Dr. Otis Brawley, Chief Medical Officer of the American Cancer Society

(Music)

Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret, here we are, two years after the passage of The
Patient Protection and Affordable Care Act and it feels like we are standing on
the precipice as apparently the Supreme Court will be making an announcement
on this Thursday.

Margaret Flinter: After years of such hard work to transform health care in
America, now the fate of the Affordable Care Act at least lies in the hands of
those justices.

Mark Masselli: Well, I am an optimistic pessimist, hope for the best and fear the
worst. We have a conservative leaning court and we still don’t know what they
may deem as unconstitutional.

Margaret Flinter: A majority seem to think that the individual mandate requiring
all Americans to buy health insurance or face paying a fine is the most vulnerable
part of the law.

Mark Masselli: Margaret, it's just hard to believe with all the great minds working
on fixing health care, insuring the 35 million uninsured, protecting Americans with
preexisting conditions from being denied coverage that all that hard work could
be in jeopardy. We should note here that a lot of money was spent attempting to
sway the court of public opinion. It's estimated that conservatives spent about
$235 million specifically attacking the Affordable Care Act.

Margaret Flinter: You know, a lot of the positive changes that were brought about
by health reform law, have already been implemented although we tend not to
hear so much about it.

Mark Masselli: It's really a shame when you realize how many people are
already being helped. Millions of young American adults are now covered,
thanks to the provision in the law allowing young people to stay on their parents’
plan until age 26.

Margaret Flinter: That’s right. But the real Holy Grail was the thought of how
many people would be protected by the law in terms of getting coverage and
then of course the General Accounting Office estimates that up to 122 million
Americans under 65 have some preexisting condition that can technically keep
them from getting health insurance. That’s a lot of people who are vulnerable if
the court decides to overturn that measure, barring insurance companies from

denying coverage to people with preexisting conditions. And I just can't imagine
anyone wants to move backward on that.

Mark Masselli: I don’t think they do. And the media departments in these major
insurance carriers are already out on the stumps saying that they will continue
with some of these directives initiated by the Health Care Reform Bill no matter
what happens in the Supreme Court.

Margaret Flinter: So the decision is in our very near future. There is certain to be
a great degree of fallout from the decision. No matter what happens, there will
be lots to talk about. Reform is happening in health care; transformation is
underway one way or another because the system, as it is now, simply doesn’t
work as well as it needs to.

Mark Masselli: Our guest today, Dr. Otis Brawley is Chief Medical Officer of the
American Cancer Society.

Margaret Flinter: And Dr. Brawley has written a book which he will be talking
about on the show today that’s concerned with the continued health disparities in
this country. He will also talk about the changing landscape of cancer treatment
and how genomics can revolutionize health care and cancer care specifically in
the future.

Mark Masselli: We will also hear from FactCheck.org’s Lori Robertson. But no
matter what the topic, you can access all of our shows by Googling CHC Radio.

Mark Masselli: And don’t forget, as always, if you have comments, e-mail us at
www.chcradio.com ; we love to hear from you.

Mark Masselli: We will get to Dr. Brawley in just a moment but first, here is our
producer Marianne O'Hare, with this week’s Headline News.

(Music)

Marianne O'Hare: I am Marianne O'Hare with this Headline News. No matter
what the decision, the Supreme Court decision on the Affordable Care Act will
continue to create ripples for some time to come. But those who have served on
the frontlines of health reform see this time as still ripe with opportunity for
effectuating continued progress in the health reform arena. Former Acting
Administrator for the Centers for Medicare & Medicaid, Don Berwick, says the
Supreme Court’s decision is not the whole game here, that there is enough
momentum and bipartisan awareness that the current health system is simply
unsustainable at its current rate of growth. He says, the support is continuing to
trend upward on paying for quality of health care, not quantity of fee for service
care and that there must be more transparency on health care costs and
outcomes, as well as universal application of electronic health records.

President Obama is about to receive one bill for consideration that was a rare
example of bipartisan compromise on Capitol Hill this year, a bill requiring the
pharmaceutical industry to pay $700 million over several years to the FDA in
exchange for more responsiveness to drug trials and the drug approval process.
Measure is accepted to save the government hundreds of millions of dollars in
drug costs as well.

The downturn in the economy and the high number of Americans, uninsured or
insured with high deductible plans, are fueling one key sector of the health care
industry. Retail health clinics are in a growth spurt, growing by about 10% per
year in number. With the escalation of health care cost, that trend is expected to
continue.

The health industry is growing elsewhere; China is expected to really add to the
bottom-line. The previously closed health care industry in China has been
opened to investors. It's expected to generate about $500 billion worth of
business in private hospital, construction and medical facilities growth in the
coming years.

And finally, they are here. Drug-resistant bacteria, previously identified only in
New Delhi, India, has shown up in several patients in Rhode Island. Health
officials were able to isolate the patients and keep the outbreak under control but
warned this could just be the tip of the iceberg. I am Marianne O'Hare with this
Headline News.

Mark Masselli: We are speaking today with Dr. Otis Brawley, Chief Medical
Officer and Executive Vice President of the American Cancer Society and author
of How We do Harm: A Doctor Breaks Ranks and Talks About Being Sick In
America. Dr. Brawley is an oncologist and epidemiologist based at Emory
University Medical School. He is on the CDC’s Breast and Cervical Cancer Early
Detection and Control Advisory Committee and he is the former co chair of the
U.S. Surgeon General’s Task Force on Cancer Health Disparities. Dr. Brawley,
welcome to Conversations on Health Care.

Dr. Otis Brawley: Thank you for having me.

Mark Masselli: You know your recently published book of How We Do Harm is a
clear indictment of the American health care system which you unflinchingly call
a subtle form of corruption, and yet, you don't blame any one party but you say
everyone is partly to blame for the fact that we have the most expensive health
th
care system in the world yet rank 50 globally in terms of life expectancy. How is
it that we have fallen so far short in your estimation of the promise of a decent
health care system for the United States?

Dr. Otis Brawley: We need to start focusing on preventing illness. We have
allowed our health care system to be a system that addresses illness and it's
much less a system that actually keeps people healthy. We spent $8,000 per
man, woman and child on health care in United States last year, and that’s
almost twice as much as the number two country, which by the way is
Switzerland. We spend more on health care than any other country yet, we have
such terrible outcomes and we have so many people who don’t get just very
basic health care. We have huge gluttony and over-consumption. Some of that
over-consumption can actually cause harm at a time where we have part of the
population that doesn’t consume enough health care. If we actually were wise
about distribution of health care, we could actually improve the health of the very
wealthy and middle class, who get to consume health care now as well as those
who are poor who don’t have health insurance.

Mark Masselli: The health care reform debate Dr. Brawley has become quite
vociferous in this country but you say the debate is really missing the mark
entirely that we need not just reform but transform it. So, I wonder how we are
going to transform it because it seems to me that after you read your book, you
come away with a sense that the DNA of the system is amiss.

Dr. Otis Brawley: When I say transform, I really mean we need to change the
culture. Look at smoking today. In the 1960s, many young kids in their teens
and ‘20s, you can't imagine that in the 1960s it was common that people would
be walking up and down the street smoking, that you could smoke in restaurant.
We have transformed how we view tobacco usage, perhaps not enough since 20
plus percent of Americans still smoke but we have transformed how we view
tobacco. The Civil Rights Movement, that was a transformation in the thinking
patterns for many Americans. We are going to have to do the same thing with
health care. We are going to have to do stress prevention and do the things that
are necessary for prevention, get good health care messages out there and
health care education to the population. And then, patients and their doctors and
their health insurers are going to have to do scientifically proven treatments and
preventatives and stop doing a lot of things that have not been scientifically
proven. And quite often, we even do things in this country that have been
scientifically proven to be harmful.

Margaret Flinter: Well Dr. Brawley I would like to talk little more about this whole
issue of prevention at least in terms of screenings. At the American Cancer
Society, of course there is a quest to cure cancer, which we all appreciate, and
early detection is one of our best weapons. And yet, you say that maybe too
many recourses are being spent, maybe wasted on unnecessary screenings and
that perhaps too many patients are being over-treated. And you gave a speech
on the subject recently where you cite the American Cancer Society as having an
unfounded policy regarding prostate cancer screening, certainly something that’s
been very much in the news recently. So this is a great opportunity to perhaps

share with our listeners, if you would, why some tests like the prostate screening
test or the protocol is off-base in your estimation.

Dr. Otis Brawley: Sure. I am not against screening; I am against screening that
has not been proven to save lives. And it is true in the 1990s the American
Cancer Society recommended prostate cancer screening before there was a
study to show that it saved lives. Indeed before any studies had started to
actually assess it, to see if it saved lives, the ACS did recommend prostate
cancer screening. Now, eventually better minds prevailed, and in 1997, the ACS
recommended that men be told of the potential risk and the potential benefits of
prostate cancer screening and their significant risks associated with medical
procedures caused by an abnormal screen and men be encouraged to make a
choice and make a decision.

Our recommendation today is still very much one of informed decision making
when it comes to prostate cancer screening because we do not know if it saves
lives. We know that there are men who think that it has saved their lives but we
don’t know if they had a prostate cancer that was going to kill them until we
support number one, research to try to figure out the types of cancers that are
going to kill versus the kinds of cancers that can be watched because they are
not going to kill. And for prostate cancer, I think we definitely need to have
informed decision making.

Now in other things, like in lung cancer, there was a spiral CT program that was
done throughout the United States in a number of places with the theory that
spiral CT screening saves lives. It's only recently in the last year that we have
actually had completed a true clinical trial to show that it actually does save lives.
And a trial by the way shows that if you screen 26,000 people at high risk for lung
cancer because of smoking history, over 10 years, you save 87 lives but you
sacrifice 16 lives; 16 people die prematurely mostly due to medical interventions
caused by the screening test having an abnormal finding. So, I am not against
screening, I am for wise screening and for using screening only when we have
science to show that it's beneficial. And I am also very leery of screening at
times because virtually every screen is a double-edged sword; there are people
who are helped and there are people who are harmed.

Mark Masselli: We are speaking today with Dr. Otis Brawley, Vice President and
Chief Medical Officer of the American Cancer Society and author of How We do
Harm: A Doctor Breaks Ranks and Talks About Being Sick In America. Dr.
Brawley, let’s drilldown further on the overall reliance on test, which leads to a lot
of wasted resources, and as you said, can even harm patients. We recently had
the President of the National Physicians Alliance on the show talking about their
Good Stewardship Program that led to the Choosing Wisely Campaign, which
urges doctors and patients to curtail the use of test in 45 targeted areas. Now
this campaign has received a lot of widespread support including from you and
yet, you caution that this is still only a voluntary program between physicians and

patients and what's needed is industry-wide campaign. How do we get there
from here?

Dr. Otis Brawley: Yeah, the only way that we are going to get there is we are
going to have to affect how people are paid. Right now, physicians, hospitals,
other health care providers, they get paid more the more services they provide.
We need to actually try to change that paradigm where they get paid for
providing good service and making sure that patients stay healthy. At the same
time, patients have to stop demanding a lot of things that are just not scientifically
proven to be useful.

Margaret Flinter: Dr. Brawley, you have noted that obesity, poor diet and lack of
exercise are going to likely overtake smoking as the most preventable cause of
cancer in this country. Tell us what you see in terms of the looming cost and
burden to our nation due to the obesity epidemic and how is the American
Cancer Society thinking about shifting this discussion about prevention of obesity
or treatment of obesity as one of our weapons against cancer.

Dr. Otis Brawley: Well first, we have to get the word out. Many people are
shocked when I say that the combination of obesity, high caloric intake and lack
of physical activity is about to overtake tobacco as the leading cause of cancer.
Truth be told, those three things are causing and fueling increasing numbers of
people with diabetes, they are an upward pressure on coronary artery disease
and they of course cause cancer. We are going to have a tsunami of chronic
disease over the next 20-30 years that taken along with the fact that we are
glutinous and non-scientific and really irrational in how we consume medicine.
And by the way, the politicians keep wanting to talk about rationing; I want to talk
about rational because we need to be rational in our use of medicine. We have
this incredible number of chronic diseases that are going to occur, we have got to
get the word out. 11% to 15% of American adults were obese in the 1970s and
it's 35% or so who are obese today; among black women, it's 49%.

Mark Masselli: You know, I was thinking as you said earlier about the trajectory
of tobacco’s limitation in our society and I was thinking recently we heard where
Mayor Bloomberg had just announced some very tough standards on the soda
industry in terms of trying to limit it. And I think Dr. Frieden, before he went off to
the CDC, he was the commissioner for Mayor Bloomberg, had suggested a tax
on this. Where do the policymakers play a role in shaping some of these
directions and directives that will help us get to better health and better outcomes
for people?

Dr. Otis Brawley: I think policymakers definitely need to realize that these things
are problems, be it the fact that people don’t get adequate health care and we
need solutions for that, we need policymakers to actually start thinking about
health care and promoting health for the public. In terms of soda taxes and that
sort of thing, personally, I am very leery of soda taxes however, I am open to any

idea about something that’s going to help us decrease this obesity epidemic. If
we want to study soda taxes, I definitely would support studying soda taxes. I
think that legislating behavior has very rarely been beneficial in terms of the
public health but I applaud the fact that these guys are at least thinking about
how are we going to promote health.

Margaret Flinter: Dr. Brawley, I would like to focus for a moment on what seems
to be a breakthrough area with cancer diagnosis and treatment in particular with
regard to genomics. It seems that we are really on the brink of transforming how
we diagnose and treat not just cancer but all diseases with a big contribution
from genomics. Tell us about the transformations that you expect to see in this
area.

Dr. Otis Brawley: Well you know, many of our definitions of cancer go back 170
years and they were autopsy patients that were studied and people said, this is
cancer, this is what killed that person. Today, we are starting to realize that what
looks like cancer under the microscope may not be very aggressive, may not
even need to be treated; in the case of prostate cancer, certain meningiomas,
they may not need to be even treated just watched. And other things tend to be
very aggressive even though under the microscope they may not look as
cancerous. And so, we are starting to come up with genomic definitions of
cancer, looking at the gene or series of genes and try to figure out what the
genetic intent of that tissue is. It's not just what the tissue looks like, it's not just
the profile of this tissue as we see it under the microscope but what inherently
within the genetics does that tissue want to do. We are redefining cancer is what
we are doing.

Mark Masselli: When you talk about the redefinition of cancer diagnosis and
treatment, real transformations are going on. Past genomics, can you tell us
about other transformations that you are expecting to see?

Dr. Otis Brawley: Yeah. In the next 10 to 15 years for example, nowadays we
think about lung cancer and breast cancer, in the next 10 to 15 years, we are
going to think about cancer in the genomic terms and actually say that it's this
type of cancer and not even talk about an organ site. I think as we get towards
that, we are going to have more targeted therapies that are actually going to look
at what’s going wrong in terms of the metabolism of the cell to make it start
reproducing and we will be able to attack very specific targets. We are going to
have drugs that would have a lot less side effects than our chemotherapies today
because they are very targeted.

Margaret Flinter: Dr. Brawley, let me just ask maybe about one more dimension
of the work of the American Cancer Society. You have been very successful at
engaging the people and engaging the patients, the communities, the
communities of advocates, tell us what the American Cancer Society is focused
on in that arena.

Dr. Otis Brawley: Well we are starting to realize that our messaging is far more
complicated than the marketing people want cute, quick advice like (18:53
inaudible). Now the advice is going to have to be learn about this and make a
decision as to whether you want to be screened. So we, at the ACS, are
spending a lot of time thinking about and working with people, who are experts in
communications, trying to figure out how to convey a much more complicated
message. The message on diet and physical activity is going to be incredibly
complicated as we try to get people to increase their intake of fruits and
vegetables and start walking to work and we are looking at messaging and we
are looking at how to best convey complicated messages.

Mark Masselli: Dr. Brawley, we like to ask all of our guests this final question.
When you look around the country, and the world, what do you see in terms of
innovation that our listeners at Conversations should be keeping an eye on?

Dr. Otis Brawley: Well, you know I just came from the American Society of
Clinical Oncology meeting and this idea of targeted therapies in cancer is
incredibly important, some wonderful work being done in genomic health to try to
predict these cancers that need to be treated versus these things that look like
cancer that need to be watched. I actually think that the things that folks need to
look at the most are also the preventative aspects. I think that we are going to
come back to an era where we will have some chemoprevention drugs. Perhaps
it may be aspirin to decrease their risk of coronary artery disease, decrease their
risk of colon cancer and maybe decrease their risk of several other diseases as
well.

Margaret Flinter: We have been speaking today with Dr. Otis Brawley, Vice
President and Chief Medical Officer of the American Cancer Society and the
author of How We Do Harm: A Doctor Breaks Ranks and Talks About Being Sick
in America. Dr. Brawley, thank you so much for joining us today on
Conversations.

Dr. Otis Brawley: Thank you. It was wonderful being with you.

(Music)

Mark Masselli: At Conversations on Health Care, we want our audience to be
truly in the know when it comes to the facts about health care reform and policy.
Lori Robertson is an award-winning journalist and Managing Editor of
FactCheck.org, a nonpartisan, nonprofit consumer advocate for voters that aim to
reduce the level of deception in US politics. Lori, what have you got for us this
week?

Lori Robertson: Well, Mark and Margaret, this week, we will look at a claim that
the federal health care law taxes sick puppies. Now this claim was highlighted in

a web video from the National Republican Congressional Committee, complete
with a picture of what looks to be a yellow Labrador Retriever with an ice pack on
his head. So does the health care law tax dogs? No. We found the claim as
really stretching the facts. The NRCC is referring to 2.3% excise tax on
manufacturers of certain medical devices. Devices subject to the tax (21:43
inaudible) begin in 2013 include cardiac defibrillators and pacemakers. The tax
would not fall on any devices used exclusively for veterinary medicine however,
there are some medical devices that are used for both humans and animals and
the IRS determines that those would be taxed. So that’s what the NRCC is
referring to when it says that sick puppies would be taxed. We find that to be
misleading. And that’s our fact check for this week. I am Lori Robertson,
Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country’s major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact, that you would like
checked, email us at www.chcradio.com . We will have FactCheck.org’s Lori
Robertson check it out for you here on Conversations on Health Care.

(Music)

Mark Masselli: Each week, Conversations highlights a bright idea about how to
make wellness a part of our communities and everyday lives. Students at
Southern Illinois University Medical School are participating in a unique program
that is designed to have a lasting impact. Tracy Jo Smith is a social worker in
Springfield Illinois who launched a program three years ago to combat childhood
obesity. The Springfield Collaborative for Active Child Health has a number of
initiatives to combat the growing problem of obese and overweight children in
that community, including one that teams young children at risk for obesity in the
Head Start Program with local medical students at Southern Illinois.

At the recent Weight of the Nation Conference, Smith presented details of the
program, where medical students met regularly with kids, teaching the children
about the importance of good nutrition and physical exercise as part of our
program for healthy life. And early results are promising. She says that children
in the program are really responding to the one-on-one attention and are
incorporating the new healthy lifestyle habits. The medical students get to see
the impact their influence can have on the outcomes of the patients’ health so it's
a teachable moment for them as well. Smith says she plans to follow these med
students through their residency and ultimately their practice to chart how their
early experience mentoring kids at risk of obesity will impact what they do as
professionals.

Head Start officials are so encouraged by the initial success of the program, they
are seeking additional funding to expand the healthy mentoring to the parents of
these children to really have an impact on the broader community. A program

that not only helps avert obesity in young children at risk but also informs the
next generation of clinicians to be better stewards of promoting health and
wellness, now that’s a bright idea.
(Music)
Margaret Flinter: This is Conversations on Health care. I am Margaret Flinter.
Mark Masselli: And I am Mark Masselli, peace and health.
Conversations on Health Care, broadcast from the campus of WESU at
Wesleyan University, streaming live at www.wesufm.org and brought to you by
the Community Health Center.