4.75 Million Lives Saved, and Counting

TRANSCRIPT:

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Dr. Charles Ryan: This is The Good News About Cancer. I'm Dr. Chuck Ryan. 

Dr. Alicia Morgans: And I'm Dr. Alicia Morgans. In each episode of this show, we talk to one of our colleagues about a new development in cancer treatment or diagnosis. We're going to break down what's new, why it matters, and how it points the way forward.

Karen Knudsen: When we look at what's happened between 1991 and now, it's more than 4 million lives saved from cancer because we are changing the course of disease, and we're able to actually convert scientific findings into better prevention, detection, and cure. 

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Alicia: So Chuck, when you invited me to do this podcast with you, I definitely thought it was a bit of a crazy idea. What– what were you thinking? Why did you bring us together today?

Chuck: Well, I'm a big fan of noting that society is making a lot of progress on a lot of fronts. We have a lot of problems. You turn on the news, you hear bad news about the climate, you hear bad news about politics, you hear bad news about a lot of different things. But in reality when you take the long view and you look over, not the last 15 minutes, but the last 15 years, 15 decades, 1500 years, you realize that humanity is making a tremendous amount of progress on a lot of different areas. Still a lot of work to do, but I think we don't speak enough about areas of progress. 

The other thing is that, when somebody's diagnosed with cancer, their mind always goes to the worst possible scenario. Cancer occupies a special place in the human psyche. And that's because for forever, it wasn't treatable. People would get cancer, they would die. And that's not true anymore. 

Now we detect cancer at an earlier phase. We have many treatments that are not only effective in eradicating the cancer, but controlling it for long periods of time, and many treatments that are tolerated for a long period of time. And that's only going to get better. 

So I was thinking about these two facts and I thought, you know, my bully pulpit, if you will, as a cancer researcher and an academic who's been studying cancer for 25 years, is to say, well, let's pull out the positive outlooks. Let's pull out the positive news. And just talk about it and what it means. Let's not do it in an unrealistic way. Let's not say everything is rosy and you know, mission accomplished, but let's say, mission is, uh, making progress. 

Alicia: You know, I think that as cancer researchers, as doctors who take care of people who have cancer, we have seen so many different sides of things. And one of the important things that I love to share with patients and with those who are struggling is that there are a million wins every day around the world when it comes to cancer. And we are making progress in so many ways against so many different types of cancer. 

So I think that there's just a lot for us to look forward to, and certainly a lot for us to do as we take care of people each day, or people are in their own journeys with cancer – whether they're a patient or someone who loves someone with cancer, there's a lot to think about and a lot to be hopeful for. 

Chuck: Great. Alicia, this is our first episode. And I thought it would be great to start by getting an overview of where we are with the state of cancer in the U.S. and globally now, really to start with some data, some statistics. 

And every year, the American Cancer Society publishes cancer statistics. And that's where people get their data from on what cancers are increasing and decreasing, et cetera, et cetera. So I thought we'd start there.

Alicia: I think that sounds great. But you know, stats can be really intimidating for people. And so I think one of the best ways to do it is to bring in Karen Knudsen. She's the CEO of the American Cancer Society, certainly a good friend of ours, and she is the best person I think to tell us about where we've been in cancer, where we are, and where we hope to go.

Chuck: Yeah, and on top of that, she's an outstanding communicator, and before she was CEO of the American Cancer Society, she ran a hospital system, she ran a cancer center in Philadelphia, and even before that, she was a world-renowned researcher on prostate cancer. So we've known her for a long time, nobody better to start out with, so let's hear our conversation with Karen.

Alicia: Let's do it.

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Alicia: Well, Karen, I'm always so happy to talk with you and really, really want to dig in, because of your background leading the American Cancer Society, and of course your background in being a key researcher in cancer care. What are the main advances in cancer diagnosis or treatment – or in any area really – from your perspective in the last few decades?

Karen Knudsen: Yeah, you know, it's something that we not only think about quite a lot at the American Cancer Society, but we actually do a research study, and document. So one of the things on the intramural side at ACS that we do is we run a research study every year to essentially report on the current state of cancer. Incidents, mortality and trends for the 200 diseases we call cancer, as well as, you know, geographic and demographic changes. So that we can set this playing field for what it is that we need to do. So we do think about this pretty deeply every year. 

And one of the things that I think may go unrecognized is that the high watermark for cancer mortality rate in this country is decades behind us. It was actually 1991. And so since that time, we've recognized a 33 percent overall decrease in cancer mortality rate. That is stunning. 

And that rate alone doesn't tell the story. When the flattening of the curve started to happen in 1991, which we can attribute to significant investment in cancer research, it started off slowly. A 0.5 percent year over year flattening of the curve. And then it became 1%. And then two years ago, we actually hit the 2 percent mark. So we're speeding up progress by this measure. 

And when we look at what's happened between 1991 and now, it's more than 4 million lives saved from cancer, because we are changing the course of disease and we're able to actually convert scientific findings into better prevention, detection, and cure. 

Chuck: So four million individuals who are alive today – actually I think it's 4.75 per your publication of last week – 4.75 million people in this country who are alive today. If that were a city in the United States, it would be maybe the second or third largest city, right? If they were all aggregated into one place. That's a phenomenal thing to think about.

Karen: It really is. It's pretty spectacular. And I think it emboldens us to do more. I think it actually is some of the proof positive of why it's so important to invest in cancer research. And I feel like we're seeing more and more specific stories. 

I do want to call out because we, when we look at that 33 percent decline and we unpack: how did that happen? The vast majority of that 33% is from prevention and early detection. 

Alicia: I wonder, when you think about those cancers that have had the most benefit, are there any examples that come to mind? Whether it's prevention, whether it's something else, that, that you want to just call our attention to? Because we're really excited to hear about these kinds of things.

Karen: Absolutely. So let's talk about some of those. And I think one of the ones that we have to discuss are advances in lung cancer. And I want to unpack that in a couple of different ways. 

So unfortunately, lung cancer in the United States still is the number one leading cause of cancer death for both men and women. So we cannot ignore the fact that it is still a major problem. However, we're making some gains and those gains are coming in multiple forms. 

One of course is prevention. So smoking cessation is something that is happening in the United States. It's happening differently in different parts of the United States, but it is happening. And so we're starting to see a reduction in lung cancer associated with that. 

And of course there are other tobacco related-cancers that we will expect to follow suit. Bladder cancer, pancreatic cancer, you know, things that we know are strongly associated with smoking. So that's incredibly important and we want to see that continue. 

That said, there are never-smokers who get lung cancer. And those never-smokers – sometimes it's associated with a genetic alteration and family history, but there are other related exposures outside tobacco that we know now through research are able to promote lung cancer. Things like radon, which is actually the second leading cause of exposure-related lung cancer in the United States. So I think we're really poised to take the prevention win through smoking cessation and now say, ‘Okay, how do we ensure that someone who's been radon-exposed, or who has air pollution exposure, can be screened for lung cancer?’ I think future forward, that's where we're going to go. 

So I get really excited when I go places like Puerto Rico, which by the way, I'm going there to talk about cancer next week. Puerto Rico, I'm pretty excited about, because they are the only place to my knowledge in the country where lung cancer is no longer the number one leading cause of cancer death. 

The first time I saw the data, I almost fell out of my chair. And how did it happen? It happened through prevention and public policy. So in Puerto Rico, it's expensive to buy cigarettes. That's part one. Part two? It's the case that you can't smoke anywhere really, but your own home. Policies made it so that you can't smoke, of course at work, but you also can't smoke on the street. You can't smoke on the beach. And so if you ever really wanted to know:what does smoking cessation do for you? The experiment's been done and it's called Puerto Rico. 

So it's pretty darn exciting to see, and I think, they're really a first. So lung is one where I said we've won across the cancer continuum.

Alicia: That is so impressive. And I feel like we're going to have a conversation even after this podcast so I can learn all of the things that you have done within the ACS to really advance things, and give us so many things to say: these are good news things, and things that we should really celebrate.

You know, you've also had a career, even before this, as an innovator and a scientist. And you will always be that, and we'll see you continue that going forward too. And you've really elevated science as a priority at the ACS. So can you us a little bit about scientific investigation? What’s the good news there? 

Karen: So, you know, cancer does touch almost every family. So right now in the United States, one in two men, one in three women over their lifetime will get a cancer diagnosis.

But as we talked about, I fully expect that cancer research – which is clearly saving lives from cancer, right – is going to help us either eradicate or make cancers a more manageable disease. 

In order to make that happen though, we have to continue to invest in science. I think we're better poised now than ever to do that. It feels to me – and this had a lot to do with my decision to go into the private sector – is that we're in this golden age of innovation in science writ large, but that oncology is particularly poised to take advantage of new technologies because we have had successes. 

Even before AI came, we were converting scientific knowledge into better outcomes, but now we are able to be assisted by these new technologies that are coming in the form of artificial intelligence and other, that not only will help us in the laboratory develop and test new ideas for prevention, detection, and cure. But it also will help us learn from every patient. 

Let's just take a rare disease, something like small bowel cancer, which I know the three of us really care a lot about, because it's touched people close to the three of us. Or uveal melanoma, right? Really difficult cancer diagnosis, a melanoma of the eye that's rare. How do you get the information for patients who have these rare cancers to understand what works, what doesn't, what the risk factors might have been. 

This is where I see things like artificial intelligence really helping us learn–  do what we always wanted to do, learn from every patient. That's going to go from a very manual process to a process where we can protect the identity of the patient, but at the same time, learn about these cancers and understand how to take that knowledge from the rare cancers and move it forward. Taking the manual away from us and allow us to move faster.

In the cancers that aren't rare, the prostate cancer and breast cancer, okay, they're not rare, but why is it then that, you know, they're so high? Well, we have an opportunity to think about, for example, a super responder of a new therapeutic that's given for someone with prostate cancer. Why did, in a trial of a thousand people, these ten people respond so well? What is it about them?

And so taking the manual away from that and laying in innovation is where I think we're going, future forward. And you actually see it, being borne out at the level of healthcare delivery, part of my world, and science, part of my world. Where integration of data specialists and data scientists are becoming enriched at the level of the laboratory, at the level of the entire cancer center, and at the level of the health system. It's a new day.

Chuck: So you've touched on really the triad or the Venn diagram of success. It's cultural change, it's science and it's policy. Cultural change around smoking took place over decades.  Mayor Bloomberg in New York banned smoking in public restaurants and bars, and I remember that was a huge deal when it happened, and now it would just seem so odd to walk into a restaurant and have somebody smoking there. And there, the policy led to the cultural change.

What do you see as the pivot points, the areas where one can push on one of those three points and lead to changes in the other? Right? So Bloomberg says no smoking in bars and restaurants in New York. And then the culture is, it just would be odd to smoke in a bar or restaurant in New York now, right?

Karen: Right. I think my personal bias, modern era, is that it's easier to start with the data or the demonstration project, right? That you can show you can do it a place–

Chuck: Start with the science.

Karen: Start with the science and then motivate people behind it – and pilot testing I think can really help. So you know, this is one of the things that I felt so passionately about, and we had a lot of policy wins in the last four years at ACS. But a policy not-win that we had was the ban on menthol smoking. And why? So, the why behind that is exceptionally strong. It's the case that menthol smoking, it's been shown, is a gateway to a lifetime of nicotine addiction. It– the flavoring of menthol masks the harshness of tobacco and then people become addicted and then they start smoking everything.

It's not a feeling. It's a scientifically documented fact, right? And to the point where the, even the U. S. government had proposed to the FDA, you know, like, look, we really think we should ban menthol cigarettes. A little bit controversial. And the other thing to know is that menthol cigarettes are targeted specifically to youth, and to communities of color. 

And so if that is eliminated, the prediction was literally that hundreds of thousands of people would benefit in the short term, and even more in the long term, from a menthol ban. Well, the experiment actually was done. In the state of California and in the state of Massachusetts.

Because the way that the ban would work – cause you have to really think through like, what are the implications for policy – is at the level of the distributor and the manufacturer. There was not one person to our knowledge who was arrested because they smoked a menthol cigarette. That's not what the ban was about. Yet the theater of this all became that people would be prosecuted because of menthol cigarettes. So that was an unfortunate one, you know, where we need to kind of go back and rethink what is the strategy for the policy. 

But I see policy in this enriched on the foundation of science, and for which there's a discussion about the implications for people in society. That's where then great policy is built. And it doesn't happen overnight, but those are the things where we can literally change the lives of millions of people in one day. And those are the great days. 

Alicia: Well, as we wrap up, you mentioned that you had some big policy wins over the last couple of years. Share those with us. Leave us with some great news.

Karen: Love to actually. I'm going to mention three very quickly. So, two at the federal level and one at the state level. So one at the federal level was to eliminate the financial penalty for follow-on colonoscopy after at home colorectal cancer testing.

So just to put this in perspective: if someone tested positive at home for colorectal cancer with stool-based testing – which is great because we can actually identify someone at risk, at home in a way that they can do it on their own time. But if they tested positive at home, now their colonoscopy is not completely covered because now it's not screening anymore. You already screened positive at home. So now you're going to have to pay for it. 

Well, the data told us that paying for the colonoscopy prevented people from doing it. So this is a– this is ridiculous, right? And so just telling that story, showing the data, the science, and what the implications were for survivalship, and then talking about the patient story, changed hearts and minds. And then– so we got a win. So as of January 1st, 2023, follow on colonoscopies paid for if you are tested positive at home. Win one.

Win two was what I really – as a former healthcare executive, as a scientist, as a head of ACS – if I could have waved a magic wand and said, there's only one, if I can only achieve one thing, it's this: and I can't believe it, but we did it. And that is to have patient navigators to be a reimbursable component of cancer care. 

Having led oncology for a 16-hospital health system, I knew firsthand about the importance of patient navigators. Patients who are navigated understand their care, they complete their care as planned, they have a better survivorship and they have an overall lower cost of care. So literally everyone wins. It makes tons of sense. There was a lot of data behind it. And it just took the building of the coalition of people to get it done. And so January 1st, 2024 became a reality. I am just– I still have goosebumps talking about it. I could not be more excited about that. 

And then the last one is an example of a state win. Because people always think like federal level, my Senator or my Congressman, and that's true, but you also have to think about your state government. So one of the things we recognized early on when I came to ACS is that too few state plans were covering biomarker testing. So how it is that we match cancer patients to the right therapy, you know, precision medicine. 

What's the point of having a new therapeutic for someone who's got a HER2 positive cancer, if their cancer is never tested for the HER2 protein or the HER2 gene? So bottom line is we went to the state of Illinois, and had it passed into legislation, that biomarker reimbursement would happen. And that created the model legislation that let us go across the country. We now have more than 20 states, where we passed it into law. 

And so, you know, I will be really happy when it's all 50 states, but it's that kind of win, that involves the science and then the telling of the patient stories and the lifting up, really, of voices across the country to get it done. So I will always look on those three as game changers, just game changers. 

Chuck: Well, Karen, congratulations on a really successful tenure, at the American Cancer Society. We believe that you have transformed this organization. We look to this organization for leadership on so many levels. And we are proud to know you, and thank you for joining us.

Karen: Oh, thank you so much. It's really been a delight, and happy to come back anytime. And, you know, thank you guys for what you're doing. I think it's really important for people to understand how science impacts their lives in a positive way, every day.

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Alicia: Wow. What an episode, what a conversation. I can't believe the way we started this off. Karen just really rocked my world with so many things to think about in terms of success. Puerto Rico, lung cancer – who knew we were making strides in all of these areas.

Chuck: And think of the millions of people, as we mentioned, who are walking around today who don't have cancer or are cured of their cancer, who wouldn't have been otherwise, over the past several decades. 

So yes, I agree. Wow. It was a great episode, and such a great way to start off this podcast, which I hope, you, the listener, have enjoyed as well.

Alicia: Thank you everyone for listening to The Good News About Cancer. I'm Dr. Alicia Morgans, a medical oncologist at Dana Farber Cancer Institute in Boston.

Chuck: I'm Dr. Charles Ryan from Memorial Sloan Kettering Cancer Center. 

Alicia: Our production partner for this series is Citizen Racecar. This episode was produced by Anna Van Dine with post production by Jose Miguel Baez.

Chuck: I would like to thank Lilly for support of this show. 

And I'd like to take just a quick moment to dedicate this first episode to our friend Felix Feng, who passed away from cancer a month ago. 

Felix was a great friend of mine, personally, and Alicia, I think you would agree, a friend of yours as well– and Karen's. And so, he was a really inspirational figure and he's in our thoughts as is his family as we as we start this podcast.

Alicia, I'm really looking forward to recording these podcasts with you. I think we're going to learn a lot. We're going to talk to some interesting people and I hope we're going to inspire people to become cancer researchers. But more importantly, I hope we're going to inspire patients to have a positive outlook about the conditions that they face. 

Cancer remains a significant cause of suffering for humanity. We know that, but we are making a lot of progress, if you know where to look. So we're looking forward to this and – onward. 

Alicia: Onward is right, because there is good news about cancer.