Universal Needs: The Role of Universal Health Coverage in Reducing Cancer Deaths and Disparities

By Graham Colditz, MD, DrPH

In the British journal, The Lancet, this week Dr. Karen Emmons and I comment on an analysis of health insurance, cancer mortality and the impact of the great recession 1. This note expands slightly on our comment and adds focus on the Vice-President's Moonshot options to improve access to cancer treatment and outcomes for cancer patients. We note that with over 14 million new cases diagnosed worldwide and over 8 million cancer deaths in 2012 2, there has been renewed focus on the accumulating global burden of cancer. A growing emphasis is now on how to increase the availability of evidence-based prevention and treatment strategies 3. In the US there has also been interest in the role of government-funded health insurance, and the rapidly increasing cost of cancer care. Globally, as of 2009 only 75 of 194 countries had legislation that provided am mandate for Universal Health Coverage (UHC) and only 58 were attaining UHC 4. In the Lancet this week, Majhiben Maruthappu et al draw on data regarding the global economic downturn to evaluate the relation between public sector expenditures on health care, change in unemployment, and cancer mortality 5. Changes in economic status, investment in cancer care and outcomes are complex and difficult to study, but critical if we are to understand the impact of different policy approaches on cancer morbidity and mortality at a population level.

Using the natural experiment created by the global economic downturn, the authors show strong relationships between unemployment and increased mortality from treatable cancers. To evaluate change in unemployment (or in public expenditure on health) in relation to change in cancer mortality, they use multivariable regression analysis assessing change within each country. They draw on detailed cancer mortality data for more than 70 countries from the World Bank and the World Health Organization mortality data from 1990 to 2010. They chose mortality from 6 cancers (prostate, female breast, male and female colorectal cancer and male and female lung cancer) as the primary outcome for assessment of the relation to unemployment changes, and assessed time lags from the recession to account for treatment impact (or lack of treatment) to emerge in the mortality data. They also evaluated changes in relation to an aggregate measure of treatable cancers (breast, prostate, colorectal) and untreatable cancers with 5-year survival less than 10% (lung and pancreas). This focus on cancer mortality avoids the long delays between many prevention or lifestyle changes and cancer incidence 6 more directly addressing the timing of, and access to, treatment and cancer outcomes. A 1% increase in unemployment was associated with a significant increase in the age-standardized mortality from treatable cancer, but no significant relation was observed for untreatable cancers. Grouping countries by health development index did not show important differences. Supplementary Figure S2 plots the unemployment and the trend in cancer mortality demonstrating this significant relationship. The authors conclude that the primary means by which increased unemployment likely has an adverse impact upon cancer mortality is through reduced access to effective care, which universal healthcare coverage can directly address. Further they show that increases in public health expenditure as a percentage of GDP was significantly associated with mortality reductions using these same cancer endpoints and that the results persisted for up to 5 years after increases in public health expenditures.

Studies of unemployment have previously shown relationships with cancer mortality, for example following the Great Depression 7. These new data bring the evidence to contemporary health care delivery and health systems. Furthermore, studies within the US show that cancer patients are more than twice as likely as their same aged peers to file for bankruptcy 8. This risk is particularly higher among those under age 65, who do not yet have access to the only universal health care mechanism in the US (Medicare) and social security (income) protection 8. Socioeconomic gradients have been reported for survival after colorectal cancer in Australia 9 and Sweden 10. Hence, even these broad social programs are not sufficient to buffer the impact of the cost of care. Higher expenditures on cancer care per case is related to lower excess cancer mortality 11. Here the added protection of universal health systems against the adverse effect of recession-induced unemployment adds further weight to the arguments for standards of care being available to all cancer patients, regardless of their personal economic or insurance resources.

These data make a strong case for universal healthcare coverage and its protective effect on cancer mortality, especially during economic downturns. Disparities in cancer outcomes between countries are likely a function of such policies on coverage and allocation of health resources 3,12. Many countries provide such coverage, but many do not, or do so in ways that issues of affordability have not been addressed. Importantly, the current study does not include data from China or India, which together have almost 37% of the world’s population 13. These two countries, each with relatively low percentage of GDP spent on health and limited access to cancer care,14 will no doubt see a dramatic rise in cancer burden in the coming years due to the population age structure and economic development, and the impact will likely be felt worldwide.

There are also persistent disparities in cancer outcomes within countries, and attention is also needed to models of care and coverage. Data examining the impact of cancer treatability on racial/ethnic disparities underscores the importance of policy-focused approaches to close the access gap. Tehranifar, et al., found that there are few disparities in survival rates for cancers that are largely untreatable 15. However, social disparities emerge in situations where the knowledge, technology, and effective medical interventions for controlling a disease exist, allowing individuals with greater access to important social and economic resources (e.g. knowledge, income, and beneficial social relations) to delay and avoid death from that disease 15. Within the United States, integrated healthcare systems demonstrate the ability to eliminate disparities between race / ethnic groups in cancer mortality that have persisted in the general population 16. As the authors note, against a background of rising health care costs, spending restrictions must be accompanied by improvements in efficiency, or it is likely that poorer quality of care will lead to higher mortality levels. Integrated health systems, which provide multi-disciplinary care pathways and focus on quality improvement, are one means of addressing quality and efficiency concerns 17.

In the US, Vice-President Biden has called for renewed efforts to address the burden and growing impact of cancer in the US and worldwide. The new data here add to the evidence that implementing universal healthcare coverage would further reduce the toll of cancer by making it possible to implement evidence-based treatments and prevention strategies that are already in hand. Universal coverage is a key United Nations Development Program Sustainable Development Goal (SDG 3), which has been described as the single most powerful concept that public health has to offer 18.

Although in many countries universal health care coverage overall is seen as an important societal investment, this has not to date been the case in the US. However, it may be very difficult to achieve the promise of improving treatments for cancer without providing coverage to those impacted by cancer. Universal coverage specifically for all cancer patients would meet the IOM recommendation to reduce disparities in access to cancer care for vulnerable and underserved populations 19. Further, universal cancer coverage would likely generate a far faster return on investment than through discovery and development of new therapies that are decades away from being implemented.


References

1. Colditz GA EK. The role of universal health coverage in reducing cancer deaths and disparities. Lancet 2016; http://dx.doi.org/10.1016/ S0140-6736(16)30376-2.

2. Ferlay J SI, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F,. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer, 2013.

3. Sullivan R, Peppercorn J, Sikora K, et al. Delivering affordable cancer care in high-income countries. Lancet Oncol 2011; 12(10): 933-80.

4. Stuckler D FA, Basu S, McKee M,. The political economy of universal health coverage. Montreux, switzerland, 2010.

5. Maruthappu M, Watkins J, Noor MA, et al. Economic downturns, universal healthcare coverage, and cancer mortality in high- and middle-income countries, 1990–2010. Lancet 2016; published online May 25. http://dx.doi.org/10.1016/S0140-6736(16)00577-8.

6. Wei EK, Wolin KY, Colditz GA. Time course of risk factors in cancer etiology and progression. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2010; 28(26): 4052-7.

7. Stuckler D, Meissner C, Fishback P, Basu S, McKee M. Banking crises and mortality during the Great Depression: evidence from US urban populations, 1929-1937. J Epidemiol Community Health 2012; 66(5): 410-9.

8. Ramsey S, Blough D, Kirchhoff A, et al. Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. Health Aff (Millwood) 2013; 32(6): 1143-52.

9. Beckmann KR, Bennett A, Young GP, et al. Sociodemographic disparities in survival from colorectal cancer in South Australia: a population-wide data linkage study. BMC Health Serv Res 2016; 16(1): 24.

10. Eloranta S, Lambert PC, Cavalli-Bjorkman N, Andersson TM, Glimelius B, Dickman PW. Does socioeconomic status influence the prospect of cure from colon cancer--a population-based study in Sweden 1965-2000. Eur J Cancer 2010; 46(16): 2965-72.

11. Stevens W, Philipson TJ, Khan ZM, MacEwan JP, Linthicum MT, Goldman DP. Cancer mortality reductions were greatest among countries where cancer care spending rose the most, 1995-2007. Health Aff (Millwood) 2015; 34(4): 562-70.

12. Berrino F, De Angelis R, Sant M, et al. Survival for eight major cancers and all cancers combined for European adults diagnosed in 1995-99: results of the EUROCARE-4 study. Lancet Oncol 2007; 8(9): 773-83.

13. United Nations Department of Economic and Social Affairs PD. World Population Propsects. The 2015 revision. Key findings and advance tables. Working Paper No. ESA/P/WP.241. New York: United Nations, 2015.

14. Goss PE, Strasser-Weippl K, Lee-Bychkovsky BL, et al. Challenges to effective cancer control in China, India, and Russia. Lancet Oncol 2014; 15(5): 489-538.

15. Tehranifar P, Neugut AI, Phelan JC, et al. Medical advances and racial/ethnic disparities in cancer survival. Cancer Epidemiol Biomarkers Prev 2009; 18(10): 2701-8.

16. Rhoads KF, Patel MI, Ma Y, Schmidt LA. How do integrated health care systems address racial and ethnic disparities in colon cancer? J Clin Oncol 2015; 33(8): 854-60.

17. Shortell SM, McCurdy RK. Integrated health systems. Stud Health Technol Inform 2010; 153: 369-82.

18. United Nations. Gaol 3. Ensure healthy lives and promote well-being for all at all ages. 2015. https://sustainabledevelopment.un.org/sdg3 (accessed March 20 2016).

19. IOM (Institute of Medicine). Delivering high-quality cancer care: Charting a new course for a system in crisis. Washington, DC, 2013.

Be Less Refined: Eat More Whole Grains

Editor's note: This post originally appeared as a Health Beyond Barriers podcast on Minds Eye Radio. It was produced in English, Spanish, Bosnian, Vietnamese, and Arabic through a collaboration with LAMP, Language Access Metro Project.

By Hank Dart

Whole grains. For something so often recommended as part of a healthy diet, they can seem pretty elusive.

We sort of know what they are - but not really.

We know we should be eating more of them - but don't really know how best to do that.

Well, the good news is that whole grains are pretty easy to get a grasp on with just a handful of helpful tips.

But, first, let's try to answer the question:

Why should we even care about whole grains?

As with most diet recommendations, the quick answer to this question is: for your health.

Whole grains are packed with fiber and other key nutrients and have been found to lower the risk of diabetes, heart disease, and certain cancers. They can also help keep weight in check and the digestive system running like clockwork.

On top of this, research has found that whole grains can lower the risk of dying prematurely. Results from a study that followed over 74,000 women and 43,000 men for around 25 years showed that those who ate the most whole grains over that time had a nearly 10 percent lower risk of dying from any cause than those who ate the least.

So, whole grains aren't just an out-of-the-blue recommendation put together by disgruntled dieticians. They can have a real impact on many of the most important - and preventable - diseases.

With that in mind, let's move on to the next big question:

What are whole grains?

Most of us know what grains are. They are things like wheat, oats, rice, bulgur, and millet. This is an incomplete list, but you get the idea.

In their natural state, grain kernels have three key parts - bran, germ, and endosperm. When a grain contains all three of these it is considered a whole grain.

This is different from "refined" or "enriched" grains - like white rice and white flour - that have the bran and germ removed during processing. Bran and germ are rich in many healthy compounds, like fiber, vitamins, minerals, and phytoestrogens.

So, now that what we know what they are, we need to ask:

What amount of whole grains should we eat?

The latest Dietary Guidelines for Americans recommends that at least half of the grains we eat each day should be whole grains. While that's a little ambiguous - for most adults, it translates to about 3 - 4 ounces of whole grains every day. That's the equivalent of around 3 - 4 slices of whole grain bread, or 1½ to 2 cups of cooked brown rice. Every day.

It's not a huge amount, but it's enough that it's important to make sure you have enough healthy whole grain foods on hand. Which begs the question:

What's the best ways to find healthy whole grain foods at the store?

Luckily, we're all probably familiar with a number of healthy whole grains, like - 100% whole wheat bread, brown rice, bulgur, rolled oats, and even whole-grain pasta. So to buy more whole grains, all we need to do is take the extra step of actually putting them in our shopping carts more often.

After these easy-to-find foods, it can get a little trickier to identify healthy whole grain foods, but it's not really that hard.

First, and most important: Let the label be your guide.

Choose foods that have as the first ingredient on the food label a grain that starts with words like "whole grain" or "whole." The first ingredient in the list is the most common ingredient in the food. So, if the label on your breakfast cereal starts with "whole grain oats," then whole grain oats are the main ingredient.

This isn't a perfect system because some foods can have whole grains as a first ingredient but also have a lot of added sugar. Sugary breakfast cereals can be a good example of this. So it's best to choose whole grain foods that also have little or no added sugar.

It's also important not to let the color of a food be your only guide. Some dark breads, for example, may seem to have a lot of whole grains in them, but in fact, may have little in any - getting their color from things like molasses.

Now that we know how to find healthy whole grains, let's ask one final question:

What's the best way to fit more whole grains into our diet?

The one word answer: slowly.

If you've been eating a lot of refined grain foods, moving to whole grains can take some getting used to. Whole grains have an appealing and complex taste, but they do taste different than refined grains. So making the transition slowly gives you time to adjust and build up habits for long term success.

Start by mixing half-and-half white rice and brown rice. Do the same with white pasta and whole-grain pasta - and other grain foods you regularly eat.

Then slowly increase the amount of the whole grain foods. Over time, you may not even miss the refined grain options.

Making healthy whole grain choices doesn't mean giving up completely on the refined grain foods we like. With a little effort, though, we can add more whole grains into our day and give our diets, and our health, a real boost.

And don't we all deserve that?


Additional resources

The Nutrition Source - Harvard School of Public Health
http://www.hsph.harvard.edu/nutritionsource/whole-grains/

Choose My Plate - USDA
http://www.choosemyplate.gov/grains-tips

Dietary Guidelines for Americans 2015 - 2020
http://health.gov/dietaryguidelines/2015/guidelines/

Your Disease Risk - Siteman Cancer Center
http://www.yourdiseaserisk.wustl.edu


References

1. Dukas L, Willett WC, Giovannucci EL. Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women. Am J Gastroenterol 2003;98:1790-6.

2. Ye EQ, Chacko SA, Chou EL, Kugizaki M, Liu S. Greater whole-grain intake is associated with lower risk of type 2 diabetes, cardiovascular disease, and weight gain. J Nutr 2012;142:1304-13.

3. Aune D, Chan DS, Lau R, et al. Dietary fibre, whole grains, and risk of colorectal cancer: systematic review and dose-response meta-analysis of prospective studies. BMJ 2011;343:d6617.

4. Huang T, Xu M, Lee A, Cho S, Qi L. Consumption of whole grains and cereal fiber and total and cause-specific mortality: prospective analysis of 367,442 individuals. BMC Med 2015;13:59.

5. Wu H, Flint AJ, Qi Q, et al. Association between dietary whole grain intake and risk of mortality: two large prospective studies in US men and women. JAMA internal medicine 2015;175:373-84.

6. US Departments of Agriculture and Health and Human Services. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Washington, DC: US Departments of Agriculture and Health and Human Services; 2015.

Photo: Wheat field by François Philipp (CC License, CC BY 2.0)