Who will get rich if I don’t get cancer?

Yesterday’s Times includes an intriguing piece by Roni Caryn Rabin, “Studies Link Daily Doses of Aspirin to Reduced Risk of Cancer.” It summarizes a recent study in The Lancet study by Rothwell and colleagues: “Short-term effects of daily aspirin on cancer incidence, mortality, and non-vascular death: analysis of the time course of risks and benefits in 51 randomised controlled trials.” This article and others suggests that daily aspirin may reduce both the risk of cancer, particularly colorectal cancer, and cancer mortality.

I’m not convinced that you should run out and buy baby aspirin just yet. Offsetting risks of stroke and GI bleeds should be considered.  An accompanying Lancet commentary by Andrew Chan and Nancy Cook notes that neither the Women’s Health Study nor the Physicians’ Health Study—two huge well-conducted studies–found protective effects. Rothwell and colleagues excluded these papers from their analysis because they involved use of aspirin every other day, rather than daily use. This still seems quite pertinent. Other questions have been raised, too.

Whatever the specific merits of daily aspirin, the Times’ concluding paragraph provides what might be the sobering comment in the entire piece:

Some cancer doctors commended the new research, saying said that despite the limitations of the analyses, no other long-term clinical trials of aspirin and cancer are likely to be done because of the enormous expense involved and the fact that aspirin is a cheap generic drug.

This matter-of-fact indictment of our health care system is especially damning because it is so casually delivered, within a story that has nothing ostensibly to do with the usual health policy debate… Here we have a preventive intervention that might significantly reduce cancer mortality. Unfortunately, the medication in-question is dirt-cheap, and already widely-available. So it’s just not profitable for firms to spend the considerable sums required to nail down its effectiveness in preventing cancer.

As Ezra Klein observed in the related context of diabetes, this problem is familiar to advocates of public health. If a firm develops some novel therapeutic to more-effectively treat colon cancer, it will make tons of money. If that same firm discovers a simple way to prevent me from getting cancer in the first place?Well, it will be much harder to capture the same financial returns. So reputable firms don’t pursue many simple innovations that might bring huge social benefits. (Too often, the gap in actual evidence is filled in your local nutrition supplement store, whose shelves are stocked with unevaluated products hawked on late-night TV. That’s another matter.)

This isn’t the usual kind of scandal we ponder when we consider the shortcomings of big pharmaceutical companies. No data are being withheld. No sleazy marketing is undertaken. Nobody at big Pharma is behaving unethically. It really isn’t these companies’ fault. They don’t exist to maximize health outcomes or to minimize the number of life-years lost due to cancer. They exist to earn to a decent return for their shareholders, and to do so in a socially and ethically responsible manner. Their core commercial mission often, but not always, overlaps with broader social goals.

The real problem resides with us, members of the policy community and the interested public. We rely too much on the private commercial calculations of private firms to implicitly set public health policy. And if pharmaceutical companies face systematically biased incentives to pursue treatment advances involving lucrative patentable drugs, the political economy of health care, the prestige structures of medical research, and the American cultural marketplaces include similar incentives that similarly bias our attention and rewards towards acute care and medical treatment rather than prevention or (God forbid) cost-reducing and simplifying innovations.

Cancer patients–allied with the people and the ecosystem that cares for them—comprise a powerful, concentrated, and rightly appealing constituency. Meanwhile, beneficiaries of primary cancer prevention are a diffuse, disorganized constituency. Prevention Interventions from smoking cessation on down are worthy, generally boring non-urgent items on everyone’s list. Senators won’t lose their jobs or encounter shaming images of protesters in wheelchairs when they cut money for state smoking quit lines, flu vaccines, or HIV prevention. You won’t win the Nobel Prize in physiology or medicine for a meta-analysis of baby aspirin studies, for brilliant shoe leather epidemiology studies leading to the back-to-sleep recommendations for SIDS, or for health services research showing that we don’t need to use some costly medicine for something when much cheaper medications will do.

I hope the new PCORI (patient-centered outcomes research institute) does better. The early political signs are mixed. In the knife fight over money to implement health reform, the prevention and public health fund was trimmed with little public opposition or debate. The fund includes some of the most cost-effective spending in the entire new law. Other features of the Affordable Care Act, ranging from the new accountable care organizations to provisions requiring free coverage of evidence-based clinical preventive services, may also provide a better balance of incentives for primary and secondary preventive care.  It will remain an uphill fight because the issue goes much deeper than that, to the basic rewards of our health care financing and research systems.

Yesterday’s Times happen to include another story, “A Cheap Drug Is Found to Save Bleeding Victims” that gives one novel reason for hope. The piece, by Donald McNeil, Jr., discussed rather similar market failures in the domain of emergency medicine. The article concerns tranexamic acid, which is apparently quite useful to help trauma victims.

The article begins with a familar lament:

For months, a simple generic drug has been saving lives on America’s battlefields by slowing the bleeding of even gravely wounded soldiers.

Even better, it is cheap. But its very inexpensiveness has slowed its entry into American emergency rooms, where it might save the lives of bleeding victims of car crashes, shootings and stabbings — up to 4,000 Americans a year, according to a recent study.

Because there is so little profit in it, the companies that make it do not champion it.

In this case, we appear headed to a more sensible ending, in part because American combat surgeons have noticed the drug’s success in British military field hospitals. Dr. David E. Lounsbury, co-author of a 2008 Army textbook, “War Surgery in Afghanistan and Iraq: A Series of Cases, 2003-2007,” tells the Times:

“An old generic doesn’t have any hair-on-your-chest bravado, so we didn’t even take it to the battlefield…”

That the British pioneered it “makes complete sense to me,” he added. “I worked in their hospitals, and they did pretty much everything we did — but much more cheaply.”

We have much to learn from other nations—not just Britain, but many others, too—who operate less-richly-resourced, but hence more disciplined and sometimes more creative medical and public health systems. We don’t much like to learn from others. We prefer to boast: “We have the best health care system in the world.” We actually don’t. Even if we did, our arrogance would still lead us to miss opportunities to improve it.

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