“At this time of my retirement I'm more optimistic than at any time in my life about the ability to control cancer and to eliminate it as a major cause of death in our country and indeed in the world; I think we're beginning to see all the pieces come together.” The words are those of Harmon J. Eyre, MD, who has served as Chief Medical Officer of the American Cancer Society since 1993, and who will be stepping down on January 1, after a transition period of working with his successor, Otis W. Brawley, MD (OT, 8/25/07 issue).
But in a telephone interview, Dr. Eyre also warned that “there are a huge number of things we need to do to make this [progress] happen.” In order for advances against cancer to continue at a steady pace—especially as the 78 million US baby boomers age—he said the nation needs to concentrate its resources on research, access to high-quality care (including screening and early detection), and public policy.
He said that if the US commitment to cancer control remains strong, he can envision the day when people will be tested for genetic and molecular markers and given preventive agents to lower their cancer risk based on the results of these tests.
“I personally believe that chemoprevention will ultimately be a big part of how cancer is controlled,” Dr. Eyre said. “It's going to be the equivalent of taking a pill if you have high cholesterol to prevent a heart attack.”
In the time since Dr. Eyre began his training at the National Cancer Institute in 1968, much has happened to fuel his optimism. “Between my volunteer time and my staff time I've been involved in the American Cancer Society for more than 37 years… I've watched a lot,” he said, and the biggest turnaround he has seen has been the drop in incidence and death rates from cancer that began in 1991–92 and was documented in 1994–95.
Since that time cancer death rates have continued to drop at about 1% per year. “When I started in medical oncology most everyone died you were taking care of,” Dr. Eyre remembers.
But today, he said, the situation is just the opposite, and there are 10.5 million cancer survivors and growing. “That change, that turnaround in incidence and death rates has been huge,” he said. He added that the turnaround over the course of his career has been especially marked for the four major cancers: lung, breast, colon, and prostate—except for lung cancer deaths in women.
By 2015, “for the four major cancers that impact over half of all deaths in America the death rates will decline by 50 percent in all of them except for lung cancer in women,” he said.
Dr. Eyre called “discouraging” the statistics on lung cancer deaths in women, which he attributed to a slower decline in the number of female smokers compared with the decline in male smokers. But, he said, “The death rate in women from lung cancer will go down. The question is how fast and how far it will be by 2015. We know that it has peaked.”
ACS Challenge Goals
The ACS has set US challenge goals for 2015 of a 50% drop in the total cancer death rate and a 25% drop in the total cancer incidence rate. Overall, the nation is drawing closer to reaching those goals, Dr. Eyre said. The latest US cancer death rates in numbers are for 2004; the overall cancer death rate from that year was 2.1% lower than for 2003.
“For the last two years of reported death data the cancer death rates have declined, and the incidence rates have declined substantially as well.”
Dr. Eyre said he attributes the decline in cancer incidence and death rates to a combination of factors. “In order to make major moves forward in the control of cancer, it requires prevention, early detection and quality treatment. It's not any one of them alone that works. In lung cancer it's clearly the lower smoking rates in men, so that's a prevention strategy,” he said.
In breast cancer, he said, roughly 50% of the progress has been due to early detection through mammography and about 50%, to better treatment.
“In prostate cancer it's less clear, but it's a combination of early detection with PSA and improved treatment.” In colon cancer it is all three factors, he said, noting that colonoscopy screening for colon cancer is especially effective because it prevents the disease by removal of polyps before they become cancerous.
Dr. Eyre cited the doubling of the National Institutes of Health budget and unraveling the molecular causes of cancer, processes at the cellular level, as “huge triumphs” contributing to the decline in cancer incidence and death rates.
But he expressed concern that the flattening of the NIH budget may lead to erosion in the progress against cancer. “We need more research supported, and we need more careers supported.”
Decried Shelving of P-4 Breast Cancer Prevention Study
Specifically, he decried the shelving of the large P-4 Breast Cancer Prevention Study comparing raloxifene with letrozole as chemoprevention in high-risk women—which was reviewed and approved scientifically but put on hold by the NCI Director last summer.
“This is an example of the kind of thing that gets blocked,” said Dr. Eyre. “These trials are expensive; they're big trials, and they require thousands of people. But these are part of the key to the future of cancer control, and if we don't have the funds and we can't do them, we're going to be delaying part of the ultimate solution to cancer.”
Dr. Eyre said that in addition to strengthening the research base that undergirds advances in earlier detection and better treatment, the nation also needs to tackle the problem of the uninsured and address the patchwork quilt of health policies that undercuts cancer-control efforts.
Access to care is fundamental to making strides against cancer, he said, noting that studies have shown that uninsured women who develop breast cancer are three times more likely to have late-stage cancer when it is detected than insured women. “As a country we have to get this uninsured problem solved,” he said.
As for health care policies, he said that such policies at the local, state, and national levels all need to promote health and wellness. But he noted that today, there are glaring discrepancies in health policies from state to state and city to city. “We have a hodgepodge of different policies,” he said.
He cited New York City, which has strong tobacco control policies and where smoking rates are plummeting, as compared with Virginia, which has low cigarette taxes that promote smoking and where smoking rates are not plummeting.
The ACS is on record as supporting legislation that would give the US Food and Drug Administration the power to regulate tobacco.
As for obesity, a known risk factor for certain cancers, Dr. Eyre said it, too, warrants health-promoting policies. “The obesity problem is not just a personal choice issue,” he said. “We don't have incentives in place to eat healthy.” He cited restaurants that serve twice as much food as should be eaten at one sitting and cities that lack sidewalks and recreation areas conducive to exercise.
Dr. Eyre said the aging baby boomer population has raised issues that concern the ACS, especially how to support caregivers who are taking care of a relative with cancer. He cited the emotional and psychological stress, the intensity and the vast amounts of time inherent in caring for someone with cancer.
Asked if he is concerned that the baby boomers may overwhelm the cancer medical care system, since cancers are primarily diseases of aging, he said this population underscores the necessity of refocusing the US medical system more specifically on prevention and early detection, rather than just on treatment when cancer is advanced.
“We have a disease-care system now,” he said, rather than a system geared toward the prevention of disease.
Dr. Eyre also said the nation needs to ensure that its oncology workforce of physicians and nurses is large enough to meet the increasing demand that will be placed on it by the aging baby boomer population. He said that not only are more oncology training slots necessary, but there also need to be effective ways of attracting health professionals to the oncology field.
In addition to his ACS staff time, Dr. Eyre has been a volunteer with ACS for more than 22 years, including serving as its national volunteer president in 1988. Before joining ACS, Dr. Eyre was a medical oncologist at the University of Utah in Salt Lake City, where he served as Associate Chairman of Internal Medicine and Deputy Director of the Huntsman Cancer Institute.
Asked if he is truly retiring, Dr. Eyre said yes. He will return to Salt Lake City, where he plans to spend more time with his four grandchildren, the oldest of whom will turn 13 in January. He said he also looks forward to getting back to skiing; Utah's ski areas are known for their fluffy powder snow.
Ovarian Cancer: Pretreatment CA-125 Predicts Progression-Free Survival
Pretreatment CA-125 independently predicted progression-free survival in patients with epithelial ovarian cancer, and the relationship was particularly strong in those with optimally debulked disease or serous or endometrioid subtypes, according to a study presented at the Society of Gynecologic Oncologists 38th Annual Meeting on Women's Cancer.
A normal CA-125 level is rare in these patients, and it is not simply a marker of mucinous disease, reported the authors, led by Kristin K. Zorn, MD, of Magee-Womens Hospital of the University of Pittsburgh Medical Center.
Right now, Dr. Zorn said she wouldn't use pretreatment CA-125 to guide patient care, as the relationship between a single pretreatment level and the overall pattern has not been elucidated, but it is reassuring to have some idea of what it means to have a normal CA-125, as there has been little previous data on the topic.
The study was an ancillary data project of the Gynecologic Oncology Group and included 1,299 patients from seven GOG Phase III trials who were treated with a standard regimen of intravenous cisplatin and paclitaxel and had pretreatment CA-125 levels available.
For 1,290 of those patients, the CA-125 level was recorded postoperatively but prior to the first chemotherapy cycle, and for nine of those patients, the level was taken preoperatively and no postoperative value was recorded.
The trend toward shorter progression-free survival with increasing pretreatment CA-125 persisted in a multivariate analysis that included age, performance status, stage, debulking status, histology, and tumor grade.
A onefold increase in pretreatment CA-125 level was associated with a 9% increase in the risk of disease progression overall and in the serous subgroup.
The median pretreatment CA-125 level was 246 U/mL. Only 8% of patients had a normal level, defined as less than 35 U/mL, and 20% had a level above 1,000 U/mL.
In a formal discussion of the study, Angeles A. Secord, MD, of Duke University, said: “Their results demonstrate that single pretreatment CA-125 values can provide valuable information regarding survival in patients with ovarian cancer. The strengths of this study are many.”
These strengths include the large number of patients; the fact that patients were unselected, coming from GOG trials held at multiple centers, and that they were treated with paclitaxel and cisplatin in a uniform manner; and the prospective collection of data.
The weaknesses include the heterogeneity in the included clinical trials; lack of a central laboratory and the arbitrary cut-off value of 35 U/mL for the upper limit of normal; and the limited numbers of patients with normal CA-125, with mucinous histology, and with clear-cell histology.
New ACS Program Targets Access to Quality Care
A new initiative of the American Cancer Society is designed to call attention to the urgent need for quality, affordable health care for all Americans. As part of the initiative, which the Society calls unprecedented in its almost 100-year history, significant resources will be devoted toward creating an aggressive public awareness campaign that highlights the barriers that average Americans, including the 47 million who do not have health insurance and the countless others who have inadequate insurance, confront when facing cancer.
“The American Cancer Society believes that, after tobacco use, lack of access to quality health care in the United States could be the biggest barrier to continued progress in the fight against cancer,” said ACS President Richard C. Wender, MD. “Reducing suffering and death from cancer may only truly be possible if all Americans are able to visit their doctor for regular check ups, early detection screening tests and prompt, quality cancer treatment if and when they need it.”
The advertising campaign tells the stories of real people who faced cancer diagnoses—for example, “Kathy,” who had no insurance when diagnosed with breast cancer; and “Raina,” who had insurance when she faced thyroid cancer but still faced financial debt that resulted in her medical bills being turned over to collection agencies.
“Unfortunately, millions of Americans think they are covered, but find out too late that their insurance is inadequate, and as a consequence they often face substantial financial burdens, including being denied the care they need,” Dr. Wender said. “No one should have to choose between taking care of their health and paying their bills.”
The ACS has specified four principles as defining meaningful health insurance and highlighting major problems in the health care system that are impeding progress against cancer and other major diseases. The principles state that health insurance should be adequate, affordable, available, and administratively simple.
The American Cancer Society Cancer Action Network will apply the four principles to federal and state health insurance reform proposals to determine whether the proposals would improve health care for the uninsured and underinsured, a news release notes.