'I question what I know': Leading cancer scientist Otis Brawley on valuing orthodoxy in medicine

‘I question what I know’: Leading cancer scientist Otis Brawley on valuing orthodoxy in medicine

OOtis Brawley has dedicated his career to defending orthodoxy in medicine. Now, he says, advances in cancer treatments and early detections are rapidly outpacing the medical community’s ability to assess them, warranting greater caution lest doctors inadvertently cause more harm to patients. cancer patients.

“I think we really need to start controlling ourselves better,” said Brawley, professor of oncology and epidemiology at Johns Hopkins University and former chief medical officer and executive vice president of the American Cancer Society, during of a virtual STAT event on Tuesday.

Brawley pointed out that a number of drugs for patients with advanced cancer that are FDA-approved do not yet have randomized control data to support them. Many of these drugs, he said, have received FDA approval because they can potentially increase median patient survival rates by three to four months. “One has to ask, is the pain of taking the drug, including the financial pain and accompanying side effects, worth the chance of having a median survival increase of three months?” Brawley asked. How to improve quality of life, he said, should remain an important consideration in the pursuit of extending the lives of cancer patients.


Similar concerns apply to cancer screenings, Brawley said, noting that with the development of multiple multi-cancer early detection (MCED) blood tests underway, “if we’re not careful, it will be the west. wild of screening. ”

Brawley is an advisor to Grail, the largest MCED developer, and would therefore not comment on specific products. But he said that as they currently stand, MCED tests should not be done in place of other standard screenings – particularly because there is a risk of overdiagnosis, a phenomenon in which patients meet a pathological criterion. of cancer, but do not experience any symptoms or damage to their body. These patients could be encouraged to undergo unnecessary treatments for cancers that might never become a problem otherwise.


“We have a long history in medicine, going back to the Pap smear, where we instituted screening without properly evaluating the test,” Brawley said, citing other historical examples as precedents, including chest x-ray screening for lung cancer. in the 1960s and mammograms in the 1970s. The problems of overdiagnosis and overtreatment led many medical professionals to conclude, “‘Let’s slow this down because we’re going too fast and we’re starting to hurt people,'” a he declared.

For decades, Brawley pushed back against the conventional wisdom of “finding [cancer] early and cut it. In the 1990s, he began to wonder if routine prostate-specific antigen (PSA) screenings actually protected men’s lives. “In metropolitan Seattle, the prevalence of men diagnosed with prostate cancer was higher than the prevalence of left-handers,” he recalled.

It became clear that some men were at risk of getting treatment they didn’t need, which could be more harmful to them than the cancer itself. “In the 1990s, if you were diagnosed on Tuesday, you were told you had to have your prostate removed by the end of the week,” Brawley said. Since prostate cancer screening guidelines changed, the initial treatment for about half of men diagnosed with prostate cancer today is observation.

Now, as scientists move closer to cancer screening based on genetic risk factors, there is also a risk that people will enter treatments for cancers they will not develop in their lifetime. “We have to be very careful when doing genetic testing,” Brawley said. “I am very much in favor of studying to better understand how to do it. We’re not ready to do that yet.

Brawley also advised caution in developing race-based cancer screening guidelines. “I’m just very, very concerned that this will make people think that race is synonymous with biology,” Brawley said. “The unintended consequence of focusing too much on race and ethnicity is that in the United States, where we all see things through this racist lens, people tend to think that race determines things that it doesn’t really determine,” he added.

Rather than focusing on racial differences in health that are, by and large, determined by socioeconomic factors, Brawley advised doctors to address health disparities by ensuring that everyone gets a adequate treatment. She is frequently asked if black women should be screened for breast cancer earlier in life, starting at age 35. . “And if we could provide that 40% with adequate screening, adequate diagnosis and adequate treatment, the number of lives that could be saved and the number of years of life that could be saved would be far greater than if screening worked for black women aged 35. at 44.

Brawley further advised the medical community to be wary of extrapolations beyond what is known from clinical trials. “If the patient does not fit the clinical trial or is far from qualified to participate in the clinical trial, we should not treat them with the clinical trial drugs,” he said.

Throughout his 35-year career, Brawley said, his rule of thumb has been to follow the advice he received from a Jesuit priest before going to medical school: “Remember no, there are things you know, things you don’t know. , and the things you believe in. Doctors have this terrible problem of confusing what they believe with what they know.

“I question what I know more than anything else,” Brawley continued. “Because often what I know, or what we know in medicine, turns out to be wrong.”

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