Why would the organizers of a big scientific symposium on cancer want me in the line-up? Chalk it up to the economics of public health. The topic of my talk in Memphis a few days ago: opportunities for connecting public health and medical care delivery.
As the nation’s second leading cause of death and the target of more than $100 billion in annual health care spending, cancer is a big deal by any measure. The War on Cancer has been underway throughout my lifetime, during which time the federal government has spent over $100 billion on cancer research. Most of this fiscal effort has focused on discovering cures – therapeutics to treat disease once it develops. By contrast, most of the progress in reducing cancer incidence and mortality has occurred through public health strategies, particularly tobacco control measures and to a lesser extent detection and removal of precancerous lesions through cervical cancer and colorectal cancer screening.
To be sure, some very exciting progress is now at hand in the search for new cancer treatments. But the brutal facts are that scientific discoveries of novel cancer therapeutics are driving up the costs of cancer care at rates widely viewed as unsustainable. Most of the new cancer drug molecules discovered in the past 10 years are priced at more than $5000 per month, and the survival benefits they confer fall far below acceptable thresholds of cost-effectiveness. Research shows that cancer patients are often willing to pay for these modest health gains, but insurance programs transfer most of these costs to society at large and therefore create real opportunity costs –crowding out the capacity to invest in prevention, education, research, and other desirable social interests.
Is public health part of the solution? To be sure, the most effective public health strategies for reducing cancer incidence and mortality are still under-deployed and under-used in the U.S.: tobacco prevention and cessation programs, policies and programs to reduce obesity through improved physical activity and nutrition, vaccination against HPV, screening for colorectal cancer, and environmental health regulations for air quality. Credible estimates suggest that full deployment of these strategies could cut premature cancer mortality in half.
Expanding cancer prevention may just prove to be a linchpin in keeping the cancer treatment enterprise viable over the long run. As the cost of cancer care rises, so does the value of strategies that reduce the fraction of people who requires this care, and that delay the onset of disease. Prevention is not without its own economic and social costs, but they tend to be much more politically palatable than rationing care, reforming drug pricing and payment policies, and shifting treatment costs to patients. Perhaps this is why the leaders of the nation’s National Cancer Institute-designated cancer centers published a letter this week urging Congress to maintain funding for the Affordable Care Act’s Prevention and Public Health Fund. And perhaps this is why a guy like me gets to give a talk at a major cancer conference on the economics of public health.
Most encouragingly, the scientists and clinicians participating in the Annual Mid-South Cancer Symposium in Memphis last Friday were not just talking about their connections to public health. They were actively building and improving these connections. The Baptist Center for Cancer Care, the symposium organizer, is based in Memphis but serves an extensive catchment area that stretches deep into the rural Delta region of Mississippi and Arkansas. This organization is pushing the envelope in working with public health agencies and community-based organizations to engage low-resource, heard-to-reach populations in the full continuum of cancer prevention, screening, and care, using mechanisms such as community navigators, community health workers, care managers, and telemedicine. And they are conducting high-quality research to demonstrate the effectiveness of these strategies. Dr. Raymond Osarogiagbon, one of the mobilizing forces in this work as an affiliated cancer researcher and physician at Baptist, has two large studies funded by NCI and PCORI to investigate the effectiveness of a coordinated, multidisciplinary model of delivering thoracic oncology in the region that has the highest lung cancer incidence and death rate in the nation. Together with researchers at the nearby University of Memphis School of Public Health, Baptist and its partners are building a powerful locus of community-based research and evidence-based practice. Eric Carlton, a faculty member in the school and fellow traveler in the field of public health services and systems research, is studying the formation, implementation, and impact of multi-organizational partnerships involving health care and public health organizations across the greater Memphis region. Eric’s work is supported through one of our center’s Junior Investigator Awards in PHSSR, funded by the Robert Wood Johnson Foundation.
Even though the war on cancer is every bit as old as I am, there is still considerable reason for optimism – especially in Memphis.
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