancer compete with HIV/AIDS for resources? The truth is unfortunately yes. I think that some competition can be quite healthy, can be healthy for both HIV as well as for cancer. I think we need to realize that some of the things that we should be doing to prevent cancer are things that we should be doing to prevent AIDS. They are both terrible diseases. We also need to realize that in terms of lung cancer and some of the smoking-related cancers, the continent of Africa is where they were with HIV/AIDS in 1980. In the next thirty years if we do nothing about smoking, we are going to have an epidemic of lung cancer, an epidemic of a number of smoking-related diseases to include heart disease. 2010 for Africa for smoking-related disease is really just like 1980 for HIV. And just as many people wish that politicians, public health officials, nongovernmental organizations, had done some different things in 1980 and 1981 to prevent the HIV epidemic that we see in 2010, 30 years later. I’€™m telling you we have an opportunity to not make those same mistakes in 2010, so that in 2040, people with my job won’€™t be talking about the lung cancer epidemic and the cardiovascular disease epidemic due to smoking in Africa.

8. Does cancer have the potential to address health systems problems in Africa? In other words, if we address cancer, could we be uplifting health systems at the same time? I believe that if we can address cancer, which is one chronic disease, and address it effectively, we will improve healthcare for other illnesses throughout Africa. I think that the number of doctors who are trained in cancer and oncology will lead to people being trained in other things. I think hospitals that treat cancer patients will also treat other diseases. In the United States we’€™ve seen this happen that a hospital that adopts a cancer service line sees improvements in infectious disease treatment, improvements in radiology and imaging which actually affect other disease as well. Yes, I think that a focus on cancer actually will improve the healthcare systems in Africa. I also think a focus on cancer prevention will improve health, decrease the amount of diabetes, heart disease and other diseases as well as decrease cancer risk.

9. We know Africa has a massive shortage of nurses, doctors and other professionally trained healthcare workers. How can we still offer good cancer services in this face of such shortages? Two answers to that. Number one I think the shortage of doctors, nurses, and healthcare providers is actually even more reason why we need to focus on preventing people from needing those services. Decrease the demand for doctors, and nurses, and healthcare providers by decreasing the number of people who get those diseases. It makes our anti-smoking messages, our diet and exercise messages, even more important. Next, there are certain things that can be done in the treatment of cancer and in the treatment of other diseases that maybe don’€™t necessarily need a nurse or a doctor. Maybe there are certain smart people who have not been trained as a nurse or a doctor who can do certain things providing good healthcare. In the United States, we call those folks physician assistant, we call them other types of healthcare providers names but maybe we can actually train some people in short courses, sometimes three or four months, to do specific things that would be quite helpful in the treatment of various diseases.