Are wealthier people more likely to receive a diagnosis of cancer?

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CREDIT The Dartmouth Institute

Do wealthier people receive too much medical care? In a Perspective article recently published in the New England Journal of Medicine, H. Gilbert Welch, MD, and Elliott Fisher, MD, of The Dartmouth Institute for Health Policy and Clinical Practice examine the association between income level and cancer diagnosis.

Using data from the Surveillance, Epidemiology, and End Results (SEER) program, Welch and Fisher examined incidence and mortality trends for four types of cancers: breast cancer, prostate cancer, thyroid cancer and melanoma. They chose these specific cancers because the likelihood of diagnosis is sensitive to the intensity with which physicians look for these cancers – the combined effect of factors, including the frequency of screening and diagnostic exams, the ability of exams to detect small irregularities, and the threshold used to label results as abnormal. As Welch and Fisher note, these factors can have a dramatic effect on the apparent amount of disease. In simple terms, the harder doctors look for these cancers, the more they find.

Using 2000 U.S. census data, Welch and Fisher compared incidence and mortality of the four cancers in high- vs. low-income counties (median incomes greater than $75,000 and less than $40,000, respectively). Among their findings:

  • High-income counties have recorded a much greater increase in the incidence of these four cancers than low-income counties.
  • The combined death rate from the four cancers is similar in high- and low-income counties, which Welch and Fisher say suggests that the underlying burden of disease is actually similar in high- and low-income counties.
  • Mortality from these cancers hasn’t been increasing (as one might expect given the increase in diagnosis), but rather decreasing-due largely to improved treatments for breast and prostate cancer.

What accounts for the higher incidence of cancer in high-income counties? Welch and Fisher say there could be several contributing factors: affluent people may expect and demand more testing. Also, health systems serving relatively wealthy and healthy populations may see offering more testing “as a good way to produce more patients and increase business.”

If we want to move toward more sustainable and affordable health care systems, we’re going to have to understand what’s driving the overutilization of care and develop better ways to address it,” Fisher said.

Among the remedies Welch and Fisher suggest are moving toward alternative payment models, such as accountable care organizations, that move us away from the traditional fee-for-service model; reducing, or at least disclosing, financial conflicts of interest (such as doctors who receive payments from breast and prostate care centers); and promoting a more nuanced and balanced view of medical care.”Doctors and other health care professionals tend to overstate the role of medical testing in promoting health – particularly in people who aren’t sick,” Welch said. “A healthy diet, regular exercise, and a sense of purpose are very often the best tools people, at every income level, have to maintain good health.

Welch and Fisher. Income and Cancer Overdiagnosis – When Too Much Care Is Harmful. N Engl J Med. 2017;376(23):2208-2209. doi: 10.1056/NEJMp1615069 [Abstract]

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New ‘blood biopsies’ with experimental device may improve cancer diagnosis and follow-up

The investigators are conducting “liquid biopsies” by running blood through a postage-stamp-sized chip with nanowires 1,000 times thinner than a human hair and coated with antibodies, or proteins, that recognize circulating tumor cells. The device, the NanoVelcro Chip, works by “grabbing” circulating tumor cells, which break away from tumors and travel through the bloodstream, looking for places in the body to spread.

CREDIT Cedar-Sinai

Use of the chip in liquid biopsies could allow doctors to regularly and easily monitor cancer-related changes in patients, such as how well they’re responding to treatment. The research earned the lead investigators a place on the U.S. Cancer Moonshot program, an initiative led by former Vice President Joe Biden to make available more therapies to more patients and to prevent cancer.

It’s far better to draw a tube of blood once a month to monitor cancer than to make patients undergo repeated surgical procedures,” said Edwin Posadas, MD. “The power of this technology lies in its capacity to provide information that is equal to or even superior to traditional tumor sampling by invasive procedures.”

Although some forms of prostate cancer are so slow-growing that they pose little risk to patients, other forms of the disease are lethal. Identifying which patients have which type of disease has become a crucial area of study because prostate cancer is one of the leading causes of cancer death among men in the U.S. Nearly 27,000 U.S. men are expected to die from the disease in 2017, according to the American Cancer Society.
The research team has determined that in certain cancer cells, the nucleus is smaller than in other, more typical, cancer cells. Patients with the most advanced cases of aggressive prostate cancer have cells with these very small nuclei.

The investigators’ teamwork also revealed that very small nuclei are associated with metastasis, or cancer spread, to the liver and lung in patients with advanced cases of prostate cancer. Those nuclei developed before the metastases were detected. Identifying very small nuclei early in the disease progression may help pinpoint which patients have high risk of developing cancer that can spread and be fatal.

Hsian-Rong Tseng, PhD, professor, Department of Molecular and Medical Pharmacology in the David Geffen School of Medicine at UCLA and the other lead investigator, said that his work with Posadas is focused on improving the quality of life for cancer patients.

We’re on a mission to dramatically change patients’ everyday lives and their long-term outcomes,” Tseng said. “We now have powerful new tools to accomplish that.”

Posadas and Tseng join an elite cadre of academicians, technology leaders and pharmaceutical experts as partners in the Blood Profiling Atlas in Cancer (BloodPAC) Project, a Moonshot program. Participants will collect and share data gathered from circulating tumor cells. Posadas and Tseng expect to contribute microscopic images from 1,000 circulating tumor cells that have not yet been analyzed, as well as additional data and cells they have cataloged.

For the past five years, Posadas and Tseng have collected blood samples from cancer patients to profile and analyze the circulating tumor cells and other components. That process has helped them understand how prostate and other cancers evolve. The two investigators and their teams hope their findings will contribute to developing effective, targeted treatments for many types of cancer.

Minimally invasive methods to both diagnose and follow cancer, through simple blood tests, offer a unique and novel approach that can lead to earlier diagnosis and treatment, leading to more cures,” said Robert A. Figlin, MD, director of the Division of Hematology Oncology and deputy director of the Samuel Oschin Comprehensive Cancer Institute at Cedars- Sinai.