A World Without Cancer by Margaret Cuomo (yes, Mario Cuomo’s daughter)
I’m a sucker for M.D.’s coming up with a complete cure for cancer. I just love the idea of addressing the global issues of cancer and coming clean about the fact we need to have a different paradigm.
Dr. Cuomo spends the first half of her book talking about the ills of the current cancer system, and the second half listing basic things that we can do to reverse the tide. Midway along, we get a call for a new institute based on the idea of preventing cancer. So that’s how we’ll get a World Without Cancer: start a new institute.
In looking at the information, the discussion of the ills of the current system was far more informative than the cursory overview of what we can do about it.
Dr. Cuomo makes general claims about cancer care, but most of them apply to breast cancer. In discussing breast cancer, mammograms reduce breast cancer deaths from 3.5 to 3 per 1000 patients (p.47). We have an interesting take on the need to get informed consent from patients: “some will become informed consumers…Many will not, and that’s reasonable too” (p.55). In a disturbing insight about what constitutes a clear margin in cancer surgery: “no strict agreement on how large it should be, leaving surgeons to make decisions” (p.61) We get another support of the lumpectomy over complete mastectomy, and the fact that the choice is not given to many women (p.62).
On p. 72 we learn that Gleevec cures CML, the rare exception to chemotherapy drugs. (In a follow up, Gleevec is no longer first line therapy as of 2011 as CML is too often resistant (http://jnci.oxfordjournals.org/content/103/4/E1.long)
When we move into the money matters, things get really ugly.
The pharmaceutical industry is the most profitable industry in America, holding monopolies on its products for twenty years (p.86). Oncology drugs provide the highest source of growth for the industry (p.84). Medicare and Medicaid are barred from negotiating prices for drugs, unlike the Veteran’s Affairs Department which pays 48% less on the most frequently prescribed drugs (p.87). In 1991 Medicare paid 7,100 on average for lung cancer chemotherapy. In 2002, the same treatment cost $40,000, an increase of 500% without any increase in survival rates (p.88).
Despite discussions of market economics, the disconnect between insurance payer and covered patient shows that consumption of the drugs is not significantly altered by costs (p.92). New drugs on the market may be called “new standards” (1.2 months more life at $80,000 cost) or “game changer” (2 months more at $120,000 cost). In comparison, placing patients in end-of-life hospice care provides an average of 3 months more life (p.99). We pretend we can afford to pay for everything (p.109) and institutes looking at patient outcomes are barred from considering cost as part of their evaluations (p.110).
Despite being insured, we are currently seeing rationing with cancer drugs. “Prescribing different medicines to different patients based on their health care plans.” (p.111). Of households affected with cancer, 25% used up all savings, and 11% were unable to meet basic necessities despite having insurance (p.120). Adults with Medicare can pay as much as $6,000 out of pocket for cancer therapies of marginal benefit (p.121).
Doctors get paid to prescribe and administer treatment (p.159). One third of oncologists felt uncomfortable discussing the costs of chemotherapy with their patients (p.123). Dr. Cuomo ends her discussion of the current state of cancer care by asking us to change our whole gestalt (complete picture) and not to demonize any one player (drug companies, doctors, FDA) while we look for other solutions.
Dr. Cuomo’s solutions are not a prescription for a world without cancer. They are a step in the right direction. As a radiologist, she takes issue with the ordering of so many CT scans, each one equaling 100 to 800 chest X-rays (p.172). The CT machines themselves have a 13 fold variation between highest and lowest exposure to radiation depending on how the machine is calibrated. So most people are getting more radiation than they need to during a CT scan (p.173).
The diet piece of cancer prevention reads like every cancer prevention diet: fruits and vegetables, berries, cruciferous vegetables (broccoli), tomatoes, dark leafy greens. We should buy organic, eat more fiber and fish, drink green tea, limit alcohol, and avoid processed foods. Add turmeric to your diet and avoid red meat. Limit alcohol and avoid processed foods.
Dr. Cuomo is not a fan of supplements except to gush over vitamin D, recommending fairly high doses of that and calcium.
When I picked up the book, I was looking for a paradigm change. What I got was a reality check that a trillion dollar cancer-war industry needs to change (ie. lose an enormous amount of money). That industry has, since the war on cancer started, gone in one direction (more drugs, more expensive drugs) and has every incentive to keep doing more of the same. In the meantime, I’m supposed to eat well.