Dr. Brawley: How we do harm

Anonymous

All I can say is BRAVO Dr. Brawley 

"The System Really Is Not Failing ... Failure Is The System

At a recent Association of Health Care Journalists meeting in Atlanta (where Dr. Brawley also serves as a professor at Emory University), he slammed everyone in the health care system for overuse of under-proven treatments.

There really is a subtle form of corruption in American health care. Who is at fault for this corruption? Quite honestly it's the doctors, it's the hospitals, it's the hospital systems, it's the insurers. It's the drug companies, it's the lawyers and it's even the patients. Everyone is at fault for the fact that the system really is not failing. Quite honestly, failure is the system.

We have doctors who want money. We have companies that want money, they give - those doctors give unnecessary chemotherapy. In my business those doctors give unnecessary surgeries and treatments, unnecessary imaging. They make promises about screening tests that we don't know.

... My own American Cancer Society recommended every man over 50 get prostate cancer screening, every black man over 40 back in 1992, without adequate scientific data.

...Quite honestly, a whole bunch of doctors have drunk the Kool-Aid. They don't actually understand that prostate cancer screening may not save lives. The fact that some of them make money off them helps them to not understand, of course 

You see, what we need to do and what we desperately need to do is not reform health care. We need to transform how we view health care. We need to become much more appreciative of prevention efforts. We need to reimburse doctors who coach and talk to patients far better than we are.

Today we give doctors who do interventions in patients a lot more money than they should be getting and doctors who talk to patients very little money. The incentive on the doctor today is to not talk to patients, just move them in, move them out and get volume.

We need to understand and appreciate science. We're not going to have improvements in our healthcare system until the mass population demands that doctors appreciate science, justify their recommendations and justify their decisions. We need the skeptical, educated consumer. We need people who consume medicine to think about health care the same way they think about buying a television set at a Best Buy."

 

http://www.kaiserhealthnews.org/stories/2012/may/02/otis-brawley-ahcj-american-cancer-society.aspx

riverhorse

People will start viewing health care as a consumer product when they start paying for it as they do consumer products. That would mean understanding the price of the services and being able to compare prices. Just as a for instance in BC world breast radiation treatment is pretty standard and rarely if ever an emergency. Yet who has ever tried to compare prices and select the best value? I for one have at least asked for itemized billing so I could be sure that I could at least see the dates of the treatments and be sure they matched my records. Of course I am not paying the full cost, nor is my insurance company. There is the price, the negotiated price for my insurer and the percentage I need to pay. How can anyone ever shop as though they were at Best Buy with such a system. No wonder costs are out of control.

Anonymous

Riverhose, you're right, the present system does not allow patients to be informed consumers, that's why Dr. Brawley says it's a failure 

1Athena1

Wow - this is a pleasant surprise. I never thought Otis Brawley, of all people, would give the ACS the criticism it is due for its flawed public messaging. 

kane744

I started questioning about many recommended tests and asking if there may be a less expensive alternative. Many times there are and they tend to be safer as well. Start asking questions questions questions. I always tell my doctor that I'm just trying to spend my Medicare dollars wisely. 

kira66715

I met him on Monday--9/24-- when he came to give a talk: he gets furious at the archaic methods we still use to diagnose breast cancer, and advocates science over beliefs.

Sometimes the science isn't there, but he gave a great talk, and it was a pleasure to meet him.

Kira

LuvRVing

I read the book - very interesting read.

voraciousreader

He is a shining light in medicine. Along with Dr. Eric Topol, a visionary and also a maverick, change IS coming and ultimately more lives will be saved. Having read books written by both of them, it brings me great joy to know neither remains quiet and they are both sowing the seeds for, as Dr. Topol eloquently describes in the title of his book, "The Creative Destruction of Medicine." Dr. Brawley bravely describes what is wrong. Dr. Topol explains how medicine can be fixed. The revolution in medicine that will occur, will begin with the patients rather than physicians. I tend to agree.



I would be honored to have either of them as my physician...

kira66715

He's writing a second book that should be out shortly--Dr. Brawley. It was a pleasure to talk to him, and he is a visionary. And very approachable in person.

Kira

voraciousreader

Kira... I thought the most sobering part of Dr. Brawley's book was his exposing the ignorance of highly educated physicians and patients alike. The argument that he makes regarding technology's role in medicine, most specifically, the use of statistics, is a valid one and gives me hope the the tide will change. When I see an advocacy group embrace the statistics, then I will know for sure that the winds have changed!



I look forward to his next book!

violet_1

Bump...

Great Thread...!

Anonymous

I read the book after a recommendation from somebody on this forum (probably VR .  Loved it.  It helped me look at some things in a different light.  For example, I don't know why it had never occurred to me that an oncologist's biggest money maker for the practice is chemotherapy.  It's the only treatment they offer "in house".  Radiology and surgery are "outsourced".  Now I'm not saying that all doctor's would push chemo to make more money....but if you were "biologically" on the fence with it - it would be in their best interest (monetarily) to recommend it.  Who knows how much that weighs into their decision consciously or subconsciously?

Colt45

A system that doesn't have a cure for such a prevalent disease (group of diseases) IS failing.



If there was a cure, the system wouldn't be failing anyone in the cancer world.



Find a cure, Dr. Brawley. The current treatments, with all their flaws, are the only things in the damned cupboard. Hard to complain about what's being served when there's nothing better in the cupboard. I like that Dr. Brawley hates what's being served------but when is he or anyone else going to stock the cupboard with something better? Educated consumers do more than look for bargains/ bang for the buck buys-------educated consumers look for products THAT WORK. When I buy a TV at Best Buy, my number one concern is THAT IT WORKS. Where are the cancer products that work? If someone makes 'em, we'll buy them. Where are they, Dr. Brawley? The next Dr. Brawley book that I read has to be titled: "The Cure for Breast Cancer". Sorry for the sourpuss attitude.

Mardibra

Colt - bravo....totally agree!

Colt45

I did edit my last post since Mardibra said she agreed, I don't want her to look like she agrees with something I altered after she said so.



Do you STILL agree? I got pretty ornery there.

Mardibra

Still agree!  Cancer has a way of making us all a little ornery.

jessica749

 SusanGarden, I haven't read the book and perhaps I should to better enter into this discussion, but I don't know about saying that recommending treatments is in the doctor's interest because they make money on it (oncologist/chemo). 

    If they were so interested in making $$$$ they wouldn't be recommending oncotype dx left right and center for everyone and insisting only high scores get chemo.  At least, that's what Sloan was doing a few years ago.  Clearly, they made no money off of the dx test, and it only helped them to make even less money by not administering chemo...

Colt45

I had made a point a while back in another thread that if there was some universal conspiracy to sell chemo that they would be touting more impressive treatment outcome statistics.



There are bad doctors. There's bad everything. We, as adults, know this. We as consumers have to vet them. I'm sure some oncologists are trying to make money and are not being 100% forthcoming. Those doctors are despicable humans. LEAVE THEM.



The problem isn't oncologists recommending chemo.



The problem is that they don't have something better to recommend.



Let's get a freaking cure already and then nobody will moan about oncologists recommending the hell out of it--------BECAUSE IT'S A FREAKING CURE.



IS chemo systemically OVER RECOMMENDED? The treatment outcome data that's out there ISN'T doing 'chemo sales' any favors... because frankly, it's not that impressive. Is it the oncologists' fault that there isn't something better?



As Jessica749 said, the Oncotype is working against MORE chemo sales.

Beesie

I'm sorry, but the "Find A Cure" arguments drive me up the wall.  Breast cancer isn't a single disease with a single cause.  Doesn't everyone know that by now?  There is not likely to be any single treatment that "cures" all types of breast cancer and works on all patients.  Personally I don't want doctors and scientists wasting their time looking for this elusive "cure for breast cancer".

I believe the way to cure breast cancer is one patient at a time. We need to better understand the genetic make-up of each individual case of cancer so that every patient can get treatments that specifically target her unique cancer cells. Personalized medicine. That will happen. That is happening.  However until we fully understand the genetics of breast cancer, we can't know how to effectively kill off every different type of breast cancer cell.  Because there won't be a single cure. There may be a single process, but there will be many different cures, different drug cocktails put together to address each individual woman's cancer.  That's the future.

And we need better screening and diagnostics.  So that we can catch cancer early and hopefully minimize the treatments necessary to wipe out that cancer.  So that we know which patients are cured by surgery alone and which need additional treatments.  And then so that we know who has been cured by those additional treatments and who still needs more treatment.  Today too many women get treatments they don't need because we don't have the means to know that they don't need these treatments.

So I doubt that we will hear the big announcement "We have found a cure for breast cancer" and I doubt that we'll see a book from Dr. Brawley entitled "The Cure for Breast Cancer". But I do believe that over time we will cure most if not all women diagnosed with breast cancer. Of course we are all frustrated that we aren't there yet.  But yelling "Find the Cure" doesn't get us any futher down the road. I think the "Find the Cure!" rallying cry is misguided.  It simplifies what is an extremely complex disease and it implies that if only scientists worked a little harder or thought about a "cure" instead of some other treatment, we'd have the cure. The process to cure each woman diagnosed with breast cancer is a whole lot more complicated than that.  I think most of the people who yell "Find the Cure" know that, but maybe it just feels good to yell.

violet_1

Beesie,

Spot On... And yes I do think it's frustration cry about finding a cure the one and only single cure. Not going to happen.

It is a very, very complex disease and they know it's more than one or two or three diseases--its a bunch of' em.



And I don't believe it's a big conspiracy deal either ... even though I'm sure some medical specialists might bend if there's a borderline decision... tipping toward the monetary side.



Cancer Today magazine seems to take quite a balanced, cutting edge, up to date approach and has articles that the layman can understand without being overly simplistic. It often sites further studies to go search out per article...:) I highly recommend getting a subscription! I'm always learning something from that magazine which inevitably leads me to further studies and clinical trials.

There's a HEALTHY RATIONAL BALANCE between the flooding of pink ribbon awareness, medical conspiracy theories, and a ONE CURE idealization...I promise.

But, often, as BC patients it's a frustrating & emotional journey to understand that...& it takes lots of patient & diligent searching to come to that place of understanding.

Bless us all...this is a tough row, Ladies...



Violet

Mardibra

Maybe we should be yelling, "find the CURES". Yes, BC is complex and I also believe that my cure and yours will be individualized. However, that can't happen fast enough for me. Until then we only have what they offer today.

Colt45

"Find the cureS"!



It's called breast cancer. So I lazily say "cure" sometimes. If it were called breast cancerS, I'd make sure I said cureS every time.



The magazine isn't called CancerS Today, but everybody lets the editor off the hook.



We understand.

Colt45

I'll say this:



With so many different breast cancers-----how 'bout we cure ONE?



I want to see a subset of patients with one of the many breast cancers out there be told "we KNOW how to cure your cancer. Here, take THIS and you'll be cured. You don't need THAT or THE OTHER THING".



I want to see doctors KNOW what is and isn't going to work.



Right now, they're all just GUESSING that something is going to help... or not. I think doctors are more confident with some guesses moreso than they are others. But they're just guesses.



Until they KNOW, I'll have to temper my angst that doctors are giving women "treatments they don't need".



I'm more upset about what we don't know than I am about doctors erring on the side of treatment in a case where they literally do not know what is needed/ helpful. I can understand why doctors do that. And I don't mean the docs whose motivation is to make a buck selling chemo.



Not KNOWING is the problem. "Erring on the side of treatment because you don't know"-----not as much. JMO.



The cure(s) for most breast cancers can't be found until the cure for ONE breast cancer is found. Then two. Then three and so on.



Do we have a cure for ANY of the invasive breast cancers?



I'd buy a book on the cure for any of the invasive breast cancers, Dr. Brawley. You writing one of those today?



How about THIS cry: "Find A cure! And then another. And then a 3rd and so on!"

Beesie

But the other point of my post was that IT IS HAPPENING.  It's a slow, onerous one-step-at-a-time process..... that is already going on. 

Does anyone really think that medical researchers are not trying to find treatments that cure more and more women of breast cancer, until everyone diagnosed can be cured?  What's the goal of all the drug and treatment clinical trials?   What's the point of all the research that digs into the genetic make-up of cancer cells?  How do you think the Oncotype test came to be, which assesses 21 genes within the breast cancer cell to determine the probability of advancement of the cancer?

Oh, and yes, some 'cures' have been already been found.  Tamoxifen and the AIs save lives.  Herceptin saves lives.  Some women are 'cured' by these treatments. But not everyone, and we can't say yet who will be successfully cured and who won't be. Or who has been successfully cured and who hasn't been. That's the screening/diagnostic problem I referred to in my earlier post.  So the work continues.

"Do we have a cure for ANY of the invasive breast cancers?"  "A" cure? Maybe not.  But with a combination of surgery and treatments, do we cure any invasive cancers?  Absolutely. Look at long-term survival rates.  Here's the 2010 Seer data: (Note that DCIS cases are not included in this data.)

Year of diagnosis   10 yr survival rate  15 yr survival rate    20 yr survival rate

1975-1979                62.4%                  56.0%                      51.7%

1990                         77.0%                  71.8%                      67.5%

1995                         80.6%                  75.9%                   Not Available

2000                         84.5%              Not Available             Not Available

Is it good enough?  NO. I'd guess that the 20 year survival rate for those diagnosed in the year 2000 will probably come out somewhere in the range of 75% - 77%.  A small percentage of women who survive 20 years will still succumb to the disease but most who've survived 20 years will in fact have been "cured".  So this means that over about a 20 year period, survival rates will have improved from just over 1/2 of women being cured to more than 3/4s of women being cured. When you consider that Herceptin was still in trials in 2000 and wasn't yet approved, I think there will be significant improvements in survival rates as more data comes in for more recent years. 

My heart breaks when I read about another women dying of breast cancer.  One death is too many.  And the uncertainty we all face is hard to live with.  But this doesn't stop me from seeing the progress and acknowledging the work of the medical and scientific communities who are dedicated to curing every woman diagnosed with breast cancer. I was diagnosed almost 8 years ago.  Some of the information about breast cancer that we have available today, and much of the work that is being done, looks like rocket science compared to what was going on just 8 years ago.  The idea that medical scientists aren't working hard enough, or aren't looking for the cure(s) is, to me, just absurd.

Colt45

"The idea that medical scientists aren't working hard enough, or aren't looking for the cure(s) is, to me, just absurd"





Beesie, has someone taken that position?

Colt45

@Beesie:

Thank you for that data. It looks promising, but I was wondering if it's affected at all by a shift in the stage demographics... E.g., are we seeing survival improve as a result of more sucessful treatments for the same stage cancer(s) that previously didn't do as well?



Or are we just seeing more early stage cancers in the sample (cancers that were always more treatable), thus NOT truly indicating progress in treating someone with stage 3 or stage 2, etc., but rather just finding more stage 1 subjects to treat and thus skew the data/ results?

Cures have to eradicate regardless of stage, or we're really not talking CURES so much as treatments that are reliant on stage and other favorable variables for success. JMO.

jessica749

So many things to comment on, not enough time right now. Just to say, doctors and all people 'tip' the scales in borderline cases to what they know, what they practice. It's not about money necessarily, it's about treating the problem at hand, and what they are trained in!  If you go to a surgeon about a "borderline" problem, s/he's more likely than a non-surgeon to recommend surgery.  If you go to a non-surgeon about a 'borderline' problem, s/he's more likely to advocate a wait and see approach.

And I believe that the doctors I've been to-the ones I've agreed with and disagreed with, the ones that gave me good advice, and the ones that gave me bad advice - were all motivated simply to treat the patient, in the best way they believed and were trained to do.

That each made $ off of me is besides the point. It's a profession, a job, an income at the end of the day. Yes. It is not volunteer work. Thankfully. 

Agree with Colt that there are bad mds just like there are bad apples in every walk of life, and it's your job to steer clear of those people/weed them out as best you can as a medical consumer.

Beesie

Colt, the data seems to suggest that the improvements in the overall survival numbers are not due to an increase in the number of early stage women being diagnosed because in fact more women in recent years have been diagnosed with regional development of BC (i.e. nodal involvement) rather than having a localized (in the breast only) diagnosis.  As for whether we are seeing survival improvements across all stages, unfortunately SEER only provide 5 year survival by stage data, but the 5 year survival stats do show improvements across the board (with the exception of the '95-2000 data for those diagnosed with distant BC - that one number doesn't fit with the rest of the numbers - it begs the question as to whether there was a calculation  or sampling error).

% Diagnosed:             1989-1995       1995-2000      1999-2005     2003-2009

Localized                         62%                 63%                60%               61%

Regional                          29%                 29%                33%               32%

Distant                              6%                   6%                  5%                 5%

.

5 Year Survival %:       1989-1995       1995-2000      1999-2005     2003-2009

Total                               84.7%              87.7%             89.1%            89.2%

Localized                        96.3%              97.5%             98.3%            98.6%

Regional                         76.6%              80.4%             83.5%            84.4%

Distant                            21.3%              25.5% (??)       23.3%            24.3%

What's interesting to me is that the overall 5 year survival rates haven't improved that much over all this time, yet the data I previously provided showed that the 10 year, 15 year and 20 year survival rates have improved significantly.  So this suggests that more and more women are living longer after a diagnosis of breast cancer, and ultimately, more are surviving long-term.  So I guess something is working, then. Good enough? Of course not. But it sure does appear that more and more women who are diagnosed with breast cancer are in fact being 'cured', even if we have yet to find 'the cure'.

This articles from BC.org talks about survival rates over an even longer time period:

Breast Cancer Survival Triples in Last 60 Years

voraciousreader

Not sure why anyone who hasn't read Dr. Brawley's book would comment about Dr. Brawley without knowing what he thinks about finding a cure. His book is extremely important with respect to the landscape of cancer care in The United States. His book is very critical of physicians, researchers, patients, their families, advocacy groups and politicians. Did I forget anyone? He is very frustrated about the delivery of cancer care and spares no one with respect to everyone's responsibility in delivering and receiving care. While his perspective is based on his specialty in oncology, most of what he is critical of is applicable to medicine in general. His book is not about finding a cure for cancer. His book is not about rationing health care. His book is about rational healthcare. He believes once we have an enlightened discussion about healthcare, then we can have a discussion about finding a cure for cancer and other maladies. He is a very brave and vocal advocate for all of us who are interested in the future of medicine.

Colt45

@Beesie:



Great legwork, as usual. I REALLY appreciate all of your sincere efforts. I think I speak for many when I say that.



God bless.

Colt45

@vr:



I'll speak for myself in response... I'm guilty of responding to a confabulation of recollections earlier posters made of him and things he supposedly said in his book(s) or said when they met him.



Did I taunt Dr. Brawley unfairly?



In some sense, yes. Because I didn't read his books or speak to him. I am responding to a collective representation of him by people who have a favorable opinion of him.



What is at the heart of my misguided, unfair personal slaps at good old Dr. Brawley?



As much as I recognize 'over treatment' as a real issue-----when we're talking about breast cancers (that are still SO mysterious and unpredictable to our medical minds), I get extremely uncomfortable with what I perceive as overconfidence by doctors who do not understand breast cancers near well enough to be so outraged that people are being overtreated.

I agree the concept of people being overtreated is an easy one to be passionately against. I lament that some people are overtreated... But without more knowledge about WHO is ok with 'just this and that treatment' -------how can anyone vilify doctors for erring on the side of treatment? Until you KNOW more------don't be so outraged by the recommendations these supposed 'OVERTREATING' doctors are making, because the outraged people really don't know WHO is being overtreated.



It makes me crazy that we obviously are so lacking in understanding of breast cancers, yet some make bold statements about overtreatment and attack doctors for recommending what their training has taught them in the admitted absence of BETTER treatments and more knowledge.



Dr. Brawley has found a collective ear for his points of view and he is selling books to them. It's the American way.



I wish such a brilliant mind had his nose to the grindstone for a cure(s) rather than cashing in on angst with book sales.



Lord, I'm pissy today. Lol.



Perhaps I'm shortchanging Dr. Brawley, though. Maybe he's doing both? I am probably attacking a Dr. Brawley representation more than the actual Dr. Brawley. He'll get over it.