Category: Blog

Cancer in America: History, Progress, and Challenges Ahead

“Its palliation is a daily task, its cure is a fervent hope.”- William Castle, describing leukemia in 1950.

In The Histories, Herodotus records the story of Queen Atoosa of Persia (Atoosa), specifically the unusual illness that struck her in the form of a bleeding lump in her breast rising from a malevolent form of breast cancer. Following the discovery, Atoosa self-quarantined, yet was persuaded by the Greek slave, Democedes, to excise the tumor. The rest of Atoosa’s story vanished from the Histories, but we do know Atoosa’s illness was the first recorded case of mastitis, often interpreted as a symptom of inflammatory breast cancer.

Atoosa’s story, however, was an exception in the fact that cancer was exceedingly rare in the distant past. Despite the existence of ancient medical literature terms for migraines (Mesopotamia), seizures (Egypt), and leprosy-like illnesses (Book of Leviticus), the ancient medical literature on cancer is absent. Explanations for this absence are no mystery. Cancer is mostly an age-related disease; the risk of breast cancer is one in 400 for women under thirty and one in seven for women over seventy. The spectrum of cancers is influenced by changes in modern life, including the decline in stomach cancers following the introduction of modern refrigerating.

Cancer’s name originated in the fourth century BC as karkinos, from the Greek word for “crab.” Cancer, seen as a tumor with swollen blood vessels around it, reminded Hippocrates of a crab dug in the sand with its legs spread in a circle. Hippocrates described illnesses as an unbalancing of the four cardinal fluids: blood, black bile, yellow bile, and phlegm. Inflammation was the excess of blood, jaundice was the excess of yellow bile, and tubercles was the excess of green phlegm. For Galen, the Greek doctor who practiced among the Romans in the second century AD, cancer indicated the excess of black bile. Galen supposed this excess was evident because it came from one other illness: depression. For Galen, depression and cancer were the physical and psychic diseases that intertwined due to the excess of black bile, and tumors were symptoms of deep bodily dysfunction.

Galen died in 200 AD, but his black bile theory of cancer persisted for centuries. This theory lost ground in the sixteenth century; however, due to the confirmation of the non-existence of black bile. New theories about the origins of cancer developed in the seventeenth and eighteenth centuries, including cancer being the result of viruses and organ lesions.

Critically, the modern understanding of cancer began in the eighteenth history, with physicians exploring the association between cancers and chemical exposure. In 1775, Percivall Pott noticed the development of cancers among chimney sweeps and suggested that testicular cancer resulted from soot. In the nineteenth century, Ludwig Rehn observed the association between exposure to aniline dye and bladder cancer of industrial workers.

The twentieth century saw major medical breakthroughs in our understanding of cancer, including Rous’s discovery of the first tumor virus, Papanicolau’s development of the Pap test, the establishment of the National Cancer Institute, confirmation of the link between cigarette smoking and lung cancer, and the development of radiation, chemotherapy, Rituximab, Gardasil, and the Cancer Moonshot program. The history of cancer is a story of discovery, centuries of an inability to understand cancer, and an untold amount of suffering and grief of those affected. I also present this history to highlight the advances in cancer treatment in recent decades and how those developments impact cancer mortality.

In January, the American Cancer Society released its Cancer Statistics 2023 report, which revealed that overall cancer mortality has decreased by thirty-three percent since 1991. Data also revealed that women between the ages of twenty and twenty-four had a sixty-five percent reduction in cervical cancer from 2012 to 2019; importantly, this age range was the first to receive the human papillomavirus (HPV) vaccine. Additional findings in the report include the following:

  • A three percent annual increase in prostate cancer from 2014 – 2019.
  • A more than fifty percent decline in mortality rates from cancer for children from 1970 to 2020.
  • Persistent disparities in prostate cancer mortality rates among Black men, which are two to four times higher than those in any other racial or ethnic group.
  • A continual decline in cancer mortality from 2019 – 2020 (1.5 percent), despite disruptions from the COVID-19 pandemic.
  • Lung cancer incidence decreased on an annual basis for both women (1.1 percent) and men (2.6 percent).

The overall decline in cancer mortality in the United States results from reductions in smoking, advances in treatment, and increased early detection for some cancers, translating to 3.8 million fewer cancer deaths from 1991 – 2020. Significant declines in mortality rates from childhood cancer result from improvements in treatment and high participation in clinical trials for the most common cancers (e.g., leukemia), especially among children. Though a monumental achievement, the fight against cancer ensues and will require intense collaboration among policymakers and leaders in the medical sector to fund the development of more effective treatments and, eventually, a cure. Equally important will be a push to close inequities in treatment, as the risk of overall cancer death was twelve percent higher in Black individuals than White individuals; mortality rates in Black women remain about forty percent higher than in White women, despite a lower incidence of cancer.

Leadership from the White House is and will be critical in eliminating cancer. In 2022, the Biden Administration relaunched the Cancer Moonshot Initiative, committing the United States to reduce the death rate from cancer by half by 2047. The Administration also called on Congress to fund the President’s proposal to create the Advanced Research Projects Agency for Health (ARPA-H), a program aimed at further innovating health research, starting with a focus on cancer and Alzheimer’s. Numerous accomplishments followed the relaunch of the Initiative, which include over $200 million in grants issued by the Centers for Disease Control and Prevention (CDC) to advance prevention and screening, a large national trial launched by the National Cancer Institute to develop effective blood tests to detect one or more cancers, implementation of the PACT Act to expand health care access to veterans exposed to toxic burn pits, and proposed rules by the Food and Drug Administration to prohibit menthol cigarettes and flavored cigars.

Importantly, expanding health care coverage to victims of carcinogens from environmental disasters will be a critical prevention and treatment strategy. Recent environmental disasters such as the train derailment in East Palestine, Ohio highlight how victims of these disasters are at risk of developing cancers if federal officials do not respond quickly. The train derailment in East Palestine left a trail of toxic chemicals, including cancer-causing vinyl chloride. Lawmakers in Ohio and U.S. Department of Health and Human Services officials are calling for the use of Section 10323 of the Affordable Care Act (ACA), which promises Medicare to Americans exposed to certain environmental health hazards. Section 10323 was created in the wake of a vermiculite mine that spread deadly airborne asbestos in Libby, Montana, killing hundreds and sickening thousands. Following the disaster, former U.S. Senate Max Baucus (D-MT) inserted Section 10323 into the ACA to cover the whole community of Libby with Medicare. Similar conversations have arisen about providing Medicare coverage for the whole East Palestine Community, though legal experts, including Lawrence Gostin of Georgetown University Law Center, believe implementing this provision in East Palestine would be unlikely unless the federal government established a pilot program to ensure broader coverage. Even if the provision were to fail to cover the residents of East Palestine, the push to increase Medicare coverage for citizens knowingly exposed to carcinogens from environmental disasters is an important policy component the Biden Administration and future administrations should consider incorporating into their health care strategies. The fight against cancer, as illustrated by this history, has made significant progress. Much work remains to be done, and good policy can ensure the accomplishment of that work.

The Rise of Ozempic & Prescription Weight Loss Drugs

Ozempic is an injectable drug used to lower blood sugar in adults with type 2 diabetes and to lower the risk of heart disease. But over the past few months, Ozempic has been hailed as a “miracle drug” by celebrities, tech moguls, and social media influencers alike. In September 2022, an article from Variety described how Ozempic injections were used by celebrities across the industry to lose weight ahead of “major events”, with the most enthusiastic users being non-diabetic. Nevertheless, Ozmepic’s rise in popularity is not limited to Hollywood. As of today, TikTok videos with #ozempic have been viewed more than 637.6 million times and will likely continue to rise. While many videos feature prominent influencers on the app, dozens more feature ordinary users documenting their experience taking Ozempic with hashtags such as #ozempicjourney.

The recent popularity surge of Ozempic also coincides with the Food and Drug Administration’s (FDA) approval of another weight-loss drug known as Wegovy in 2021. Similar to Ozempic, Wegovy is a semaglutide injection intended to facilitate weight management in overweight or obese adults. By mimicking hormones that regulate food intake in the brain, Wegovy works as an appetite suppressor. The FDA’s approval of Wegovy resulted in higher demand for the drug and led many to seek out similar weight-loss prescriptions. The rising demand of these drugs led to a shortage of Ozempic in the United Kingdom in May 2022, followed by another shortage in the United States this past February. An article in Time magazine found that over five million prescriptions for Ozempic were written in 2022 alone, along with similar drugs. And in a study published by the New England Journal of Medicine, researchers found that adults with obesity but no diabetes had weight reductions of 5% or more after taking Ozempic for several weeks. 

Beyond its popularity on social media, Ozempic has also been known to have various side effects, including possible thyroid tumors, pancreatitis, kidney failure, and vision changes. One of the most documented side effects is referred to as “Ozempic face”, which can result in fat loss from the face and the appearance of sagging skin due to drastic weight loss. In addition, it is necessary to continue taking Ozempic indefinitely to maintain the weight loss. 

Currently, it is unclear how drugs such as Ozempic and Wegovy may affect people who are of normal weight or fall outside of the FDA’s criteria. While doctors have warned about the dangers of off-label use, the shortage of available prescriptions has made it more difficult for people with diabetes or obesity to have access to it. However, the rising popularity and recent shortages of Ozempic has led to a broader conversation on health and our relationship to food. In recent news, Weight Watchers has announced their acquisition of a telehealth company known as Sequence, which connects patients with doctors who can prescribe Ozempic and other drugs such as Wegovy and Rybelsus. Going forward, it may be useful to consider how the prescription of weight-loss drugs can be improved to provide affordable access for those with certain medical conditions and to educate the public on its effects. 

Gender-Inclusive Health Care Means Access to Gender-Affirming Care

Gender-affirming care is a form of healthcare that includes medical, surgical, mental health, and non-medical services for transgender and nonbinary people. Early-gender affirming care is crucial to the well-being of transgender and nonbinary children (TGNB) and adolescents because it helps with social transitions and can provide resources while navigating the complicated American healthcare system. Overall, the gender-affirming care model affirms diversity in gender identity and highly focuses on the needs of each individual

Gender-affirming care is important. In the United States alone, an estimated 1.4 million people identify as transgender, and 1.2 million adults identify as nonbinary. Studies have shown that receiving gender-affirming care has been associated with lowering nearly 73% of the odds of suicidal thoughts among TGNB. Many prestigious medical organizations such, as the American Academy of Pediatrics, the American Medical Association, and the Endocrine Society, support gender-affirming care

Unfortunately, a number of bills have been introduced in the last two years attempting to limit, ban, or criminalize access to gender-affirming treatment for minors. Republican state senators have taken several measures to limit access to gender-affirming care by banning critical components of this care such as puberty blockers, hormone therapy, and surgeries for minors. For example, the “Arkansas Senate passed a bill prohibiting doctors from treating transgender, and nonbinary minors (TGNB) with puberty blockers and gender-affirming surgery…” To that end, Arkansas is not the only state to propose these types of bills. Just last month, Tennessee’s Senator Jack Johnson opened a discussion on a bill he is co-sponsoring to limit gender-affirming care such as hormone therapy and other medical services for TGNB. Moreover, there is recent news that Georgia Congresswoman Marjorie Taylor Green will introduce a bill calling gender-affirming care for minors a felony. Congresswoman Green called gender-affirming care “a new-disturbing ideology” that is making billions from “confused children who believe they are transgender.” Several states across the country have acted to restrict such care for minors

Although the ideology behind restricting gender-affirming care for minors was due to minors not having the “mental capacity to make such decisions,” republican senators are now also reaching out to take away access to affirming care from low-income people, including adults. Senator Jackson is also backing the HB1215 bill which prohibits Tennessee’s Medicaid program from working with healthcare insurance companies from covering gender-affirming care. Until this year, most proposed legislation targeted people under 18, but now some block Medicaid from covering it for all ages

While the opposition against gender-affirming care started to “protect” youth, now it is targeting all the transgender and nonbinary communities. Transgender rights advocates view bans on gender-affirming care as part of a broader attack on transgender rights. To have gender-inclusive health care means to have gender-affirming care as an option for transgender and nonbinary people.  

Threatening Affordable Access to Abortion: Mifepristone, The “Abortion Pill”

On January 3, 2023, the U.S. Food and Drug Administration (FDA) updated its risk evaluation and mitigation strategy (REMS) for reproductive health relating to “the abortion pill,” mifepristone. Mifepristone is a pill, used in combination with misoprostol, to terminate intrauterine pregnancies no later than 10 weeks past the individual’s last menstrual period. Additionally, it may be used for early-stage miscarriage management, and management of 2nd and 3rd trimester pregnancies where the fetus is no longer viable and has died before birth.

In 2011, the FDA implemented the Mifepristone REMS Program to place restrictions on the drug’s distribution and use. Specifically, it implemented an in-person dispensing requirement where the drug may only be dispensed in a clinic, medical office, or hospital through direct supervision of a certified clinician. This prohibited mifepristone from being sold in retail pharmacies or through the mail. The drug’s restrictions were criticized for creating barriers to patient access for medicated early-stage abortions and management of pregnancy loss. Additionally, those that opposed the restrictions claimed its implementation disproportionately harmed minority groups and communities that faced structural barriers to reproductive care. This accelerated throughout the COVID-19 pandemic, and advocacy efforts spearheaded by the American College of Obstetricians and Gynecologists pushed the FDA to reform the REMS program.

In 2021, the FDA completed a review of the REMS Program and set to modify the restrictions to help improve patient access and create efficiencies in health care delivery. Implementations of the Program’s modifications were halted until the FDA approved mifepristone’s updated prescription information by their manufacturer, resulting in the implementations officially going into effect on January 3, 2023. The FDA’s update removed the in-person dispensing requirement and a new pharmacy certification process was added that allows certain retail pharmacies to dispense mifepristone directly to patients who have a prescription. Additionally, given the impact of the Dobbs decision, this update will affect clinic practices based on the abortion laws and regulations of the state that the practices reside in.

Following the FDA’s updated policy, stores like Walgreen and CVS planned to offer mifepristone through their pharmacies in the states that legally allow abortions. However, on March 3, 2023, Walgreens publicly stated it would not be dispensing mifepristone in 20 states after being threatened by public officials. Headed by Missouri Attorney General Andrew Bailey with other attorney generals from Republican run states, a warning letter was issued to CVS and Walgreens on February 1, 2023. The letter alleged abortion pills sold through the mail would be federally illegal based on the Comstock Act, claiming the Act includes language that prohibits the mailing of articles designed to prevent conception or induce an abortion.

In early January of 2023, the Department of Justice (DOJ) noted that the Comstock Act does not prohibit abortion pills being mailed when those sending the pills lack intent that the drugs will be used for illegal purposes; however, Bailey argued against the DOJ and claimed the text of the Act is what governs, not “the Biden administration’s view.” Bailey further threatened CVS and Walgreens with civil litigation through either state attorneys or private citizens.

Walgreen’s announcement affects states where medication for abortions is legal, such as Alaska, Iowa, Kansas, and Montana. In a statement, Walgreens specified that once it was certified by the FDA to sell the abortion pill, the company will dispense the drug complaint to state and federal laws. The threat to selling mifepristone has opened a larger question about state authority in regulating FDA approved drugs and medicated abortion access. Since Walgreen’s announcement, activists have pushed to boycott Walgreens. Currently, there are 2 lawsuits arguing that states do not have the authority to regulate FDA approved drugs; one targeting a state’s restriction on abortion pills, and the other challenging West Virginia’s state abortion ban. If the court rules in favor of the plaintiffs in these cases there may be grounds to claim that FDA policy trumps state law on abortions, but more time is needed to determine the outcome of bans on the abortion pill through state and federal action.

“Ending” the Public Health Emergency Will Further the Suffering of Elderly Individuals

The elderly population (those 65 and older) in the U.S. continue to face a disproportionately negative impact from the COVID-19 epidemic. While elderly individuals account for only 16% of the total U.S. population, they represent close to 90% of recent COVID-19 deaths in just the last few months. Throughout 2022, deaths among elderly individuals routinely spiked as the year progressed. The number of deaths among elderly individuals increased by 125% between April and July; a disturbing trend continuing to October, which experienced over 2,000 more deaths than in April. Even with these spikes in COVID-19 deaths among elderly individuals, the Biden Administration announced that the COVID-19 Public Health Emergency will end on May 11, 2023. The proposed end of this incredibly important federal program will be devasting to elderly populations as it will likely limit access to crucial COVID-19 prevention and treatment.

The end of the COVID-19 Public Health Emergency will create cost barriers for both testing and vaccines. Elderly individuals under traditional Medicare will no longer have access to at-home tests free of charge and even those with Medicare Advantage plans are not guaranteed to receive them for free. When it comes to PCR and rapid tests administered by physicians, elderly individuals under both traditional and Medicare Advantage plans may now experience cost-sharing fees from their testing visits. While access to free COVID-19 vaccines will still be available after May 11th, the supply of federally purchased vaccines will eventually disappear and many pharmaceutical companies will commodify the vaccine, creating cost barriers that will decrease population-wide immunization rates.

The commodification of the vaccine and the new cost barriers in testing will likely lead to a surge in COVID-19 cases in the U.S., increasing the need for treatment. Unfortunately, elderly individuals receiving Medicare will now face cost-sharing fees for COVID-19 treatment due to the end of the Public Health Emergency. This cost barrier will lead to many elderly individuals not being able to access treatment, including the drug Paxlovid. Studies have demonstrated that Paxlovid can reduce COVID-19 hospitalizations in vaccinated elderly patients by 73%, along with reducing deaths by 81% in other studies.

Clearly the public health threat of COVID-19 has not ended, as the death rates among elderly individuals remain high. It is crucial that the Biden Administration revoke this proposal and extend the Public Health Emergency well beyond May 11, 2023. This proposal displays the federal government’s unjust intent to shift the financial responsibility of controlling the COVID-19 epidemic in the U.S. onto patients, many of whom lack the means to financially take on this tremendous unresolved burden. This will undoubtedly cause further harm to elderly individuals, who may include our parents, our grandparents, and our neighbors.

The Dangers of E-Cigarette Marketing: The Fight to Protect Our Youth

It comes as no surprise that children are heavily influenced by the social makeup of their environment, especially as they enter adolescence. Today, parents face a particularly unique fear with peer pressure: the fear that their children will develop an addiction to nicotine. Peer pressure is a contributing factor influencing children to pick up an e-cigarette, or vape, for the first time. Additionally, there is a plethora of marketing tactics purposefully utilized by e-cigarette manufacturers that influence America’s youth to buy these products. Some of these tactics include emotional appeal, targeted advertisements, social media, and even “fun” flavors and colors. In fact, the original tactics used by the tobacco industry (“Big Tobacco”) are so effective that many e-cigarette manufacturers have taken over the exact same trade secrets to advertise their products. For example, e-cigarette companies have been known to implement emotional appeal to attract teens to their products, including portraying friendship, happiness, sex, and success.

Perhaps even more alarming is the success the vaping industry has seen in using colorful, eye-catching packaging full of cartoon characters and sweet flavors. These advertisements directly target adolescents and appeal to children’s affinity to candy. Further, e-cigarette companies have found massive success in marketing to teens through social media platforms. The use of fun flavors, prestigious celebrities, and persistent marketing on youth dominated apps all exert influence on viewers’ decision to vape. Notably, this past September of 2022, Juul Labs Inc. reached a settlement agreement to pay $438.5 million to thirty-three states to resolve claims that it marketed addictive products to children. The agreement now prohibits Juul from marketing to youth and even bans advertisements featuring cartoons or anyone under thirty-five years old—but what about the rest of the manufacturers?

In 2020, likely in response to the growing fear by concerned parents, the Food and Drug Administration (“FDA”) began requiring all e-cigarette products to apply for and receive regulatory approval. This announcement led to nearly 8 million applications by distributors and manufacturers. Given the length of the approval process, regulatory delays by FDA have allowed for the e-cigarette products to stay on the market for years while waiting for review and authorization, further paving the way for the youth vape epidemic America faces today. Over two years after the established FDA requirement, the review process is ongoing and flavored vapes are still widely available on the market.

While FDA sorts out its administrative delays, families are filing personal injury suits against e-cigarette manufacturers. Juul currently has a number of pending lawsuits filed against it in relation to severe lung conditions, stroke, seizures, and nicotine addiction. These claims are made possible through product liability, which holds a manufacturer, distributor, or seller of a dangerous product financially liable for injuries caused by their defective product. Although legal success is possible, this litigation can be a time-consuming and expensive way to reach justice for those injured without addressing the initial problem of vape accessibility among the youth.

Perhaps the best solution here lies in implementing stringent regulations at the federal level, which would preempt any loose state laws. Policymakers should aim to halt children and teens’ access to vapes while maintaining other effective ways for adults to quit smoking. The youth of America deserve to be protected from this kind of harmful marketing that can detrimentally impact their health and their future as a whole. In the modern age of technology, marketing influence is practically inescapable. Thus, legislators and policymakers alike should step in and assist FDA to protect American youth now before it is too late.