Author: Guy Cheatham

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.

NAEP, Literacy, and Health Outcomes: Why Health Law and Policy Leaders Must Focus on Literacy as a Vehicle for Patient Welfare and Decision-Making

The National Assessment for Educational Progress (NAEP) is the largest nationally representative and continuous assessment of what students throughout the United States know and can perform in specific subjects. NAEP is one of several tools guiding state and federal lawmakers as they draft legislation and craft strategies for educational improvement. This assessment, delivered every two years, was delayed in 2021 due to the COVID-19 pandemic, meaning this assessment now gives policymakers, education leaders, and other concerned stakeholders a sense of how the COVID-19 pandemic impacted student achievement.

In October, the latest NAEP results were released. Fourth-grade reading averages are lower than all previous assessment years going back to 2005, and the 2022 average mirrors the 1992 average. Eighth-grade reading averages are the lowest the nation has seen since 1998, and not significantly different compared to 1992. Importantly, the years between 1992 and 2022 show little variance in reading proficiency, and inequities in reading proficiency persist. Policymakers and education leaders are responding by investing in research-backed solutions, like diversifying the teacher workforce, implementing the science of reading, and increasing access to high-dosage tutoring. These investments have and will continue to prove effective, but education policy leaders and practitioners should not be the only parties responsible for this task. Health law and policy leaders should also prioritize improving literacy rates as there is a direct relationship between literacy and health outcomes.  

Literacy proficiency is critical to success, both in the classroom and later in life. Additionally, literacy and health are closely connected. Limited literacy is a barrier to accessing health information, proper medication use, and utilization of preventative services. In terms of medication, medication management capacity (MMC) is critical for identifying medications and understanding how they should be taken. MMC is critical for patients dealing with temporary and chronic ailments and diseases. Research confirms the significant association between low literacy and difficulty identifying medications. One example connecting literacy and MMC pertains to the use of asthma treatment. Determining the relationship between literacy and asthma knowledge and self-care, researchers found that eighty-nine percent of patients reading at less than a third-grade level had difficulty using a meter-dosed inhaler (MDI) properly. In contrast, just less than half of patients reading at a high-school level struggled using an MDI. Research also confirms that patients with low literacy skills are more likely to ask fewer questions about their medical care, which may affect their ability to learn about their medical conditions and treatments.

Reading and health outcomes go hand in hand. Investing in literacy is a key strategy for ensuring stronger health outcomes in the long term, and healthcare practitioners are pushing for the healthcare field to increase involvement in literacy. In Ohio, healthcare leaders speak about the continued difficulties patients face in understanding the condition of their health due to limited literacy, and those leaders are making investments to eliminate the barriers low literacy creates in healthcare. Kettering Health, a healthcare non-profit, invested $60,000 to start an Imagination Library Program in Green County, Ohio. Kettering’s involvement in early literacy sets an example for other states to follow and exemplifies the role health law and policy leaders can play in ensuring better patient outcomes.

A patient’s ability to make critical healthcare decisions rests on reading proficiently. Healthcare law and policy leaders should pay close attention to what NAEP reveals about the state of literacy, partner with state and local education leaders to craft early literacy strategies and convince lawmakers to prioritize early literacy investment. Literacy is a key vehicle for health equity. If healthcare leaders do not respond quickly to last month’s NAEP results, barriers to accessing health information and proper care will persist.