A recent paper, by Byers of Colorado School of Public Health in Aurora, provides evidence to support a link between poverty and incidence of death within 5 years of cancer diagnosis in the US. The study, to be published in the August edition of Cancer reports that “Patients with a lower socioeconomic status have a 35% increase in mortality”.
The study concluded that the racial inequity in cancer survival rates observed in US citizens could be attributed more to differences in wealth and education than to biological differences caused by race or ethnicity.
Byers and colleagues studied patient records for those diagnosed with breast, prostate and colorectal cancers in 1997 across seven US states. They analyzed cancer burden by comparing stage at diagnosis, treatment given and incidence of mortality within the 5 years following diagnosis. To assess the patient’s socioeconomic status, they worked out a score from the average income and level of education of the patient’s neighborhood from data collected in the 2000 census. They found that the poorer the patient, the later the cancer was diagnosed, the less aggressive the treatment given and the higher the risk of fatality within 5 years of diagnosis for all three types of cancers studied.
They also found that, in the US, cancer inequities between socioeconomic groups were not observed in patients over the age of 65 years as this age group has more universal healthcare access through Medicare. Furthermore, in Canada where healthcare access is more equally available to patients of both high and low socioeconomic status, the racial disparity observed was very small compared to that seen in the US.
The study finds that low socioeconomic status means a greatly reduced access to healthcare in the US for those under 65 years of age and issues a call to action to ensure more timely diagnoses and more adequate treatments for those in low income neighbourhoods.
Byers hopes that the study will highlight the need to uncover the full impact of socioeconomic status on cancer survival in the US to solve the mystery behind racial cancer inequities. “It is increasingly apparent that a substantial proportion of the disparities in cancer defined by race and ethnicity can be attributed to socioeconomic status. Understanding the ways in which socioeconomic status affects mortality is important for defining strategies to eliminate the unequal burden of cancer by race and ethnicity,” explained Byers.
Byers’ report will be published alongside a separate study by Sheryl Gabram (Emory University) and director at the AVON Comprehensive Breast Center at the Georgia Cancer Center for Excellence at Grady Memorial Hospital in Atlanta, and colleagues.
Gabram reports the success of Community Health Advocacy and Patient Navigation, implemented in 2001 to address the inequity in breast cancer deaths in African–American women. Through education and encouragement from community outreach volunteer workers, women were encouraged to self examine, have mammograms and attend follow-up treatment sessions if positively diagnosed. The stage of breast cancer at diagnosis of the 487 women diagnosed at the AVON Comprehensive Breast Center, between 2001 and 2004, was recorded. It was found that the percentage of stage 0, the earliest stage, diagnoses doubled from 12.4 to 25.8% and the percentage of stage 4, the latest stage, diagnoses almost halved from 16.8 to 9.4%.
It is hoped that this type of programme could be part of a viable solution to address the cancer disparities that the study has discussed, which could lead to lower incidence of cancer mortality in patients of low incomes and ethnicity minorities.
Source: Byers T, Wolf HJ, Bauer KR et al. The impact of socioeconomic status on survival after cancer in the United States: findings from the National Program of Cancer Registries Patterns of Care Study. Cancer doi:10.002/cncr.23567 (Epub ahead of print) (2008).
Cervarix is the UK’s chosen cervical cancer vaccine
GlaxoSmithKline’s (GSK’s) cervical cancer vaccine Cervarix has been awarded the UK National Health Service (NHS) contract, reportedly worth £10 million. Cervarix beat its only competitor Gardasil, developed by Merck/Sanofi-Pasteur, to win the deal and will be administered to girls aged 12–13 years of age in the Department of Health’s national immunization programme, which begins in September of this year.
Eddie Gray, GSK’s President of Pharmaceuticals, Europe, commented on the decision. “This is great news for girls and women across the UK and reflects the growing confidence in Cervarix, which provides cervical cancer protection with a strong and sustained immune response. We believe the benefits of this programme will be felt by women and their families for generations to come.”
Approximately 70% of cervical cancers are caused by repeated infection of certain ‘high-risk’ strains of the human papillomavirus (HPV). Two cancer causing subtypes of HPV are strains 16 and 18. Both Cervarix and Gardasil confer immunity against these subtypes, and so should prevent this major proportion of cervical cancers occurring.
Gardasil, in addition, immunizes against genital warts caused by strains six and 11 of HPV, which Cervarix does not. It is this wider immunity that seems to have given Gardasil the edge in previous contract bids across the USA and parts of Europe. Furthermore, Gardasil, launched in 2006, was the first cervical cancer vaccine on the market. However, Cervarix, which has yet to be launched in the US, is the cheaper option and it is thought that GSK also offered a large discount for the NHS contract and that this swung the deal.
GSK hope that winning the NHS contract will increase the notoriety of their vaccine, leading other European countries to choose Cervarix when implementing their own national immunization programmes.
Source: www.pharmaceutical-business-review.com/article_feature.asp?guid=3F07D3D2-74EB-4B03-B19E-01A93921771E
Patients respond better to a placebo if they think it costs more
Researchers have found that more patients registered a pain relief response when given a placebo that they believed to be a painkiller when told that it was more expensive. The results not only show the importance of the placebo effect in patients’ perception of drug efficacy, but may also suggest a reason for the perceived greater success of the more expensive branded medications in comparison with cheaper generic brands.
The study was conducted by Dan Ariely from the Massachusetts Institute of Technology in Cambridge and was published in the Journal of the American Medical Association. “It is possible that the therapeutic efficacy of medications is affected by commercial features such as lower prices. Because such features influence patients’ expectations, they may play an unrecognized therapeutic role by influencing the efficacy of medical therapies, especially in conditions associated with strong placebo responses.” explained Ariely
In this recent study, volunteers were given a vitamin C placebo pill and told that it was a newly developed analgesic. It was mentioned to a half of those given the placebo that the price of the new wonder drug was $2.50 per tablet, whereas the other half heard that the cost had been discounted to just $0.10 per tablet. The volunteers were given a series of mild electrical shocks both before and after taking the placebo, and their perceived pain measured. A total of 85% of those who took the ‘$2.50’ pill experienced pain relief versus the 61% of those who took the ‘10 cents’ pill.
Ariely believes that placebos work because people are expecting them to and that the cost of a drug seems to be one factor connected to people’s belief in its efficacy. When told that a drug is cheap or discounted, people lose confidence in the effectiveness of a drug. This reduces the potency of the placebo effect and so may reduce their experience of the actual drug itself.
Source: Waber RL, Shiv B, Carmon Z, Ariely D. Commercial features of placebo and therapeutic efficacy. JAMA 299(9), 1016–1017 (2008).
Overcaution in maternal medicine trialling may be putting pregnant women in danger
It seems that there is currently too much caution being used in the development, or lack of development, of drugs to protect pregnant women from disease. Some 99% of the mortalities of pregnant women are of those living in the developing world. White, McGready and Nosten address the issue in their report in PLoS Medicine, stating that “maternal and perinatal conditions are a major contributor to the global burden of disease.”
Drug development for maternal health is severely lacking, possibly owing to the adverse effects on the unborn child of the drug thalidomide given to pregnant women in the 1950’s, and pharmaceutical companies are unwilling to underwrite research into drugs for maternal health because of the associated taboo.
It makes considerable sense to exercise caution in trialling any drug for pregnant women, particularly in the first trimester, whilst the embryo undergoes organogenesis. However, the threat from tropical diseases, particularly malaria means that delaying or reducing the frequency of clinical trials of drugs for pregnant women may be extremely detrimental and that more encouragement should be given to research groups to investigate how such diseases may be combated during pregnancy.
The authors of this study warn that the shortfalls in the amount of time and money being invested into maternal medicine are leading to a huge lack of lifesaving drugs available to pregnant women. “We are too risk averse, and can no longer afford to ignore the problem of how best to treat tropical infectious diseases in pregnancy,” they cautioned.
A medicine may be withheld from a pregnant woman even though reproductive toxicology studies have not shown any dangers of adverse effects because there is not enough clinical evidence available. However, if pregnant women are not prescribed the drugs then it becomes difficult to collect any clinical data. This means that mothers to be may not receive effective medication for a potentially fatal disease because of hypothetical effects on their unborn child.
The authors report that, “Of over 500 antimalarial drug trials conducted between 1966 and December 2006, only 31 evaluated antimalarial treatments specifically in pregnant women, and 14 of these were from a single center.”
Source: White NJ, McGready RM, Nosten FH. New medicines for tropical diseases in pregnancy: catch-22. PLoS Med 5(6), e133 (2008)