In a year that brought us new KRAS-inhibiting drugs, deepened our understanding of HER2 in breast cancer, and highlighted new potential for mRNA vaccines, the cancer field was also rocked by uncertainty of the future of research funding, equity in cancer delivery, and the integrity of review at FDA.
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In a lively conversation with The Cancer Letter’s Paul Goldberg, Brawley, who is the Bloomberg Distinguished Professor of Oncology and Epidemiology at Johns Hopkins University and co-editor of the Cancer History Project, started off on a positive note, highlighting several major discoveries made in 2025.
“Let me talk about some of the science that excites me. In the last year, we’ve known for years that KRAS is important. There are a whole bunch of tumors, be it lung cancer, colon cancer, some of the brain tumors, neuroblastoma, where KRAS is an important gene,” Brawley said. “Well, this year we got inhibitors of KRAS G12D, G12V, and G12R. So, all of a sudden we have drugs that truly have the potential of inhibiting KRAS and positively affecting a whole bunch of tumors. And so to me, this is one of the things that really excites me.”
Despite these great breakthroughs happening in oncology, cures and treatments are not being delivered equally in the U.S., Brawley said.
This numbered among his concerns for the field, which included the loss of Rick Pazdur at FDA as well as talented young investigators choosing alternate career paths.
“I think we’ve lost some of our young good investigators,” Brawley said. “A lot of the training grants are not being funded. I know several young, talented people who are looking to Europe. I know several young, talented people who are looking to Wall Street, go tell investment banking firms where to put their money as opposed to doing the science to develop the new drug or to develop the new understanding of cancer. So we have been harmed.”
Many of the established systems that have shaped the field of oncology in the U.S. have faced a shakeup this year. Brawley and Paul agree it is time to talk about rebuilding.
“We do need to talk about rebuilding,” Brawley said. “Part of the rebuilding is how do we finance it? Part of the rebuilding is how do we organize it?”
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This episode was transcribed using transcription services. It has been reviewed by our editorial staff, but the transcript may be imperfect.
The following is a transcript of this week’s In the Headlines, a weekly series on The Cancer Letter Podcast:
Jacquelyn Cobb: Hello everybody. Today we have a very special episode for you celebrating the end of this very eventful year. To do this, Paul recruited his very good friend and co-editor of the Cancer History Project, Otis Brawley, who is also the Bloomberg Distinguished Professor of Oncology and Epidemiology at the Johns Hopkins University Sidney Kimmel Comprehensive Cancer Center. From personal experience, whenever these two get talking, any listener is in for a good time, so enjoy and we’ll see you next year.
Paul Goldberg: Otis, this is the first year in our long-running tradition, we hope, of looking back at the year that has gone by and seeing what we have learned or unlearned. So it’s kind of an unstructured discussion like many that we have in the course of the year. And I guess, gosh, maybe you should go first. What have you learned this year?
Otis Brawley: Well, there have been a number of challenges, of course, but there’ve been a number of… When I look at what’s going on, and you and I are both kind of science nerds. We’re kind of like the guy who sits in the stands at the baseball game with his scoresheet and knows every player and knows what their batting average is and what their gifts are and what their weaknesses are. As I look at what’s going on in this marathon that we call cancer research or some people would call the war on cancer, and you need to realize it is a war on cancer, this is number one. And actually one of my mentors, a fellow named Vince DeVita used to always say, and still is always saying that this is a great time to be in oncology because we’re discovering so many things. And I think that’s really true.
As I look at the past year, there’s a lot of really good things that have been discovered, a lot of great understanding. We can go through some of those things. And as always, the discovery is perhaps half the battle. The other half of the battle is delivery. And we should talk about disparities and the fact that one of the things that we’re starting to see a lot is there’s a lot of people who don’t get delivery of all of these amazing things that are happening in cancer. And I suspect it’s true if I were a diabetes doctor or a cardiologist.
Paul Goldberg: Yeah. Well, yeah, as you said, it’s half the battle. The other half… Well, I’m not even sure it’s half the battle. Maybe it’s a third of the battle because access is maybe the other third. And roughly speaking, maybe the other one-third coefficient would be policy. And that’s kind of what we mostly—we often focus on. And as to paraphrase Vince DeVita, this is a great time to be a journalist. And it is. It really is. It’s also, strangely, we’ve been doing one thing. One thing that’s different this year from the previous years is that we’re doing a lot of podcasting. Basically, more than once a week, we’re on a podcast, five times a month at least. So it’s just changed everything, changed a lot for us. And actually, it seems like we’re being accessed a lot more, but also it’s the time. So let’s look at policy, our one-third for now.
Otis Brawley: Yeah. Let’s look at policy, but I want to celebrate some of the science too.
Paul Goldberg: Oh, well, let me shut up and you celebrate.
Otis Brawley: All right. Let me talk about some of the science that excites me. In the last year, we’ve known for years that KRAS is important. There are a whole bunch of tumors, be it lung cancer, colon cancer, some of the brain tumors, neuroblastoma, where KRAS is an important gene. And we’ve been looking for KRAS inhibitors. And we developed a couple of years ago an inhibitor to KRAS 12C, which is one particular type of KRAS and we’ve been looking for inhibitors of other mutations. Well, this year we got inhibitors of KRAS G12D, G12V and G12R. So, all of a sudden we have drugs that truly have the potential of inhibiting KRAS and positively affecting a whole bunch of tumors. And so to me, this is one of the things that really excites me. Now, I’m going to be honest with you. I like to talk about saving lives or preventing deaths.
Or sometimes I say because of that person’s work, people are not dead. We are not at that point yet, but these are good leads for good drugs that I think in the very near future are going to prevent some deaths.
By the way, the KRAS tumor that everybody would love to see a drug in is pancreatic cancer.
We have some P53 reactivators. P53 is an important gene mutation and it shuts down. And when it shuts down, cells don’t go into programmed cell death. Well, if we could reactivate P53, maybe some cancer cells would actually kill themselves. And we’ve now got some P53 reactivators that seem to have some activity, and these things are going to get better over the next few years.
Our understanding of HER2 in breast as well as several other cancers is getting better and better. A couple of years ago, everybody talked about HER2-low. Now we’re talking about HER2-ultra low. And we’ve got a drug that had a wonderful finding this year, trastuzumab deruxtecan in HER2-ultra low. This is going to positively affect women with certain types of breast cancer and other people with certain types of things such as gastric cancer, I’m going to predict, in the future.
The mRNA vaccines have been in the news a lot. I actually happen to like the COVID mRNA vaccines, by the way. I happen to think that they’ve saved over two million American lives from COVID. That was a political remark and a remark of scientific truth, by the way, I think. There are some mRNA neoantigen vaccines that seem to be very active in both melanoma and HPV driven tumors. The most common HPV driven tumor right now is cervical cancer, but fast on its heels are HPV driven head and neck tumors. And so I’m actually very, very excited about those findings. And by the way, everything that I’ve said to date is reason why we need to support cancer research.
Paul Goldberg: Ah, you’re going to politics.
Otis Brawley: I’m getting into politics.
Paul Goldberg: You’re crossing into that coefficient of politics.
Otis Brawley: Yes. Yes.
Paul Goldberg: Everybody listen up.
Otis Brawley: Yeah. We need to support. We have seen so many positive things come out of cancer research. It would be a shame to not continue pursuing these avenues of study. The United States right now is the leader in cancer research. And if we don’t continue supporting these avenues of study, we will very quickly end up seeding our leadership to people in Europe and people in China.
Paul Goldberg: Sure. Well, let’s talk a little bit about how this year went by. Correct me if you disagree, but I think it kind of breaks up almost evenly into two segments.
The first one is we’re all catastrophizing about the state of science in cancer and the funding, the state of funding for science for cancer. As OMB proposes a budget that for NCI, and NIH that cuts an enormous amount, what is it, 40%? And then there are other cuts like the 15% limit cap on the indirect costs. So basically a catastrophe. And then Congress says no. And that’s Republicans in Congress say, “No, we have other priorities.” And NCI ends up with a pretty good budget. I mean, its flat funding is terrible some years, but this year it somehow feels like a new lease on life.
And then something else happens, which is really astonishing. We’ve had some possibilities for NCI directors, some of whom were in the dietary supplements business—at least one. Some of them actually were quite great. And now we ended up with Tony Letai, who is terrific. He’s a card carrying scientist. He is apolitical as far as I can tell. And maybe he is political, but it’s nobody’s business. He’s a political appointee, but he would be a great hire for any administration.
So suddenly here we are. We are okay. But on the other side of this, which is FDA, I have no idea what’s going on. This is to borrow an image from Winston Churchill. It’s like a fight of bulldogs under the carpet, and I have no idea which bulldog has bitten what.
Otis Brawley: Well, Dr. Letai, and I hope I’m not giving him the kiss of death, I am very optimistic. He’s a good guy. He understands the cancer problem. He’s committed to science and committed to the science problem.
The FDA I cannot speak to, especially given that Rick Pazdur announced that he’s retiring.
Paul Goldberg: So let’s talk about Rick Pazdur.
Otis Brawley: Yeah. Rick Pazdur is the consummate scientist, the consummate physician, and the ideal human being to be doing drug regulation. And I can tell you that a lot of people in the drug industry, the pharmaceutical industry, like the fact that Rick is there. Yes, he’s the policeman. Yes, he’s the guy who for years decided what oncologic drugs got approved and didn’t get approved, but he was a certain amount of continuity, predictiveness that a lot of drug company executives and a lot of drug company physicians and scientists actually liked having in that job. And we’re going to miss him. We are going to miss him.
Paul Goldberg: Yeah. He invented the entire system and he is the link between academic oncology and pharmaceutical industry and the government. A lot of this came through sort of the pathway known as Pazdur’s brain.
Otis Brawley: Yeah. It’s kind of weird. We’re essentially giving the obituary for somebody’s career, or at least the government portion of his career. I think he still has a few years left and people will hire him to do various things to help them out.
Paul Goldberg: Yeah. Yeah. I’m not as worried about Rick because Rick will find his way and he is, as you said, everything the way you described them. But I am worried about FDA and I’m worried about us, meaning as Americans and as humans actually, because one of the things he kept running into reportedly was this new pathway, priority, whatever it is, review, vouchers. So that’s just ripe for abuse. And he was saying that it’s probably illegal.
Otis Brawley: I don’t understand it, so I really can’t comment on it.
Paul Goldberg: No, no, no. I wasn’t trying to get you to do that, but since kind of taking the long view of it, imagining oncology without Pazdur at OCE, and he still had many, many, many good years left in him and was eager to be a public servant. And he only lasted a month, roughly, in this job at CDER, as head of CDER. This is a tough time for all of us.
Otis Brawley: Very much so.
Paul Goldberg: Thank you.
Otis Brawley: Yeah. Best to Rick, and I’m thinking about the… There’s a wonderful set of employees at the FDA, still at the FDA. And I’m thinking about them because I know morale has been very much affected.
Paul Goldberg: Yeah.
Otis Brawley: I’ve often worried that policy does not appreciate science and the scientific method, and policy really needs to be driven by orthodox science and orthodox interpretation of the science. We need more prospective randomized trials instead of less.
We’ve gotten into trouble in the past because instead of doing a long-term prospective randomized trial, it might take 10 years. We have taken a small observation and implemented it throughout the American population. And then 30, 40 years later, realized that we were hurting people. And there are a number of examples of that from bone marrow transplant, lung cancer screening with chest x-ray in the 1960s, even some of what we did with Pap smear screening in the late 1940s and 1950s, people were heard because we did not appreciate the power of those interventions.
Now, I just mentioned interventions that ultimately do save lives when they’re done correctly, but we implemented them before we understood how to do them correctly and people got hurt because of it.
And so I really like when policy is driven by people who look at what the clinical studies show, and they interpret those clinical studies in an Orthodox conservative approach. Ironically, I’m calling for a conservative interpretation of science, not gun slinging or not making it up as we go along.
Paul Goldberg: Well, you’ve been doing this for years.
Otis Brawley: Yeah. Yeah. I’ll be off color and tell you that my favorite t-shirt recently says ‘Science: Because figuring things out is better than making shit up’.
Paul Goldberg: Indeed. Yeah. Those are the choices. Speaking of which, somebody should figure out what to do with a t-shirt. Maybe we should publish it, if that’s the right word, ‘gold standard science’ we put on the front, and then the back it might say something like, ‘What the hell is that?’ That’s just an idea.
Otis Brawley: Okay.
Paul Goldberg: And then maybe it should say The Cancer Letter somewhere.
Otis Brawley: Well, let me explain this to the population. You talk sometimes a little even above me.
Paul Goldberg: Oh, please.
Otis Brawley: Notice I said even above me.
Paul Goldberg: that means you taught me well.
Otis Brawley: Right. The gold standard in clinical trials is the prospective randomized trial and the result of a prospective randomized trial. Now, I very frequently hear people who don’t even know what a prospective randomized trial is who are saying things that there is no science to document, calling it gold standard science.
Paul Goldberg: That’s new though. That’s new.
Otis Brawley: That’s new. That’s something that we —
Paul Goldberg: I traced that to our HHS secretary and now the FDA commissioner and maybe CBER director, not CDER director who knows the difference. So yeah, so go ahead. I’m sorry to interrupt.
Otis Brawley: Yeah. Well, I’m not criticizing anybody. I’m just saying we need to be careful of what our wording is and we need to be orthodox to the science. We need to be conservative in our interpretation of the science, and we need to be conservative in our design of science. And I will tell you, I do worry when I hear people talk about gold standard science and make statements, and then they start quoting science that doesn’t exist or misquoting science that does exist. I’m not talking about any particular individual right now.
And I think that for years I’ve been in the prostate cancer wars where I’ve been trying to get people to understand their pros and cons to prostate cancer screening, but many of the people who are very pro prostate cancer screening just totally misinterpret the literature or misquote the literature. And many of them don’t apologize.
And of course, I once went up against Suzanne Somers, who at one point in time when I actually said a truth, I’ll never forget, she said, “Dr. Brawley, you’re not making my point.”
Paul Goldberg: Thank you. You can’t. But the only thing that’s probably worse than gold standard science, which is deliberate, has to be deliberate obfuscation, unless it’s, of course, the defense from that saying, “No, no, no, it’s just ignorance.” But there’s also something called common sense measures. Common sense is the exact opposite of gold standard, which is evidence-based medicine, which is a movement in medicine.
Otis Brawley: Yeah, I disagree with you a little bit. I used to sit through some of those Oncologic Drug Advisory Committee meetings where… And I was one of the people who actually listened when the public statement section came along where anybody from the street could get up and get two minutes at the microphone to talk about the drug that was being debated before the Oncologic Drug Advisory Committee.
And for our listeners, the ODAC is like a grand jury put together by the FDA. When they have a application for a drug and they’re not sure whether or not they should approve it, they will call together a group of about 20 to 24 experts and they’ll ask them a series of questions relevant to the approval of the drug and then take that information and make a decision about approval.
And I’ll never forget one day this little old lady from a cancer advocacy group, and she’s a wonderful woman who cares about her disease. It was a pediatric disease, and she said a truth, which I think is important for us all to realize and reflect on. She said, “We don’t care if the drug works or not. We have to have something.” And that made me realize there’s a whole bunch of folks who want to grab on to false hope, even if you’re telling them it’s false hope.
And we need to get back to science and reality. We just need to get back to science and reality and people need to… And us in medicine, I’m spending a lot of time on this nowadays, us in medicine need to get better at explaining the science that we do, why it’s important and—what we do and why it’s important. Everybody in science needs to have that elevator pitch.
Paul Goldberg: Well, common sense science and common sense anything is… Evidence-based medicine is flying by instruments. Common sense can lead you into some very strange straits as you’re one of the people who fights that frequently, but let’s just set that aside for now because we could have… This is not a conversation you can have without scotch. So let’s just say we do not have the modality that is needed to support this discussion.
So let’s talk more about this year, what we have learned. Again, the timing is six months of catastrophism roughly, and six months of saying, “Hey, things are not so bad and maybe we’ll get through this.” Do you think we get through this?
Otis Brawley: Well, I think we’ve lost some of our young good investigators. A lot of the training grants are not being funded. I know several young, talented people who are looking to Europe. I know several young, talented people who are looking to Wall Street, go tell investment banking firms where to put their money as opposed to doing the science to develop the new drug or to develop the new understanding of cancer. So we have been harmed.
I do worry a great deal that the Europeans, who are actually trying to hire a number of American scientists, will get better. I worry about the Chinese who are also out there competing against us. We’ve had a period of more than 50, 60 years where in medicine and cancer medicine, especially, we have reigned supreme and I’m worried that we’re going to lose that. I will agree with you that the harm that I’ve seen is less than what I would’ve predicted when it started happening, when a number of laboratories had to shut down, number of people had to start figuring out how do we keep our animals alive until we can get to the point that we can do science again.
It certainly is not that bad. And again, another thing, I’ve been saying for 15 years that we need to find alternative methods to finance cancer research. The history is that in the 1930s, ’40s and ’50s, foundations overwhelmingly found the money to subsidize research, be it the Kellogg Foundation, the Ford Foundation, there are a number of others that were out there. The American Cancer Society in the early 1950s funded more cancer research than the National Cancer Institute. Then it was the government that really picked up after World War II and really accelerated. And then finally in 1971 with the National Cancer Act, and Nixon never called it Nixon’s War on Cancer, that was other people. We had this huge acceleration of money going from the NIH to universities to do cancer research. And actually other institutes at the NIH did the same thing, which is frequently not talked about, but the National Cancer Act was a wonderful thing for cardiology, for infectious disease, even for mental health and children’s health.
But in any event, we had this rise in government-funded research that started in the 1950s, really took off in the 1970s. And I think that’s been a good run, but we need to find alternative ways. It might involve more venture capital because venture capital has become a big, big thing out there. It might involve things like the CPRIT Texas model, but I don’t know what the model is. I know we need to find an alternative model, and I know that we’re at a point where we have such an amazing understanding of what cancer is, and that amazing understanding of what cancer is leads us to ideas on how to interfere with it that leads to ideas about both prevention as well as treatment. We’ve got those ideas about prevention and treatment being drugs and interventions that have come forth, some of whom clearly work. And it would be, pardon me again, a damn shame if we got to this point and we then decided not to follow through to completion.
Paul Goldberg: Well, the amounts of money involved in R&D can be so huge and-
Otis Brawley: That’s right.
Paul Goldberg: … appropriations have not kept up. So what’s the NCI budget? It’s pretty minor compared to even the giving from the high net worth individuals, like the Dells just gave six point something billion to something or other.
Otis Brawley: Yeah. I think the NCI budget this year is seven billion.
Paul Goldberg: Yeah. So in essence, you could spend a whole lot more and look at the R&D by pharma companies, which of course would all stop if NCI died.
Otis Brawley: Well, many people don’t realize that the two actually support each other quite nicely right now. And again, I want to say again, we need to find alternative ways of funding for the future. The government-funded research funds a lot of very basic research and understanding of cancer. And the drug companies are interested in applied research. They’re more the engineers. And they come up with the treatments. They take risks just as the federal government does. The federal government funds some research that ends up going nowhere. The drug companies fund a lot of drugs that end up never being used. But the federal government research program trains a lot of people who go off and work in the pharmaceutical research programs. And so there’s a good interplay. And the federal government has recognized that over the years, the Bayh-Dole law from the early 1980s, for example, which actually figures out how the money that comes from federally funded… How the money that results from federally funded research and patents that are supported by that federal research, how that money is distributed.
Those are all recognition of the interaction between the two. And it’s been very fruitful. I just mentioned a whole bunch of drugs from this year. And by the way, I’ve got other science from this year that I’m actually thrilled about and I would love to see continued support.
Paul Goldberg: I guess we should talk about it.
Otis Brawley: Yeah. We should.
Paul Goldberg: Celebrate some more. We should give you little flags.
Otis Brawley: Yeah. Yeah. Well, I’m a screening guy, I’m a screening epidemiologist and we got these multi-cancer early detection tests out there. I consult for one company. I’m not pushing anyone of these tests right now. However, I would tell you that I think the future can be bright. It’s helping us learn a great deal about what cancer is and how cancer behaves. I think the first area where some of these tests are going to actually influence patients and may be influencing patients even now is looking at circulating tumor DNA for what we call molecular residual disease. And that is if a person seems to have no evidence of disease or no evidence of cancer after treatment for their local disease, doing the blood test to figure out if there’s additional evidence that there’s no disease present. Molecular residual disease is looking for residual tumor circulating. And we’ve seen that.
There’s a test out there that’s approved in colorectal cancer, but this year we saw tests in breasts, lung, bladder, lymphoma, and maybe a couple of other cancers coming out there. And I actually hope, and this is a dream, that molecular residual disease testing will ultimately become a valid surrogate endpoint to speed up some of these clinical trials, clinical trials in cancer treatment, clinical trials in cancer screening. Again, I have to tell you, it is a hope. You and I have had this conversation about a valid surrogate endpoint going back into the 1990s.
Paul Goldberg: When the argument was that there’s no such thing.
Otis Brawley: Yeah, this may be.
Paul Goldberg: Well, there is one surrogate endpoint, which is fully meeting the Prentice principles [Prentice criteria], which is your respiration, for living, is a surrogate for being alive. That’s a full effect of… Anyway, all three criteria are satisfied in that one, but I don’t think there’s anything else. But does it worry you right now with the MCEDs that we might be resorting to quote gold standard science and common sense instead of the gold standard in science?
Otis Brawley: No. The MCEDs need to be evaluated in a scientifically—just in a scientific way like anything else. One of the things that the MCEDs have against the multi-cancer early detection test is there’s a whole group of people who don’t understand science and think if the test finds cancer, it must be good. If it finds cancer that appears to be early, it must be even better.
And there are a whole bunch of folks who don’t understand that the purpose of a screening test is to prevent someone from dying. And right now, the only way we can show that we prevent someone from dying is with a long-term randomized trial where we compare a group of people who are screened versus a group of people who are not screened. And that takes 15, 20 years in many instances. With this molecular residual disease testing, we might be able to shorten that.
And again, I gave you a whole bunch of the Washington hedge words. Might. I didn’t say definitely would, but I think this is an area of investigation that we need to go down.
Paul Goldberg: Well, speaking of gold standard science and scientific and gold standard in science and all of the rest of the words we’ve been discussing, it all kind of takes us to a question of the scientific method and its role in settling debates. And that seems to be one of the issues here is how do you get the public, the voters to understand the scientific methods so you can have this conversation? You see where I’m going?
Otis Brawley: Yeah. Yeah. There’s a lot of people who are not very scientifically literate, and then there’s a whole bunch of scientists who are not very literate in their ability to convey what science is. And so you got the two problems. You got people who are not very good at explaining it and people who are not very good at understanding it, and we need to work on both. And unfortunately, going and fixing the curriculums in grade schools and junior high schools won’t fix the problem for years.
Paul Goldberg: Yeah. But what about patient groups for whom this is life and death? By the way, we have not heard from patient groups directly. Maybe we have because Congress did stop these Draconian cuts.
Otis Brawley: Yeah. Well, I have been very praising of some patient groups and very critical of others. Some of the worst people in terms of harming cancer patients are some of the patient advocacy groups and they harm cancer patients by not being very scientific, appealing to the emotions and getting people to do things that are unproven. They’re getting people to do things that don’t even make your gold standard science.
Paul Goldberg: But gold standard science is that which I think it is. Not I, but the keeper of gold standard science. But yes, yes, you are exactly at that point. One of the smartest pieces we’ve run, kind of eye-opening pieces we’ve run this year in The Cancer Letter was about just that, the scientific method and how people do not understand it.
It was a piece by George Weiner and Elizabeth Jaffee. And boy, was that a fantastic piece of, well, of work and insight to how to make those arguments, how to speak to people without maybe even using the words scientific method. But maybe you should just go into kind of how politics of the thing has been developing because I don’t think of someone like RFK Jr. as a conservative, classically speaking, classical liberal or whatever. He’s kind of an outlier in the Trump administration. You see where I’m going with this? Because my guess is that his way of thinking, his gold standard science and all of this isn’t going to go away should Democrats win.
Otis Brawley: No, I think we need to take our arguments about supportive science to the people. I think we need to try to explain to folks the importance of mRNA vaccines in COVID or the importance of some of the things that we’re doing. We’re still in the prostate cancer screening wars. That’s an area that nobody in the administration has talked about, so I feel very comfortable discussing that one. We need to explain to the community of men in the country the pros and cons of prostate cancer screening, the things that are open questions, the things that are closed questions. We need to talk about the importance of getting quality care when one decides to get care.
Yeah. We need to stop thinking about politicians and stop thinking about certain individuals and actually start making an appeal to the population as a whole. And that way we bypass some of the bad patient advocacy groups. And then there’s some of the good patient advocacy groups. I have to mention the fact that there’s some really good patient advocacy groups because some of those, especially like the National Breast Cancer Coalition, they’ve been very supportive of me and my career and some of the things that I’ve tried to say and tried to do. And they are some of the folks who understand the science. Matter of fact, Fran Visco and the group started something called Project LEAD more than 35 years ago, where they were teaching advocates how to ask questions and how to understand the science.
Man, we need more Project LEAD. I might try to start doing something like that in Baltimore.
Paul Goldberg: Oh, that’s an excellent idea. And it is based on the actual scientific method and it is kind of the foundation of this whole thing. And the other tidbit with them that’s fascinating is it’s not about your disease, it’s about the other woman’s disease.
Otis Brawley: Yeah.
Paul Goldberg: It’s about everyone’s disease. It’s about breast cancer, for God’s sake.
Otis Brawley: Yeah, that’s a really important point. So much of the badness that I see in oncology is people who are out for something for themselves or for their family, the hell with everybody else. And yeah, I recently had an opportunity to go to the Jamaica Hospital in Queens and I found a whole bunch of folks there. It was really beautiful. There are all kinds of races and religions and they all have one thing in common. I finally referred to it as an unrepressed Mother Teresa gene. They cared about each other and about all the people who they were taking care of. They actually understood what the meaning of the word profession is for those who are in nursing or medicine. And I’m actually writing some stuff now and they’re one of my examples of how you practice medicine.
Paul Goldberg: Well, of course. And then look at what we’ve heard from patients, which isn’t a whole lot in this whole era of… Well, in the past year. It’s not been really any different from the past. The patients have been pretty silent or no more vocal than before. And I’m wondering how to explain that because for patients, maybe they have not been silent, but there’s no foundation. And I don’t mean as in funding, but no means for getting their experience and their thoughts out there into the world.
So breast cancer has Fran Visco and NBCC and they knew what to do and how to do it and what needed to be done. Well, they learned partly from the AIDS movement, but they took all of the right lessons. And we do not have an AIDS movement equivalent that goes kind of pan-cancer.
Otis Brawley: Now, the other thing that I wish we focused more on from policy is health promotion. One of the things that has come to fruition in terms of our research is our understanding of what the causes of cancer are and what a healthy life is and what a healthy life is not. And much of that, we get through policy. It’s policy that leads to us having low smoking rates in the United States and the most successful, and there have been a number of public health interventions that have been successful over the last 100 years from the introduction of vaccines against measles, mumps, and rubella to the smallpox, which we have eradicated from the planet, but let’s get into cancer and cardiovascular disease.
The work that we’ve done on tobacco control since the mid 1960s is just absolutely amazing. We’re starting to take a few steps back and we still aren’t finished, but the work that we’ve done in tobacco control is absolutely amazing. It’s about 15% of American adults are smoking today. 1955, it was 55% of adult men. In 1965, it was 35% of adult women. Those were the maxes, but it’s 15% of adults today, and we can go lower.
In Maryland, where I live and work, we have counties where the childhood smoking rate for teenagers is 20%, and we have counties where the childhood smoking rate for teenagers is 3%. I quote those to show what we can do and what we need to do. And those are policy issues. It’s making it hard for people to find a place to smoke, making it expensive for people to buy tobacco, teaching people the harms of tobacco through public health messaging and what we teach them in the schools.
We have to worry about vaping, which is not cigarette smoking, but I still worry about vaping causing lung illness. These are policy things that we still need to focus on. And I worry that we are starting to lose focus. In the last nine months, the smoking offices at the CDC, FDA, and NCI have all been radically reduced. Some of them closed.
Paul Goldberg: That’s a bad thing. Maybe it’s time to reopen them because that was early in the administration situation, possibly having to do with Elon Musk or possibly not. Who knows? Actually, the first order of business for this administration was to stop the menthol guidance, right?
Otis Brawley: Well, the previous administration…
Paul Goldberg: Flubbed it first.
Otis Brawley: … Chose not to abolish menthol. Current law allows the Food and Drug Administration to regulate the amount of menthol that is in tobacco. Menthol does not naturally occur in tobacco. Tobacco is spiked with menthol, and by spiking tobacco with menthol, you actually make tobacco much more addictive. And there are certain populations that love menthol. Black men, for example, who smoke cigarettes overwhelmingly smoke menthol cigarettes. Even many cigarettes that we think of as not menthol tasting have a small amount of menthol added to them because of this addictive thing. The FDA could actually just tell the tobacco industry this evening, “Effective tomorrow, you are not allowed to put menthol in any tobacco products.”
The Biden administration chose not to do that and the Trump administration has also chosen not to do that.
Paul Goldberg: Well, yes, the Biden administration did flub it pretty badly out of fear that they’ll lose Black vote. That’s kind of what it seemed like even though…
Otis Brawley: That’s my understanding.
Paul Goldberg: Yeah. Even though you were at the forefront, your understanding matters a lot here because you’re not guessing. Let’s just be sure.
Otis Brawley: Yeah, we can talk about that. I lost to the Reverend Al Sharpton.
Paul Goldberg: That’s true. Maybe we should just sort of refer back to that because there’s a couple more points to make. One of them is disparities. Are you finding it, you’re a disparities researcher, are you finding it difficult to talk about disparities to say colleagues or administrators?
Otis Brawley: Yeah. I haven’t found it difficult to talk about disparities. Actually, it may surprise some people. I’m someone who’s always talked about disparities rural versus urban, rich versus poor. I’ve been a huge proponent that socioeconomic status and poverty is what drives a large number of the disparities out there.
Many of the Black/white disparities that I spent the early part of my life documenting are driven because Black people are poor socioeconomically, as opposed to because Black people are biologically different. And one of the things that I’ve been trying to fight for the longest time is so many of my scientific colleagues will remind you that race is a sociopolitical construct and in the next sentence using the same breath, they will start talking about race as if it is a biological construct. And the current rules are that if you talk about disparities and it’s about socioeconomics, or if it’s about region of where people live, and it’s not racial, it’s fine.
And most of the racial disparities are due to socioeconomics, not all, but most. So that’s an area that we can still talk about. It is not an area that’s very well funded now, unfortunately.
Paul Goldberg: Well, that can be fixed. I guess it’s just you to have to be careful how you call it. You cannot call it DEI, but you can call it community outreach and engagement, that’s still-
Otis Brawley: Well, DEI was actually always a little bit different. Many of the cancer centers had an office for DEI and an office for community outreach and engagement. So they were totally different. Community outreach and engagement is something that when I say discovery is part of it, I actually do think it’s half of it and delivery is the other half. Community outreach and engagement is heavily involved in that delivery aspect. I would say delivery of every aspect of cancer control. I still believe that, and I think this past year has told us we don’t focus enough on prevention, risk reduction, and health promotion. We focus way too much on screening and we don’t focus enough on getting the screened people adequate diagnostics and treatment. And then all the way across that spectrum from prevention, risk reduction, health promotion through screening, diagnostics and treatment, it’s a whole continuum. We don’t speak enough about quality.
One of the things that I’ve talked about a lot this past year, and I see it starting to get a little bit more traction, is my hatred of mammogram vans. Mammogram vans are a method of getting mammography into the inner city to poor women or in the rural areas, to poor women, but there hasn’t been enough emphasis on maintaining high quality mammography on those mammograms as compared to the quality in the bricks and mortars facilities. So what I’m saying is a whole bunch of people are very proud of the fact that they were getting these poor people in the inner city low quality mammography. They didn’t say low quality, but they were bragging about how they were getting people in the inner city mammography, now they’re realizing it was lower quality than what they or their spouses would get for themselves at bricks and mortar facilities.
Paul Goldberg: Which is kind of interesting because a study would be required to say that whether this is better than nothing, right?
Otis Brawley: It might be better than nothing. It might be.
Paul Goldberg: It might be. It might not.
Otis Brawley: Yeah. And for those who are wondering how I know it’s lower quality, the American College of Radiology has said that a high quality mammogram involves, if the woman has a previous mammogram, you go find the old mammography to do a comparison. And what we have is a large number of mammogram vans, not all, I don’t want to castigate all of them, but the majority of mammogram vans in the United States, as a policy, don’t try to find old mammography for comparison. They, by definition of the American College of Radiology, are giving low quality mammography.
Paul Goldberg: Fascinating. So let’s talk more just, maybe that’s the last point to bring up. The system that we saw cracking early this year, it evolved. It was not designed from scratch. Nobody would have come up with the system of research that we have now. It has worked so far. It may still be working very well, but if it’s being brought down, and that’s a big if, how do you rebuild? Is this an opportunity to rebuild? Should that be a matter of public discussion? And how do you mark that discussion?
Otis Brawley: Yeah, we do need to talk about rebuilding. Part of the rebuilding is how do we finance it? Part of the rebuilding is how do we organize it?
I actually happen to believe that the National Cancer Institute director needs to be in even more control of the federal cancer program than he or she is now. I want to see the NCI director have much more to do with the VA, much more to do with the Defense Department, much more to do with the Department of Energy.
By the way, the Department of Energy is where a lot of the new radiation therapy equipment is being developed and regulated. We talk about photons, that was last century, and then protons. Carbon ion radiation therapy is one of the things of the future. And there were some great carbon ion studies published in this previous year.
I want to see the NCI and the National Cancer Institute Director more involved with implementation and dissemination of findings, more involved in assessment of quality of care that’s given, more involved with the dissemination of health prevention policy, as well as health prevention education.
Paul Goldberg: Well, how would one initiate that process of rebuilding, of designing… It’s a design build. It’s a design phase.
Otis Brawley: Yeah. The only way that you can do this sort of thing that I’m contemplating is you need to have people in government on both sides of the aisle who are committed to it, who are concerned about it. And it’s not something that can be done in one, two, or three years. This is a movement. And it’s a movement very much like the one Mary Lasker and Sydney Farber were involved with in the 1950s and ’60s that culminated in the National Cancer Act of 1971. But you’re going to have to have… If you look at that whole history, and you know the book Cancer Crusade, which outlines that history, you’re going to have a series of people from both sides of the aisle who are interested in cancer and cancer research, you need people who are committed to research. And I would even go so far as to say this shouldn’t be a cancer effort as much as it should be a health promotion effort.
And it should rally around not just tobacco, but diet and physical activity and the obesity epidemic that’s about to suffocate all of us. One of the things that people don’t realize is one of the huge reasons why medical cost is going up dramatically is because in 1970, 15% of Americans were obese. Today it’s well over 40% and there’s certain subpopulations, Black women, for example, where it’s well over 65% are obese and we are paying for the cost of their care. Now, this is where the fat guy, me, has to tell you we shouldn’t be blaming people for being fat. We need to look at the policies and the social environments that were created that caused that obesity and try to change those policies and encourage policies that I call healthy living or healthy prevention.
That I think is part of this rebuild coming out of what’s been a hard year for the National Institutes of Health, not just the National Cancer Institute.
Paul Goldberg: Well, that is to be continued. I think rebuild is something we need to continue to talk about and continue maybe to spearhead because it needs to happen. The conversations need to be public, I think, more than anything. So that’s kind of-
Otis Brawley: Some of your listeners may not be aware of the fact that the leading cause of cancer in the United States is still tobacco, but just behind tobacco and within the next five years or so, the second leading cause now and soon the leading cause of cancer is going to be the combination of too many calories consumed, not enough exercise to burn off that caloric energy and storing that caloric energy. And we call that storage obesity.
The obesity epidemic is about to become the leading cause of cancer in the United States, and it is already the leading cause of healthcare consumption.
Paul Goldberg: That’s an amazing point. Well, thank you. Let’s do this again next year.
Otis Brawley: All right.
Paul Goldberg: And happy New Year.
Otis Brawley: Happy New Year.
Paul Goldberg: All right. Thank you. Bye, Otis.
Jacquelyn Cobb: Thank you for joining us on The Cancer Letter Podcast, where we explore the stories shaping the future of oncology. For more in depth reporting and analysis, visit us at CancerLetter.com. With over 200 site license subscriptions, you may already have access through your workplace. If you found this episode valuable, don’t forget to subscribe, rate, and share. Together, we’ll keep the conversation going.Paul Goldberg: Until next time, stay informed, stay engaged, and thank you for listening.