We need to stop cancers and other diseases before they start
By Ethan Dmitrovsky, M.D.
It's a sad truth: Half of the men in this country and a third of the women will likely be diagnosed with cancer sometime during their lifetimes. Though many of us may escape this fate, very few of us will avoid having a family member or friend with cancer.
That's why there is much to celebrate in the nation's latest annual report on cancer. Both the rate of cancer deaths and the incidence for some of the most common cancers declined. One major reason for this good news is that smoking continues to decline, and tobacco use contributes to about a third of all cancers.
To learn how this happened, just turn to the nation's first famous scientist, Benjamin Franklin. He dispensed his discoveries as aphorisms that are as popular today as they were in the 18th century. One of his most memorable was "An ounce of prevention is worth a pound of cure." This simple tenet is woven into the Hippocratic Oath that newly minted doctors recite when they graduate from medical school. But they enter a medical system that favors treatment over prevention.
Our current reimbursement structure handsomely rewards doctors for performing high-tech procedures on patients already diagnosed with disease, but offers little compensation for teaching people to prevent disease by making healthy lifestyle choices. Nor are patients asked to assume responsibility for making such choices. The consequences are everywhere. Witness the expanding American waistline and the many illnesses that stem from obesity. Even children now face diseases only adults once had.
That's why the decline in cancer is remarkable. Imagine how following Franklin's counsel more closely would further reduce the incidence of cancer. Consider the case of lung cancer. It is the major cause of cancer death for both women and men. But this was not always true. Early in the 20th century, lung cancer was rare because smoking was rare.
We can restore this past. The recent cancer report makes this clear by recording smoking and lung-cancer patterns for every state. In Utah, where smoking is uncommon, so is lung cancer. But where smoking is common, as in Kentucky, lung cancer exacts a heavy burden.
There is a way to make Kentucky more like Utah: smoking cessation and prevention. This was proven in California, which mandated strict tobacco control policies decades ago-and was the only state where lung cancer incidence and death rates dropped for women.
Some people cannot muster sympathy for smokers. Yet as a cancer doctor, I find it hard to blame smokers given the way tobacco companies promoted the habit. Bear in mind that some smokers are unable to kick their addiction even after they've had surgery for lung cancer.
This is no time for skepticism about prevention. Cancer disproportionately afflicts older individuals. Since our nation is graying, the number of cancers in the elderly-and possibly even the overall incidence of cancer-could rise, even as the age-standardized rates continue to fall. A surge in cancer patients would overwhelm our health-care system, so it is essential to halt this trend.
Improved detection and treatments would help but are only a start. Also important would be getting people to assume personal responsibility for making choices like not smoking, getting regular exercise, and eating a healthy diet.
But for lung cancer, even that's not enough. If every national antismoking goal is met, lung cancer would still remain a substantial public health problem for decades to come. That's because more lung cancers are diagnosed in former smokers than in current smokers.
So tobacco control is essential but insufficient for former smokers. But there is another powerful tool we can wield against this cancer. It's called chemoprevention. This uses drugs, vitamins, minerals, or nutritional interventions to prevent early cancers from forming or growing. This approach has not yet yielded proven ways to prevent lung cancer in humans. But this is no reason to feel discouraged, since ongoing research holds real promise. Chemoprevention is now under intensive study in animal models and in some clinical trials, and the results could find wide application before long.
While this work proceeds, we also need to focus on identifying better ways to translate discoveries made at the laboratory bench to the bedside. For example, there is little incentive for pharmaceutical companies to test and make chemoprevention drugs because the federal approval process can take longer than patent protection lasts.
The time is right for our nation's new political leadership to spotlight prevention. If they do not, it could prove enormously costly. Cancer's financial toll alone should stir us to act. And the horrifying price paid by every cancer sufferer demands much more. I have learned this from my patients. Prevention is preferable to any cancer cure.
First published on March 17, 2009 in the Pittsburgh Post Gazette
Dr. Dmitrovsky is a physician-scientist and American Cancer Society Professor at Dartmouth Medical School. He is also a member of the AACR Science Policy and Legislative Affairs Committee.
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