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Director’s Innovation Speaker Series: Cancer Control in the 21st Century with an Emphasis on Risk Reduction


JOSHUA GORDON: Welcome everyone we will get started in just a minute, as people come in from the waiting room.

Hello again and welcome. I’m Dr. Joshua Gordon. I'm the director of the National Institute of Mental Health and it is my pleasure to welcome you all here to this edition of the Directors Innovation Speaker Series.

Today I am very pleased to welcome Dr. Otis Brawley, who is going to be talking to us about Cancer Control in the 21st Century: The Role of Behavioral Health.

Before I introduce Dr. Brawley, though, I do want to go over some housekeeping details. First of all, if you require technical assistance, please use the Q and A box to speak to the production staff. You can also at any time during the webinar, type your question for the presenter into the Q&A box. I will be selecting from the questions that are entered in the Q&A box at the end of the talk, to ask questions of Dr. Brawley.

I want to point out that there are two ASL interpreters who are joining us today. They will be switching off. So make sure you can see them on your screen, if you should need their services.

Finally, I will mention this webinar is being recorded and the recording will be made available in the coming weeks on the NIMH website. So if you have friends, family, loved ones, who want to hear the talk and weren’t able to join today, please do look for the recording in a few weeks on our website.

With no further ado I would like to introduce our distinguished speaker today. Dr. Otis Brawley is the Bloomberg Distinguished Professor of Oncology and Epidemiology at Johns Hopkins. He is an authority on cancer screening and prevention and leads a broad interdisciplinary research effort focused on cancer screening and prevention and cancer health disparities at the Johns Hopkins School of Medicine, the Bloomberg School of Public Health, and the Sidney Kimmel Comprehensive Cancer Center.  His work has focused over the years, on how to close racial, economic, and social inequalities in the prevention, detection, and treatment of cancer.

Dr. Brawley, after attending medical school at the University of Chicago, did his medical internship at Case Western before being directed by a mentor to join us here at the NIH where he did his oncology fellowship. And subsequently served as both the program director and an investigator and eventually a senior investigator, at the Clinical Center, doing really seminal work on both clinical research on cancer, and in particular prostate cancer, but also learning about and eventually becoming an expert in, epidemiology along the way.

From his early days, Dr. Brawley paid close attention to disparities in cancer rates, in cancer care, and we're going to hear some about that today.

In 2001 he left, graduated if you will, from NIH, to go to Emory where he was the director of the Georgia Cancer Center at Grady Memorial Hospital in Atlanta. He served as professor of hematology, oncology, medicine, and epidemiology, until 2018, when he went to Hopkins and assumed his current position.

It is really my pleasure to have Dr. Bawley here today. Dr. Brawley, take it away.

OTIS BRAWLEY: Thank you, Dr. Gordon. I want to also thank all of the people behind the scenes who make this happen today. It is really a pleasure to be here and talk with you. I need to share my screen, okay perfect. I am a medical oncologists and epidemiologists.  I'm going to talk a great deal about cancer and a lot about how we can control cancer and how that intersects with behavioral health. First, I should give you my disclosure, I do consult for number of companies and serve on boards. This talk has nothing to do about those activities, however.

I do want to tell you that I was taught from an early age that one should label things what you know, what you do not know, and what you believe, and one should question all things but question what you know more so than anything else.  I think these are good rules in the assessment of healthcare. As a talk over the next 40 minutes or so about disparities and about how we can control some of those disparities in cancer.

I am an epidemiologist, and we use a lot of absolute numbers, percent’s, rates per 100,000 in trends. I will try to explain those as we go through this.
We are going to discuss trends in cancer death rate over the last 30 years. Discuss disparities as they exist today and some solutions. We are going to define reasons for those trends and opportunities to reduce risk of cancer. And look and give attention to behavioral health and education, which I think is the key.

The role of culture and cultural change in practicing health behaviors are questions that we should address as is the intersection of mental health and behavioral health and the role of mental health and tobacco use, alcohol use, overeating, and energy balances. As we go through the top you will see those three things are major causes of cancer.

If you go to 2019 which I will call the last year of normal times before COVID, these are the numbers of people dying of the 10 leading causes of death in United States. You will see cancer was number two at just under 600,000. Heart disease was about 648,000. Heart disease or cardiovascular disease was number one and cancer was number two. I should point out that heart disease and cancer rates are going down, and within the next five years or so, cancer will be the leading cause of death in United States surpassing heart disease.

Let's talk about the cost of American healthcare. Healthcare in 2019, the last year of normal time, cost Americans $3.8 trillion. For every dollar spent in the United States in 2019, 17.7 percent of our gross domestic product was spent on healthcare. Let's compare that to the 1.69 trillion spent on food. Less than eight percent of our economy was spent on food while 18 percent was spent on healthcare. We spent a lot of money on healthcare.

At 17.7 percent in the United States, compares to another of other countries in a way that really sticks out. Germany is the second most expensive country in the world for healthcare in 2019 at 11.7 percent. You can see many countries that we tend to compare ourselves to, our down in the 10’s. Ten percent, sometimes 11 percent.

The American healthcare system is incredibly inefficient, and we do not follow the science. We use treatments and interventions that are lucrative sometimes and not necessarily proven effective. We often times ignore simple and inexpensive and effective interventions.

Don Berwick, who ran CMS, is fond of saying 30 to 40 percent of American healthcare is waste or fraud. This is all a plea for rational use of healthcare, not the rationing. So many politicians want to scare us with rationing. We need to be talking about rational. There's a lot of medical gluttony that is ongoing with screening test with no value, treatments that are not needed, laboratory and radiologic testing that is done for various reasons that are all illegitimate.

The emphasis is often too much on diagnosis and treatment of disease and not enough on prevention, or I will call it risk reduction. Our mindset is so on treatment, let me give you a very brief example. If you go to an interaction between an attending physician who has a third-year medical student with him or her. They have a man in front of them who is 55 years old and has newly diagnosed with mild to moderate hypertension. That physician very often times will prescribe Lisinopril, perhaps 10 mg a day, and say come back in 10 to 14 days and let’s check your blood pressure.

If you are in France and you have a physician and a medical student and a patient of that age, the exact same thing will happen. If you ask the American medical student why Lisinopril was prescribed, the American medical student will look at you like you were crazy because and say, it was to treat his high blood pressure. If you ask the French medical student why was Lisinopril prescribed, they will explain it is to lower the patient's risk of cardiovascular disease and kidney disease.

From the outset, we in American medicine are taught to make a diagnosis and treat even when we do things to prevent. I would even say when we lower cholesterol, which is obvious prevention, we are usually thinking about treating someone's cholesterol and not preventing their heart disease.

In the United States we have a healthcare system where some people consume too much healthcare, some too little, and this creates disparities. Too much healthcare can kill, and too little healthcare, obviously can also kill. We can decrease our waste and improve overall health, again rational use of healthcare not rationing of healthcare.

The true cost of healthcare, I've given the economic cost, let me give you some examples of some calculations that we did while I was at the American Cancer Society to try to estimate the cancer desperate population. How many people die needlessly every year from cancer? How large is it? What does that population look like? Where does the population live?

To start with, we found a very interesting observation. That is the more education people have, the less likely they are to die from cancer. If you look on the far left, these are rates per 100,000 for men in light blue, women in purple. You can see the death rate for people who are either high school graduates or high school dropouts. Look on the far right and you can see the death rate for people who are college graduates or beyond. There is a dramatic decline in risk of death from cancer with education in the United States.

We use this fact, every year the American Cancer Society estimates how many people are going to be diagnosed and how many people are going to die from cancer in the United States. We simply did some manipulations of the data to estimate how many people would die if every American had a risk of death of college graduates. It turns out if all Americans had the risk for a college graduate for death, instead of 600,000 deaths, there would be 22 percent less or 132,000 of those 600,000 deaths would go away if everybody had the risk of death as a college graduate. Think about that, that is not a new drug, not a new treatment, not a new screening anything, that is just getting every human being what college educated Americans get. 132,000 deaths per year would go away.

Some of that would involve not smoking and of course you have to start 30 or 40, 50 years earlier with that, so you couldn’t just do it. If I was Czar of the world, I couldn’t just do it with a snap my finger but it could be done with societal change. As a matter of fact, until the COVID vaccine, by the way, I could not come up with a drug that prevented $132,000 deaths in a year. The COVID vaccine has probably prevented 200,000 to 300,000. It is that good and we still can’t get people to take it.

Now this 22 percent of 600,000, 132,000 avoidable deaths – by the way, the United States leads the world in this statistic. We try to figure out preventable deaths in all of those other countries, higher proportion of American cancer deaths are preventable then in any Western European country. The majority of these preventable deaths, by the way, almost 80,000, are among white people. You see, when I started my career in epidemiology over 30 years ago, we called it minority health, and that we call the special populations health, and then we started calling it health disparities, under David Satcher, and now health equity. All during that time we were talking about minorities. Now we are starting to realize we are talking about whites as well.

Do not get me wrong, a black person is more likely to suffer from cancer health disparities, but the absolute number of blacks suffering from it is less than the absolute number of whites. By the way these whites live disproportionately in the southern United States. Health disparities is no longer just a racial issue.

Sorry for the graphs. In the year 1900, age adjusted to the population in the U.S. in 2000, there were 64 cancer deaths for every 100,000 Americans. That rose to 215 deaths per 100,000 in 1991, the peak year, and it has gone down dramatically. A 31 percent reduction from 1991 to 2018. This is due to wise early detection, especially in the arena of colorectal, breast and cervical cancer. Dramatic improvements in treatment, even in such things as lung cancer. But a large part of it is prevention and risk reduction, especially tobacco control. Indeed, how can we provide adequate high-quality care to include preventative services to populations that so often do not receive it, is I think, the most important question we can ask in American medicine right now. And keep in mind that unnecessary care interferes with our abilities to provide necessary care.

Medicine is a precious resource and the more we use that resource for things that don’t matter the more we deprived that resource from things that do matter. The provision of unnecessary care is a cause for health disparities.

As an epidemiologist, what I want to do is study populations that identify interventions that need to be employed and identify the populations where they can most efficiently be employed.

Now this is equality where every population get the exact same thing. This is equity where we identify a population that needs a little bit more. That population may very well be white people in Appalachia, or it may be a Hispanic group in Los Angeles, but there's going to be populations that need a little bit more and populations that need a little bit less. That is the new health disparity research identified now.

When we define populations, they can be defined in a number of ways from sex and gender, race, and please keep in mind races the sociopolitical categorization, it is not a biological categorization. Culture, family, tribe, area geographic origin. By the way, there can be genetic differences by area of geographic origin but not by race, and people frequently confuse the two. Socioeconomic status, we can have an interestingly genetic differences in population by socioeconomic status. I will have an example of that in a bit. And region of residence which can influence how people get healthcare or how people get disease.

Looking at that sociodemographic category called race, this is the death rate per 100,000 from 1990 to 2017. You can see Blacks have had the greatest decline, but they started out higher than any anyone else. Whites, you will see there is a disparity between whites and Native Americans and whites and Hispanics and whites and Asians, that we do not frequently talk about. This is the disparity by race, and you can see and if you are really optimistic, if you can extend those lines in your mind up to about 2035, everything starts coming together. They come pretty close together.

Speaking of death rates per 100,000, this is the death rate for whites in blue, blacks in red, starting in 1975, and because of an executive order from Ronald Reagan, we started collecting data on Hispanics, Native Americans and Asian Pacific Islanders and started publishing them and 1990 after the 1990 census. I want you to note that there was no black-white disparity in death rate from breast cancer in the 1970s. The disparity only happened after we learned how to screen and treat for the disease. And then we had the disparity. The disparity is greater today than it has ever been.

This is United States as a whole. I want to point out there are seven states in the United States where there is no black/white mortality disparity. This is the United States as a whole, but there are seven states where there is no black/white disparity. Six because they have very low death rates for black-and-white women, and then there is West Virginia, which is a problem for black-and-white women with very high death rates.

There are six states that have no black/white disparity for very good reason. There are actually 12 states where white breast cancer mortality is higher than that of black women in Massachusetts. This is partly because of the Massachusetts miracle, that is Mitt Romney’s Romney Care, and the provision of medical care it does reduce risk of death. But it also means people are getting a lot of things to help to reduce risk of death. We will talk more about that because many of them are going to be behavioral.

I want to note, I talked about how the largest group of people who suffer from cancer health disparities are white. I want to note that people living below the federal poverty line, 9 percent of whites, 21 percent of blacks, but look at the absolute numbers here. These are people living in poverty in the United States, and you can see that the number of Hispanics living in poverty is greater than the number of blacks, then the numbers for Asians and American Indians and Alaskan natives.

Poverty and low socioeconomic status have a lot to do with whether or not one lives or dies from cancer.
This is a very busy slide. This was taken from the National Cancer Institute Intermural Research. This is a publication from two years ago. Look at all cancers. The solid line are people from low income counties in the United States and the dotted line are people from high income. You can see since 2000, people with high income have had a dropping of their cancer death rate much faster than the drop for people of low income. You can see it with people age 25 to 64, these are people who qualify for Medicare because they are over 65. You can even see it among Medicare beneficiaries.

Look at lung, breast, colorectal, pancreas, liver, almost every cancer except for pancreas and liver, the poorer people are not having the decline as do the wealthier people. And for every cancer, poor people do not do as well as wealthier people.

How can we provide adequate high-quality care to include preventative services to populations that so often do not receive it, is an incredibly important question. There is an over emphasis in American medicine, this is my opinion, on screening and treatment at a cost of reduced deficits on prevention and risk reduction. Prevention and risk reduction can actually be cheap. Resources are over consumed for interventions and less impact and diverted from where they can have the greatest of impacts.

Let's look at the avoidable causes of cancer as I make a plea for prevention. Here is the American Cancer Society Epidemiology group, when I led it, calculating the avoidable causes of cancer. We thought 42 percent of all cancers, 659,000 cancers per year are avoidable if we could control cigarettes, excess body weight, alcohol at 5.6 percent, ionizing radiation, physical inactivity, low fruit and vegetable consumption, HPV vaccination, low fiber consumption. By the way, process meat and red meat are carcinogens. Many people do not realize that they are carcinogens. Look at the infections that if we can control these things, we could save a substantial number of people from being diagnosed with cancer. Behavioral health and healthy behaviors, overeating and depression, smoking as a form of self-medication, exercise, which is very good for mental and behavioral health, all of these things come into play.

I know this is the National Institute for Mental Health, I am going to talk a lot about behavioral health, and I am going to admit to you we are moving away from individual behavioral health, and more towards interventions to try to change things in communities. You will see that as we talk about a few things, as we try to define where the intervention should be focused. What populations, this talk is less about what the intervention should be, but more about who the populations are that we should be focusing on.

Tobacco addiction is still the leading cause of cancer, although it will tell you that within the next 5 to 10 years, excess calories in the diet, obesity, and lack of exercise, we call it energy imbalance, will become the leading cause of cancer in the United States. Tobacco rates are going down, and you will see that in a minute.

Tobacco is associated with these cancers although, it is important to note that tobacco affects literally every organ in the human body. If you were to biopsy somebody's cornea, you can go to a lab and find evidence that that person's cornea has evidence of tobacco smoke in it, cotinine and other things that come through the blood and end up in cells.

This is smoking by percentage in the United States from 1955 to 2010. I like to show this slide because many people are not aware that 55 percent of adult men smoked cigarettes in 1955 and 35 percent of adult women smoked in 1965. We have had a dramatic cultural change in the United States, and the decline in the number of people who smoke. The decline in the absolute number is shown here, and it is not as great as the decline in the percentage. Blue is the percentage of adult smokers in 1965, going down to 2015, and red is the absolute number of smokers. We have gone from about 55 million smokers to about 40 million smokers over the period of the last 50 or so years.

In 2019, the last year of normal time, it is estimated that 34 million adults smoke cigarettes - this was about 14 percent of the population. More men than women. Approximately 55 percent of current smokers have attempted to quit within the year prior, seven to eight percent were successful for six months or more. More on who those people were who were successful, in a bit. The quit rate, meaning the percentage of ever smokers who are now former smokers is about 60 percent, higher in men than women. This is interesting. Sixty percent of people who either are smokers or were smokers, are now former smokers. They quit. That is 60 percent of the smokers who are alive.

It is estimated that more than 34 million Americans smoke right now, however. Looking at the declines in smoking by education - and please note college graduates and purple, lower proportion smoking today then back in the 1960s. But everybody was about the same back in the 1960s or close to the same. You can see there is an education issue here and this whole talk has a theme about how educated people end up doing better for a number of reasons, but this is a big one here. The fact that so few people with college education smoke. When we look at smoking by area of the country, these darker colored states are the states that have higher smoking rates. West Virginia, Kentucky, and Arkansas are the absolute worst.

We've been talking about smoking in adults, it is important to note that very few people start smoking after the age of 16. Here are states where there is high smoking rates among kids. I want to note and call out the white states here who provided no data. I just want to point out the white states that provided no data. The dark red states are the states where a large proportion of our youth are smoking.

Now, will we talk about why do people smoke. It turns out that people who have generalized anxiety disorder are much more likely to smoke than people who do not. The more severe the generalized anxiety disorder the more severe they smoke. That is an important point.

Also want to point out that current smokers with tobacco, e-cigarette use, cigars, and smokeless tobacco. This is cigarette tobacco. You can note the percentages for the United States and note the percentage in the Washington DC area. This is actually evidence that we can do something positive. Montgomery County is just absolutely amazing, my boss likes to say the only smokers in Montgomery County are on I-495 passing through it.

This is smoking by race. There is a big curveball here, non-Hispanic American Indians and Alaskan natives, it is a fact that American Indians in the South, Arizona and New Mexico, very low smoking rates. Then when we get up into the plain states, the Dakotas, very high smoking rates. This is an average of everybody.

There is a huge smoking problem among American Indians and in the Plains, that does not exist in the Southwest. You can note the smoking rates for men and for women in various groups here.

When we look at education again, I noticed this earlier, something about college education has very, very low smokers. Something about those who did not graduate from high school, very high. By the way, GED, people who get a GED have the highest smoking rates, even higher than people who are college or high school dropouts. I do not know why they are so driven.

Looking at tobacco use for people below the federal poverty level, people below and just at among men, it is about even but there is a little bit of a drop here, and as we get wealthier, we are much less likely to smoke.

Among sexual minorities, here you can see for bisexuals, gay and lesbian, transgender, and heterosexual, you can see the comparison in terms of smoking. This slide calls for targeted efforts to try to prevent smoking in the sexual minority population, as well as to try to help those who do smoke quit.

When we look at past your serious mental illness, 30 percent versus no past year at somewhere around 14 or 15 percent. This slide calls out that we need to focus on helping those who have mental illness that smoke. Not to start smoking and if they do smoke, help them to stop.

This is smoking with different mental illness diagnosis. You can see schizophrenia, bipolar disorder, attention deficit disorder, dementia. Again, these are folks who we need to focus anti-smoking efforts on, either prevention or if they already smoke, try to help them stop.

This is looking at the quit ratio among U.S. adults. Remember the quit ratio I said was the proportion of people who either are smokers or have smoked, who are now not smoking. It is about 62 percent. We talked about that earlier. That translates into 55 million of the 88.9 million living adult Americans who were smokers and have stopped smoking - 55 million.

Now it is 62 percent of all Americans, but for those who have Medicaid or who are uninsured or low income, it is in the 40s. For Blacks and American Indians, it's in the high 40s. More than one half of adult persons who smoke cigarettes in 2018 say that they tried to quit in the previous year. Seven and a half percent did quit for greater than six months. It is of note that if people under the age of 25, adults under the age of 25, there is a higher quit attempt rate and also there is a higher success rate. Focusing on people aged 18 to 24, is really something of high payoff. Focusing on those who already smoke. If they made it to 18 and they do not smoke, they are unlikely to start, but focusing on people ages 18 to 24 who do smoke, there is a high payoff.

Now although quit attempt prevalence was generally similar across sociodemographic groups, the rate of succession was lower among Blacks as compared to whites, and those with less than a high school education compared to those with a high school education, the uninsured and Medicaid did far worse than those who had private insurance. Again, socioeconomics prevails here. They are more likely to try, they are more likely to be successful in quitting. Again, at all socioeconomic strata, quit attempts are very similar in terms of proportion in trying to quit, but the people who are more educated, the people who have higher income, are more likely to be able to quit.

Quit prevalence was also similar not just among socioeconomic groups but across regions of the country. People who lived in the South and in the Midwest were less likely able to quit than people who lived in the Northeast and West. I do not know exactly why that is although the South does have a higher proportion of poor people and a higher proportion of people who do not have a high school degree and people who do not have a college degree.

About one third of adults who quit in 2018 and 2019, who tried to quit – I should say one third of adults who tried to quit, used cessation treatments that are recommended to include behavioral counseling and medication. Use of cessation treatments was lower among minorities than white smokers, as you can see here. Thirty six percent of whites who tried to quit use cessation treatments, whereas it is in the 20s for others. The most used cessation treatments were medication alone or medication in combination with counseling or behavioral counseling came in third. These are the things that people are trying to use in order to quit. Again, this is of people who did try to stop quitting.

Another thing I pointed it with alcohol consumption. Five to six percent of all cancers are caused by alcohol consumption. When we look at alcohol consumption by socioeconomics, I want you to note that - this is interesting - whites are more likely to over consume compared to Hispanics and Blacks. Asians and American Indians, Alaskan natives, just not enough data.

When we look at people who live below the federal poverty level versus people who live above among men, there is not a pattern, but the wealthier women get the more they over consume alcohol.

Now energy imbalance, I’ve already told you that this is destined to become the leading cause of cancer in the United States within the five years or so, because of that dramatic decline in people smoking cigarettes. And, unfortunately a dramatic rise, which you will see in a second, in energy imbalance. It is not just obesity, it is consuming too many calories, storing too many calories, we call that obesity, and lack of exercise, and we call that burning off those calories. It is a three-legged stool.

It has been linked to all of these cancers. It is most linked to uterine cancer, but it is also linked for example, to postmenopausal breast cancer. It is linked to all of these cancers. There is some interesting biology.  It is also possibly associated with some lymphomas, with male breast cancer, and with fatal prostate cancer. The type of prostate cancer that kills.

The prevalence of obesity that is a body mass index greater than 30 kg/m², is about 42 percent of American adults, higher amongst Black women, higher amongst Hispanic women, lower amongst white women. More on that here, you can see the fattening of America is coming up in the next couple of slides. You can see 57 percent of Black women are currently obese. This is not overweight, this is obese. Note that Asians do not have this problem.

The disparity in obesity by education is vast, you can see those who have less than a high school education compared to college graduates. I want to note that non-Hispanic Black and Hispanic children and adolescents, have higher obesity prevalence as compared to other groups. Here you see Hispanics, you see non-Hispanics Blacks compared to whites and then again, Asians again. Many of these behavioral problems start out in childhood, be it smoking or obesity. These are pediatric issues.

I told you the fattening of America. This is an American problem, not a problem in other countries that we would like to compare ourselves to, tend to have. Where 15 percent of us were obese in 1970, and 35 percent in 2010, and now it is over 40 percent. We have not seen this rise in other countries. We have seen them rise in other countries, but not nearly that in the United States. This is socioeconomics and behavioral.

When we look at Black women and that huge problem in Black women, compared to Black men as well as white men and women, you can see over time here. Now, there's a lot of talk about genetics amongst black-and-white people and some people think that some of these things are inherent. Especially when you talk about triple breast cancer, which is more common, 24 percent of Black women versus 12 percent of white women. Triple negative breast cancer is a more severe kind of breast cancer where the treatment options are much more limited.

I want to point out that the risk factors for triple negative disease and epidemiologic studies include obesity, dietary differences, especially high carbohydrate diet and childhood before puberty. Reproductive patterns that include having lots of children, especially at an earlier age, and then not breast-feeding. These things actually increase the risk of triple negative breast cancer. A different molecular type of breast cancer, they are socioeconomics, some are due to behavior, but they are very heavily induced by socioeconomics. Also, by the way estrogen receptor positive breast cancer is caused in women who don’t have children by the age of 30, or never have children, and that is a socioeconomically in the United States, college-educated, white women who become professionals.

Now obesity by socioeconomics, then there is not much difference, but you can see poor women have much more obesity compared to non-poor women. When we look at geographic variations in overweight and obesity, you can see it is certain states again, especially states in the South, that have the greatest problem with obesity.

Energy imbalance and part of it is not getting good physical activity. Physical activity recommendations are generally seen here as 150 minutes of moderate intensity activity or 75 minutes of vigorous intensity activity every week. It was about 54.3 percent of people that said that they got that, but over a quarter of adults reported no leisure time/physical activity in 2018. Higher levels in females than males.

When we look at no physical activity by socioeconomic status, you can see poor people are much more likely to have no physical activity compared to non-poor people. The percent of non-Hispanic Black adults being recommended vegetable intake is lower than that for whites. Here you can see again, Blacks at 5.5 percent - it is low for everybody. This is three vegetables per day. It is low for everybody, but it is lower for Blacks than it is for whites, and one can argue that for whites and Hispanics, it is roughly even.

I showed you race, now let’s look at socioeconomics. For people who have less than a high school education it is 12 1/2 percent got three or more servings, college graduates’ 23 percent. Among men with less than high school and college graduates, again, for women and for men.

Now, when we look at vegetable, potato, and tomato consumption, again, we have this gradient where people who are college graduates do much better than people who have less than high school, and people who have high school do not do as well as those with college. This is vegetables, potatoes in gold, and appropriately, tomatoes in red.

Other areas of cancer control that we need to think about and focus on includes vaccination, sun avoidance, safe sex practices, pollution avoidance, and appropriate screening, especially for hepatitis C, which is treatable. We can treat hepatitis C and prevent liver cancer. Then breast, colorectal, cervix, lung, prostate which I will not talk about here although we can prevent colorectal cancer with colon cancer screening.

So as I sum up, identifying those most at need and then targeting or focusing our prevention efforts on them, can really bear fruit, is incredibly importance for education. Sometimes I get really upset and I say the solution to disparities in cancer is to fix third grade so that people can learn more about eating and exercise as they grow and go through grade school, junior high school, and high school.

We need to think about the role of culture and cultural change in practicing healthy behaviors. We have certainly brought about cultural change in smoking. Many young people watching this video do not even realize that there was a time when people would be walking down the aisle in a grocery store smoking a cigarette or that you could smoke in restaurants. Virginia was by the way, one of the last states to actually stop that. You could smoke in bars. When I was in my 20s, the thought that you could not smoke in a bar someday was just not possible, and now you cannot smoke in bars.

The role of mental health and tobacco use, alcohol use, and overeating and energy imbalance with mental health, we need to think about that.

I'm going to end with a picture of the old Johns Hopkins Hospital and this is where Sir William Osler used to do rounds, and the people at U. Penn might disagree with this, we at Hopkins think he invented internal medicine here. Some people at Penn think he invented it up there. I think he invented it in this building.

Important to this building are the young doctors who used to come work with Sir William Osler to learn internal medicine. They used to be given rooms up in the dome. The nurses refer to them as residence in the dome, which is how those of us who are clinicians ended up doing residencies to this day. That is where the word comes from.
Since the rooms were in a circle under the dome, every morning Sir William Osler would walk around and see each patient, and that's where the word rounds comes from. I will stop with that little bit of Hopkins history or trivia. Thank you very much.

JOSHUA GORDON: Thank you, Dr. Brawley. I am sure there would be some raucous applause if we were gathered together in person, but you have to just take mine alone, in addition to the virtual applause of many in the audience.

We have a number of audience members. I just want to remind anyone a webinar, please, if you have questions that you would like to have Dr. Brawley answer, please enter them into the Q&A function and I will be asking some of them.

One of the most intriguing things from my perspective that you touched upon was the importance and actually pretty substantial significant relationship between serious mental illness and cancer. Perhaps mediated by some of the behaviors that you mentioned, in particular, smoking. This is something that we have often conceptualized that the serious mental illness itself can be considered a disparity category for many forms of health.

You touched upon one thing that is important to do which is targeted at antismoking efforts for those with serious mental illness. I'm wondering if you have other thoughts about trying to reduce the disparities. Are there other causes of disparities in cancer rates or outcomes that accompanies serious mental illness and whether you might have thoughts about that?

OTIS BRAWLEY: The nutritional aspects have not been well studied. I think if we studied the nutrition aspects, we would find some problems there as well. I know getting a good diet with three vegetables a day - actually the NIH used to have a program where they advertised five-a-day for better health. Five to nine servings of fruits and vegetables per day is actually what the recommendation is. My suspicion is poor people or people with mental illness, oftentimes don’t focus on that. They are focused on other things that quite honestly may be more important for survival.

JOSHUA GORDON: Another aspect of serious mental illness, and this touches on a question asked by one of the audience members. There is a lot of evidence linking adverse childhood experiences to adverse mental health outcomes. The question comes in from one of our audience members - will we see a decrease in cancer rates if we could prevent adverse childhood experiences? And let me just add to that, if so, what might the mechanisms by which that might be accomplished?

OTIS BRAWLEY: I'm going to go out on a limb and guess that the answer is yes. I believe the answer is yes because I believe adverse childhood experiences lead to increased smoking rates among people who are 14, 15, 16 years old. I believe that adverse childhood experiences likely lead to increased amounts of carbohydrate intake.

By the way, there's a body of literature that says that a young girl who gains a lot of weight from birth and starts menstruating earlier because of that weight gain, that increases her risk of breast cancer when she is in her 40s and 50s. And it's literally in the case of socioeconomics, it has been tied to the fact that poor girls are more likely to have a high calorie, high carbohydrate diet, and middle class and upper middle-class girls are more likely to have a high protein, more balanced diet.

It is a fact, and it was first shown in Scotland, where they have a deprivation index and you can look at rich/poor and look at rich and poor throughout life very easily. It was first shown there, and is now been shown in the United States, that poor women, poor girls, menstruate on average two to three years earlier than middle-class girls. It is not a race thing, it is a rich/poor thing.

JOSHUA GORDON: Another factor that we in the mental health profession have been paying attention to a lot to of late is inflammation. And so this question comes in from one of our audience members. What about the role of information in cancer? We know that that is important. Could that be playing a role in some of these disparities that you mentioned?

OTIS BRAWLEY: It definitely does. By the way, the last question, I should point out women who menstruate earlier have a higher rate of breast cancer in 40s and 50s.

In inflammation, yes. Inflammation is definitely linked to cancer. It increases risk of cancer, and also increases risk of cardiovascular disease by the way. We're still trying to figure out all of the reasons of what causes inflammation. We do not have a good idea for all of the reasons that cause inflammation.

For example, one thing we do know is that people that have diabetes or people who have prediabetes, or have hypoglycemia, do have higher amounts of circulating inflammation. We have ways of measuring inflammation now from blood test and people with diabetes, people with prediabetes, have higher amounts of circulating inflammation. I should point out they have a higher risk of cancer when we look at cancer numbers.

JOSHUA GORDON: I will just point out the same questioner noted the effects, vis-a-vis their earlier question about adverse childhood experiences, that known effects of traumatic stress exposure on inflammation as well, later in life.

When we are thinking about our approach to disparities research at NIMH, one of the things we think a lot about is trying to develop interventions. You have talked about some of them. You have talked about some ideas for behavioral interventions that might reduce cancer rates, and importantly, be targeted at specific communities in order to reduce those rates in the communities that are most affected.

One of our audience members asked, many public health interventions, like those that you're talking about in mental health right now, are leaning right now on digital mental health. Thinking about patients like those that you took care of at Grady, where phones may be shared, may have inconsistent service, where Internet access may be less than ideal, I'm curious regarding your thoughts on patients facing digital tools to increase equity and reduce disparities. Are there uses for that? Are there concerns about it?

OTIS BRAWLEY: There are concerns and the concerns are actually interestingly, it's amazing how many people who go to a Grady have a smart phone. Those who don't tend to be people who are in their 60s and 70s. So I worry about older people being left behind, number one.

The other interesting thing is, and this is something that happened to me when I first got to Grady, one of the social workers said please remember we have done the study, more than half of your patients cannot read, “take one pill twice a day” off the side of the pill bottle. I was so naïve. I had just turned 40 and I had just gotten bifocals, and she had to grab me and say, no, Dr. Brawley, I am not talking about they need bifocals. I mean they can’t read.

While many of them have these smart phones, if you put things on the smart phone that you expect them to read, they can’t read it. That means that we're going to have to look at cartoons and illustrations and other things, as well as talking to people.

JOSHUA GORDON: That reminds me actually about a project that we support at NIMH around mental health being delivered in community mental health centers in rural Nepal. Where one of the efforts is trying to understand how you encourage people in those communities when they are visiting their healthcare providers, to talk about their mental health. Because there is such a low rate of literacy in these communities, they use posters with cartoons to try to encourage folks to actually ask for help for mental health services.

One of the biggest things that is important to note is to inform them that yes, actually you can get help for conditions like psychosis and depression, if you ask for it. There is actually help. Because there are concerns that it is really hopeless.

And along those lines, another question from the audience, how would increasing access to mental health and/or early mental health prevention, help prevent the behavioral contributors to cancer occurrence? I think we talked about that a little bit but maybe explicitly answer that question.

OTIS BRAWLEY: Huge. One of the great problems, and I am preaching to the choir here, one of the great problems in the United States is mental health has not been appreciated and provision of mental health has not been promoted or supported. I can even make mathematical models where the amount of healthcare dollars spent on smoking that would evaporate away if we provided early mental health to the smoker. It would pay for itself.

JOSHUA GORDON: I think that a great message to end with, Dr. Brawley. I really appreciate you coming to talk to us today, appreciate all of your work over the years in this field, and your continuing efforts as well. Thank you so very much.

OTIS BRAWLEY: Thank you, Dr. Gordon, for having me and I want to thank Katie and Jack, the interpreters, and Bailey and Ashley and the gang, who put all of this together.

JOSHUA GORDON: Thanks to that and thanks also to the team at NIMH for putting together a really wonderful series this year, themed around health disparities. And I look forward to seeing all of you at the next NIMH Directors Innovation Series Speakers.

Again, for those of you have been able to join us today, you can let your friends and family, and colleagues know that this presentation has been recorded and will be posted on the web within the next few weeks. Thanks again and see you all later.