RACIST MEDICINE

Black men more likely to die after surgery than White men, or women of either race

Unequal post-surgery death rate mainly applies to planned surgeries. Findings highlight the need for better understanding of the challenges facing Black men requiring surgery in the US

Peer-Reviewed Publication

Black men have a higher death rate within 30 days of surgery compared with any other subgroup of race and sex, finds a study of adults in the United States published in The BMJ.

This inequality in death rate was mainly observed for elective, or planned, surgeries, where the death rate for Black men was 50% higher than that of White men. 

The researchers say further research is needed to understand better the “factors contributing to this higher mortality rate among Black men after elective surgery.”

In previous studies, racial inequities in surgical care and outcomes, including a higher death rate following surgery for Black patients, have been well documented. 

However, less is known of how surgical outcomes differ by the race and sex of patients undergoing both elective or non-elective (urgent or emergency) surgeries.

To fill in this knowledge gap, the researchers used nationwide Medicare data on 1,868,036 adults with an average age of 75 years who underwent one of eight surgeries —abdominal aortic aneurysm repair, appendectomy, cholecystectomy, colectomy, coronary artery bypass surgery, hip replacement, knee replacement, and lung resection—between 2016–2018.

They analysed data for differences in death rates between subgroups of race and sex, following elective or urgent surgeries

Of the adults included in this study, 40.7% were White men, 53.4% were White women, 2.2% were Black men, and 3.7% were Black women. Just over 70% of the surgeries were elective. 

After accounting for other potentially influential factors such as age, disability, and a range of underlying chronic conditions, the researchers found that Black men had a higher death rate (3.05%) within 30 days of both urgent and elective surgery than White men (2.69%), White women (2.38%), and Black women (2.18%).   

A similar pattern was found for elective surgery: Black men had a higher death rate (1.3%) than White men (0.85%), White women (0.82%), and Black women (0.79%).

This 0.45 percentage point difference between Black and White men “implies that mortality after elective procedures was 50% higher in Black men compared with White men", say the researchers. 

And much of this difference persisted even when patients operated on by the same surgeon were compared, they note.

The researchers did not find a statistically significant difference between Black and White men following urgent surgery, with death rates of 6.69% and 7.03%, respectively.  

They did, however, find that deaths after urgent surgery were lower for both White and Black women, than men of either race, at 6.12% and 5.29%, respectively. 

This is an observational study, so cannot establish cause, and the researchers acknowledge that their results were limited to Black and White Medicare patients undergoing certain procedures, so may not apply to other groups or types of surgery.

However, results remained largely unchanged after further sensitivity analyses, suggesting that they are robust. 

The researchers suggest that structural racism within society, such as higher rates of poverty among Black patients, which can lead to poorer underlying health and challenges accessing care, may, at least partially, explain their findings, and say better standardisation of care is needed to help mitigate some of these factors and reduce inequities in surgical outcomes.

“Further research is needed to understand better the preoperative, intraoperative, and postoperative factors contributing to this higher mortality rate among Black men after elective surgery, ” they conclude.

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JOURNAL

The BMJ

DOI

10.1136/bmj-2022-073290 

METHOD OF RESEARCH

Observational study

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Inequities in surgical outcomes by race and sex in the United States: retrospective cohort study

ARTICLE PUBLICATION DATE

1-Mar-2023

Older Black men are likelier to die after surgery than others, particularly following elective procedures, new UCLA research suggests

Peer-Reviewed Publication

UNIVERSITY OF CALIFORNIA - LOS ANGELES HEALTH SCIENCES

Older Black men are likelier to die after surgery than others, particularly following elective procedures, new UCLA research suggests

Older Black men have a higher chance of dying within 30 days of surgery than do Black women and white men and women – with their odds of death 50% higher after elective surgery compared with white men.

The researchers suspect that the “especially high cumulative amounts of stress and allostatic load” that Black men face the U.S. may significantly contribute to declines in their physical health, they write.

“While a fair bit is known about such inequities, we find in our analyses that it's specifically Black men who are dying more, and they are dying more after elective surgeries, not urgent and emergent surgeries,” said study lead Dr. Dan Ly, assistant professor of medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA. “Our findings point to possibilities such as poorer pre-optimization of co-morbidities prior to surgery, delays of care due to structural racism and physician bias, and worse stress and its associated physical burden on Black men in the United States.”

The study was published March 1 in the peer-reviewed journal The BMJ.

The researchers examined Medicare data from 2016 through 2018, which were the most recent data available when they began the research, for about 1.87 million Black and white beneficiaries ages 65 to 99 years. These people had undergone one of eight common surgeries: abdominal aortic repair, appendectomy, cholecystectomy, colectomy, coronary artery bypass, hip replacement, knee replacement, and lung resection. These procedures were performed both planned (elective) and unplanned (urgent or emergent).

They found that overall, Black men had a higher adjusted mortality rate  even after accounting for other differences between patients. For Black men, the mortality rate was about 3.05% compared with 2.69% among white men, 2.38% among white women, and 2.18% among Black women. This trend largely persisted with elective surgeries, with a death rate of 1.30% among Black men, compared with white men at 0.85%, white women at 0.82%, and Black women at 0.79%. The disparity between Black and white men began as early as seven days after surgery and was still present 60 days after surgery.

Structural racism may partly explain the disparity, the researchers write. For instance, predominantly Black neighborhoods are often near hospitals lacking high-quality healthcare resources such as specialists, including surgeons with advanced training, as well as the latest diagnostic imaging studies and tests. This can lead to treatment delays resulting in more advanced disease or more difficult surgeries.

 

In addition, poorer pre-operative care for conditions such as diabetes and hypertension, and more exposure to toxic hazards that are frequently found near their neighborhoods that can increase disease severity, may also contribute to the disparity.

“These differences in neighborhood, home environment and community resources may make it more challenging for Black patients, on average, to recover at home and to make postoperative clinical visits,” they note. “Our finding that Black men experience a higher surgical mortality compared with other subgroups of race and sex is troubling, and is also seen with shorter life expectancy among Black men more generally.”

Study limitations include a focus on Black and white patients to the exclusion of other racial and ethnic groups; the observational nature of the study, which may have missed other contributory factors; and that the data are from the Medicare fee-for-service population, so the results may not apply to other populations.

Additional study authors are Dr. Mariah Blegen, Dr. Melinda Gibbons, Dr. Keith Norris, and Dr. Yusuke Tsugawa of UCLA

The study was funded by the National Institute on Minority Health and Health Disparities (R01 MD013913).

JOURNAL

The BMJ

DOI

10.1136/bmj-2022-073290 

METHOD OF RESEARCH

Data/statistical analysis

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Inequities in surgical outcomes by race and sex in the United States: retrospective cohort study

ARTICLE PUBLICATION DATE

1-Mar-2023

New study finds most targeted COVID-19 border closures ineffective, likely illegal

Peer-Reviewed Publication

YORK UNIVERSITY

March 1, 2023, TORONTO —  A research team from the Global Strategy Lab (GSL) at York University looked at border closures implemented during the COVID-19 pandemic and concluded that many were ineffective, illegal and even when they did work, were so disruptive that in the future they should only be used when absolutely necessary.  

The new study, among the first to evaluate the effectiveness of border closures initially put in place three years ago to slow the spread of the then novel coronavirus, found that targeted closures did little to curb the crisis, and, if evaluated based on what we know now, would likely be considered illegal under international law. The most extreme shutdowns, on the other hand, were temporarily effective but came at a great cost. Border closures should be used as a means of last resort and decisions around closures would be most effective if co-ordinated globally by the World Health Organization, says the paper’s lead author Mathieu Poirier.

“People just assumed at the time that these measures were effective, but that’s not necessarily the case,” says Poirier, Faculty of Health social epidemiology professor and York Research Chair in Global Health Equity and co-director of GSL. “Our study shows, using real-world data, that for most countries, in most situations, border closures are not going to be the best approach.” 

The research was published yesterday in PLOS Global Public Health. Poirier and his GSL co-authors  – York professors Susan Rogers Van Katwyk and Steven Hoffman and data analyst Gigi Lin –  looked at available information from 166 countries and evaluated whether border closures curbed spread both domestically and internationally. 

Total border closures – defined as barring non-essential travel from all other countries and implemented by the vast majority of countries in March 2020 – did temporarily slow COVID-19 transmission globally. However, the wave of targeted border closures a month earlier aimed at travellers from hotspots did not slow down the global pandemic. On a national level, targeted closures did work in some situations, but the most effective were implemented early and were so extensive that they approached a total closure. Border closures can also divert resources away from other pandemic measures and reduce global co-operation when it is most needed during a pandemic crisis. 

Border closures have a huge effect on people’s lives and the economy when compared to other measures such as quarantines, restricting public gatherings and test-and-tracing approaches. But if other less disruptive measures are not possible, then applying border closures early is key. Poirier acknowledges that deciding how early is not a straightforward process. 

“If you're not making those difficult decisions early on, then that decision-making process might already be too late, but if you are the first country to implement a closure, that’s likely going to be very unpopular.”

This challenge is further complicated by the lack of reliable real-time information available to decision-makers. 

“Some countries may not be reporting what they know, and many more countries aren't testing or don't have the infrastructure to actually know what's happening on the ground in the first place,” he adds, noting data is not solely an issue in autocratic regimes. “With these fast-moving pandemic threats, it's probably best to assume that we don't know what's happening.” 

Under the International Health Regulations, restrictions should not be more stringent than necessary and methods like border closures should only be implemented if supported by science. 

“Looking back, most countries’ border closures were likely illegal, but that science was not available to decision makers at the time,” Poirier concludes. “This research suggests closures may have a role to play in future pandemics but should be implemented with strong caution and in co-operation with other countries.”

The Global Strategy Lab is hosting a presentation of the paper at 9 a.m. EST on March 17, the three-year anniversary date of Ontario declaring a provincial emergency and the day after Canada barred entry to non-residents. Poirier, Rogers Van Katwyk and Lin will be presenting, in discussion with Kelley Lee, professor of Public Health with Simon Fraser University and Canada Research Chair Tier I in Global Health Governance. Register here.

 

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York University is a modern, multi-campus, urban university located in Toronto, Ontario. Backed by a diverse group of students, faculty, staff, alumni and partners, we bring a uniquely global perspective to help solve societal challenges, drive positive change, and prepare our students for success. York's fully bilingual Glendon Campus is home to Southern Ontario's Centre of Excellence for French Language and Bilingual Postsecondary Education. York’s campuses in Costa Rica and India offer students exceptional transnational learning opportunities and innovative programs. Together, we can make things right for our communities, our planet, and our future. 

 

Media Contact: 

Emina Gamulin, York University Media Relations, 437-217-6362, egamulin@yorku.ca

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JOURNAL

PLOS Global Public Health

COI STATEMENT

SJH is the Vice-President of Corporate Data & Surveillance at the Public Health Agency of Canada (PHAC) and previously served as the Scientific Director of the Institute of Population & Public Health at the Canadian Institutes of Health Research (CIHR). The views expressed in this article are those of the authors and do not necessarily reflect those of PHAC, CIHR or the Government of Canada.

Immunotherapy before surgery significantly improves outcomes of patients with melanoma

Peer-Reviewed Publication

UNIVERSITY OF CALIFORNIA - LOS ANGELES HEALTH SCIENCES

If cancer exhibits a weakness, exploit it before taking the target away.

That’s what researchers did in a Phase 2, randomized clinical trial showing that adding immunotherapy before surgical removal of stage III-IV melanoma significantly improved event-free survival and produced no more side effects than standard-of-care treatment, which provides immunotherapy only after surgery.

Results of the multicenter trial, led by a team that included UCLA Jonsson Comprehensive Cancer Center researchers, are published in the March 2, 2023 issue of the New England Journal of Medicine.

“This is the first clinical trial demonstrating that neoadjuvant therapy – that given before surgery – is superior to the same therapy given in the adjuvant setting – after surgery,” said Dr. Antoni Ribas, director of the Tumor Immunology Program at UCLA Jonsson Comprehensive Cancer Center, the paper’s senior author. “This is because it is best to turn on the immune system inside the cancer before it is taken out with the surgery.”

The researchers designed the study and treatment regimen on how pembrolizumab – used in this study – and similar drugs, called immune checkpoint inhibitors, are thought to work. The antibody pembrolizumab is a PD-1 inhibitor; it blocks an immune checkpoint that blunts the immune system’s response to cancer. The therapy releases the antitumor immune response – often referred to as “taking the brakes off the immune system” – enabling immune cells already existing at the tumor site to proliferate and attack the cancer cells at that place or anywhere else in the body.

“Based on this understanding, removing the bulk of the tumor, along with the tumor-infiltrating immune cells contained in the surgical specimen, is likely to take away some or even most of the potential antitumor immune cells that would proliferate after PD-1 blockade,” said Ribas, who was chair of the SWOG Cancer Research Network’s melanoma committee when the study was designed and launched. “Our theory has been – and this study confirms it – that starting anti-PD-1 blocking therapy before surgery could activate more antitumor immune cells and improve clinical outcomes compared with the same amount of drug delivered after the surgery.”

As first author Dr. Sapna Patel says, “It’s not just what you give, it’s when you give it.” She is the current chair of the SWOG Cancer Research Network’s melanoma committee and associate professor of Melanoma Medical Oncology at The University of Texas MD Anderson Cancer Center.

The trial included patients with clinically detectable, measurable stage IIIB-IVC melanoma that could be surgically resected. Patients were randomly assigned to one of two groups. Those in the adjuvant therapy group, consisting of 159 patients, were treated with surgery followed by pembrolizumab given every three weeks for a total of 18 infusions. The 154 participants in the neoadjuvant group received three infusions of pembrolizumab before surgery, followed by the remaining 15 infusions after surgery. Therefore, both study groups received the same drug and the same total number of 18 infusions, with the only difference being the timing of surgery.

The researchers found that at two years 72% of patients in the group receiving neoadjuvant pembrolizumab followed by adjuvant pembrolizumab were free of events (inability to get surgery, recurrence of the melanoma or death) compared to 49% of the patients in the adjuvant pembrolizumab alone group.

Dr. Bartosz Chmielowski, clinical professor of medicine in the division of Hematology-Oncology at UCLA and study co-author said the study’s findings could change the way high-risk melanoma is routinely treated.

“The study highlights that the timing of administration of an immune checkpoint inhibitor relative to surgery can have a large effect on patient outcomes, even though the same systemic therapy was given to both study groups,” Chmielowski said. “Our results demonstrate a significant benefit when immunotherapy is started prior to surgery to generate an immune response while the bulk of the cancer and the anti-tumor immune cells remain intact.”

The study, known as S1801, was led by the SWOG Cancer Research Network, supported by the National Cancer Institute and conducted by the National Institutes of Health-funded National Clinical Trials Network. Dr. Chmielowski was UCLA’s principal investigator of the trial. For a complete list of authors, please see the study.

Funding: Research reported in this publication was supported by NIH/NCI grant awards U10CA180888, U10CA180819, U10CA180820, U10CA180821, U10CA180868, UG1CA233329, UG1CA233328, UG1CA233247, UG1CA233180, UG1CA189860, UG1CA233178, UG1CA233160, UG1CA189821, UG1CA233320, UG1CA233331, UG1CA189850, UG1CA233330, UG1CA233234, UG1CA233193, UG1CA189956, UG1CA239767, UG1CA189869, UG1CA180830, P30CA014089, UG1CA239758, P30CA016042, UG1CA189830, P30CA076292, P30CA033572, R35 CA197633 and P01 CA244118; and in part by Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc., Rahway, NJ, USA.

Disclosures and potential conflicts of interest: Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

Article: Patel SP, Othus M, Chen Y, et al. Neoadjuvant–adjuvant or adjuvant-only pembrolizumab in advanced melanoma. N Engl J Med 2023;388:813-23. DOI: 10.1056/NEJMoa2211437

Article URL (once embargo lifts): https://www.nejm.org/doi/full/10.1056/NEJMoa2211437.

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JOURNAL

New England Journal of Medicine

DOI

10.1056/NEJMoa2211437 

METHOD OF RESEARCH

Randomized controlled/clinical trial

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Neoadjuvant–adjuvant or adjuvant-only pembrolizumab in advanced melanoma.

ARTICLE PUBLICATION DATE

1-Mar-2023

COI STATEMENT

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org

Neoadjuvant pembrolizumab administered before surgery improves outcomes of melanoma patients

Phase 2 clinical trial results show the neoadjuvant-adjuvant therapeutic approach improves event-free survival in high-risk melanoma patients

Peer-Reviewed Publication

H. LEE MOFFITT CANCER CENTER & RESEARCH INSTITUTE

TAMPA, Fla. — Outcomes for melanoma patients have vastly improved thanks to new treatment options. However, those with high-risk disease who have their tumors surgically removed still have a substantial chance of relapse. A team of researchers from institutions across the United States, including Moffitt Cancer Center, launched a phase 2 clinical trial evaluating a new treatment option for this patient population. Their results, published in The New England Journal of Medicine, show that treating resectable stage 3 and 4 melanoma patients with the immunotherapy drug pembrolizumab both before and after surgery greatly improves outcomes when compared to pembrolizumab given only after surgery.

Pembrolizumab activates the immune system to target cancer cells for destruction. It is approved to treat many different types of cancer, including melanoma that cannot be surgically removed, or be given as a post-surgery (adjuvant) treatment option. The research team, as part of the Southwest Oncology Group, initiated the phase 2 trial to assess whether pembrolizumab given both before surgery (neoadjuvant) and as adjuvant therapy after surgery could improve outcomes of patients with melanoma that can be surgically removed, compared with the identical number of doses of pembrolizumab given entirely after surgery.

“The dramatic successes we’ve seen with drug treatments for melanoma have led us to use them earlier and earlier in the patient’s course. Neoadjuvant therapy brings the powerful drugs to bear on the tumor even before surgery and has a lot of potential advantages. But many surgeons were reluctant to put off surgery for fear that the tumor would grow or spread and they would miss the opportunity for surgical cure,” said Vernon Sondak, M.D., study co-author and chair of Moffitt’s Department of Cutaneous Oncology.

This trial included 313 patients with resectable stage 3 or 4 melanoma from 90 institutions across the U.S. All patients had tumors that were still present and measurable by CT scans. In other words, they could not have already had all their cancer removed prior to the start of the trial. Patients were randomized into two groups. The first group received pembrolizumab as both neoadjuvant (three doses before surgery) and adjuvant (15 doses after surgery) therapy, while the second group received all 18 doses of pembrolizumab after surgery. With a median follow-up of 14.7 months, the 154 patients in the neoadjuvant-adjuvant group had a significantly longer event-free survival than the 159 patients in the adjuvant only group. The two-year event-free survival rates were 72% in the neoadjuvant-adjuvant group versus 49% in the adjuvant only group. The treatment benefit was observed in all patient subgroups that were analyzed, including groups based on age, sex, performance status and stage of disease. Of particular note, there were fewer postsurgical recurrences in the patients in the neoadjuvant plus adjuvant group.

One concern with neoadjuvant therapy is the potential risk of tumor growth or developing toxicities that would prevent patients from undergoing surgery. In the neoadjuvant-adjuvant group, less than 10% of patients developed progressive disease or toxicities from pembrolizumab neoadjuvant therapy that prevented them from undergoing surgical removal of the tumor. Overall, the rates and types of adverse events were similar between the two treatment groups. The percentage of patients who developed grade 3 or 4 treatment-related adverse events during adjuvant therapy was 12% in the neoadjuvant-adjuvant group and 14% in the adjuvant only group.

“Our trial results shows that the timing of administration of an immune checkpoint inhibitor relative to surgery can have a large effect on patient outcomes. These new landmark data are practice-changing and will impact how clinicians treat patients with advanced melanoma that can be surgically removed. We have been using neoadjuvant therapy extensively for several years now, but these results exceeded even my lofty expectations,” Sondak said. “The next step is to use neoadjuvant therapy to lessen the amount of surgery patients might need and shorten the length of drug treatment they might otherwise require. We’re working on precisely that right now.”

This study was funded by the National Cancer Institute (U10CA180888, U10CA180819, U10CA180820, U0CA180821, U10CA180868, UG1CA233329, UG1CA233328, UG1CA233247, UG1CA233180, UG1CA189860, UG1CA233178, UG1CA233160, UG1CA189821, UG1CA233320, UG1CA233331, UG1CA189850, UG1CA233330, UG1CA233234, UG1CA233193, UG1CA189956, UG1CA239767, UG1CA189869, UG1CA180830, P30CA014089, UG1CA239758, P30CA016042, UG1CA189830, P30CA076292, P30CA033572, R35 CA197633 and P01 CA244118) and Merck Sharp and Dohme.

About Moffitt Cancer Center
Moffitt is dedicated to one lifesaving mission: to contribute to the prevention and cure of cancer. The Tampa-based facility is one of only 53 National Cancer Institute-designated Comprehensive Cancer Centers, a distinction that recognizes Moffitt’s scientific excellence, multidisciplinary research, and robust training and education. Moffitt’s expert nursing staff is recognized by the American Nurses Credentialing Center with Magnet® status, its highest distinction. With more than 7,800 team members, Moffitt has an economic impact in the state of $2.4 billion. For more information, call 1-888-MOFFITT (1-888-663-3488), visit MOFFITT.org, and follow the momentum on Facebook, Twitter, Instagram and YouTube. 

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JOURNAL

New England Journal of Medicine

DOI

10.1056/NEJMoa2211437 

METHOD OF RESEARCH

Randomized controlled/clinical trial

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Neoadjuvant–Adjuvant or Adjuvant-Only Pembrolizumab in Advanced Melanoma

ARTICLE PUBLICATION DATE

2-Mar-2023

Study: More paid sick leave results in more cancer screenings

The findings highlight the benefits of paid leave mandates as a way to increase healthcare access and potentially improve healthcare equity in the U.S., where 1 in 4 people have no paid sick leave

Peer-Reviewed Publication

TULANE UNIVERSITY

For most Americans, the two major obstacles to proper medical care are time and money. And while insurance can sometimes reduce healthcare costs, having time to visit the doctor is just as important.

Now, a new Tulane University study published in the New England Journal of Medicine has found that more people get screened for cancer when employers are mandated to provide paid sick leave. During a 7-year period covered by the study, breast cancer screening rates increased up to 4% and colorectal cancer screenings increased between 6-8% in areas exposed to policy-driven paid sick leave mandates. 

“These non-monetary barriers to healthcare access matter,” said Kevin Callison, lead author and assistant professor of health policy and management at Tulane’s School of Public Health and Tropical Medicine and The Murphy Institute. “Improving or reducing these barriers can have meaningful impacts on people’s health.”

The U.S. is the only wealthy nation in the world to not federally mandate paid time off for being sick, according to the Center for Economic Policy and Research. According to the U.S. Bureau of Labor Statistics, about 1 in 4 American workers can’t take a single paid sick day.

The study, which was co-authored by researchers from Georgia State University and the University of California San Francisco, examined changes in breast cancer and colorectal cancer screening rates among 2 million private sector employees from 2012-2019, a time in which several states and cities adopted policies mandating paid sick leave. The workers were spread among 300 metropolitan statistical areas, 61 of which were exposed to a paid sick leave mandate during that timeframe.

Though the increases in screening rates may seem small, these results include workers who already had paid sick leave, meaning they were unlikely to decrease or increase cancer screening habits. If the results were scaled to focus only on workers gaining sick leave for the first time via mandates, Callison estimated that breast cancers screening rates increase 9-12% and colorectal screening rates increase 21-29%.

“Our effects become much larger if we're willing to assume that only the workers who are gaining paid sick leave coverage are the ones who are changing their screening behaviors,” Callison said.

Past studies have examined the relationship between sick days and cancer screening rates by comparing rates among those with leave to those without. But some workers are more health-conscious than others and may exclusively seek jobs that offer paid sick leave. By focusing on the change in screening rates brought by policy-driven mandates, this study removed some of the potential behavior-based biases.

“Because we focused on these policies that drive changes in coverage rather than people self-selecting into coverage, our argument is that we have a more accurate estimate of the relationship between paid sick leave and cancer screening,” Callison said.

The results underscore the value of sick days. Callison said it’s “reasonable to assume that more cancer screenings lead to earlier detection and better outcomes,” but more research is needed to determine if paid sick leave means cancers are caught earlier and if mortality rates decline.

To Callison, these results also represent one potential way of increasing healthcare equity in the United States.

The majority of those without paid sick leave are people of color and those with less wealth and less education. And though 17 states and 18 cities have adopted paid sick leave, 18 states have passed laws prohibiting cities from passing similar mandates.

“We know that racial and ethnic minorities tend to have higher mortality rates for certain cancers,” Callison said. “So are things like this going to improve those gaps? That’s really the next step where we want to go.”

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JOURNAL

New England Journal of Medicine

DOI

10.1056/NEJMsa2209197 

METHOD OF RESEARCH

Data/statistical analysis

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Cancer Screening after the Adoption of Paid-Sick-Leave Mandates

ARTICLE PUBLICATION DATE

2-Mar-2023

THANK JOE

Endocrine Society applauds Eli Lilly’s

efforts to lower insulin costs

Monthly price caps should be available to everyone who depends on insulin

Business Announcement

THE ENDOCRINE SOCIETY

The Endocrine Society commends Eli Lilly and Company for taking steps to reduce insulin prices and make insulin affordable for more people with diabetes.

Eli Lilly's announcement to cut insulin prices by 70% and extend the $35 per month insulin cap to people with private insurance is a positive step towards making insulin affordable for the more than 7 million Americans that rely on the medication.

“Lilly’s move to apply a $35/month cap for people with private insurance will be a significant improvement for adults and children with diabetes who use Lilly’s products,” said Endocrine Society Chief Medical Officer Robert Lash, M.D. “We encourage all insulin manufacturers to join in the effort to reduce out-of-pocket costs for people who need insulin.”

The Endocrine Society has championed measures to improve insulin access for years. Last year, we were pleased that a $35/month cap on insulin for people with Medicare was included in the Inflation Reduction Act and implemented this January 1. The Endocrine Society continues to call on Congress to pass an insulin price cap for all people with private insurance.

More than 7 million people nationwide rely on insulin to manage their diabetes. According to the U.S. Center for Disease Control and Prevention, 37.3 million people nationwide—about 11 percent of Americans—have diabetes.

While insulin was discovered more than 100 years ago, the price of insulin nearly tripled between 2002 and 2013, and the trend upward has continued over the past decade. In 2021 alone, nearly one in five American adults with diabetes—about 1.3 million people—rationed their insulin to save money, according to a study.

The Society will continue to work to improve insulin access for all who need it. 

“Our patients who rely on insulin have waited long enough. The time to act is now,” Lash added.

# # #

Endocrinologists are at the core of solving the most pressing health problems of our time, from diabetes and obesity to infertility, bone health, and hormone-related cancers. The Endocrine Society is the world’s oldest and largest organization of scientists devoted to hormone research and physicians who care for people with hormone-related conditions.

The Society has more than 18,000 members, including scientists, physicians, educators, nurses and students in 122 countries. To learn more about the Society and the field of endocrinology, visit our site at www.endocrine.org. Follow us on Twitter at @TheEndoSociety and @EndoMedia.

Pressure mounts on the other two major

insulin makers to slash prices

Analysis by Rachel Roubein
with research by McKenzie Beard
March 2, 2023 

Eli Lilly announces it will cut insulin list prices. Novo Nordisk and Sanofi haven’t said they’ll do the same.

Drugmaker Eli Lilly announced it was slashing list prices of older insulin products and expanding its program capping how much patients pay for the lifesaving drug to $35 per month.

It didn’t take long for pressure to mount on the other two main insulin makers to follow suit.

Sen. Bernie Sanders (I-Vt), the chair of the chamber’s sweeping health panel, quickly sent letters to Sanofi and Novo Nordisk urging the manufacturers to join Eli Lilly in lowering costs. President Biden called on “other manufacturers to follow.” And Eli Lilly has said its competitors should reduce their prices as well.

Neither Sanofi nor Novo Nordisk indicated plans to immediately copy Eli Lilly’s move, while pointing to other programs they have in place that substantially decrease costs for many patients.

The public pressure yesterday is a prime example of the intense scrutiny the three companies have been under for years to clamp down on the soaring costs of their insulin products. The drug is used daily by roughly 7 million Americans with diabetes to manage their blood sugar levels, and the list prices of the medications have doubled — and in some cases tripled — over the past decade, bipartisan Senate investigators said in a 2021 report.

“I think you can safely say that, like many followed price increases, expect these guys to follow price decreases, too,” said one Democratic pharmaceutical lobbyist who spoke on the condition of anonymity to be candid.

More from Biden:


The details

The move comes after congressional Democrats passed legislation last year imposing a $35 cap on how much Medicare patients pay for insulin. Republicans successfully jettisoned the part of the proposal that would have applied to privately insured patients, arguing it didn’t conform with certain budgetary rules.

Democratic lawmakers, advocates and experts welcomed Eli Lilly’s announcement, though it appears to be not as sweeping as originally meets the eye. Experts say it could particularly help uninsured patients who pay cash and those with private insurance who weren’t part of the company’s already existing program to cap monthly costs at $35 per month.

That program will be improved for patients with private insurance. That’s because the price will be automatically adjusted by pharmacies participating in the program, which amounts to roughly 85 percent of local and national retail pharmacies. Those without insurance will need to continue to download a savings card online so they can get the price cap.

The company also said it would reduce the list price of certain insulins.
For instance: Lilly’s most affordable insulin — its non-branded lispro injection — will run about $25 per vial starting May 1, compared with the current price of $82.41. The list price for Humalog, its most commonly prescribed insulin, and Humulin will drop 70 percent effective in the last three months of the year.
The company also plans to launch a new longer-acting insulin, which it says is interchangeable with a product from competitor Sanofi, but cheaper.

The money trail

One question is whether the change will impact the company’s bottom line.

Some experts said they thought it probably wouldn’t, at least not much, and pointed to the company’s stock price ticking up slightly yesterday.

“Lilly may actually not be losing much in the way of revenue by cutting the list price this way,” Stacie Dusetzina, a professor of health policy at Vanderbilt University School of Medicine. It might be a small change in the amount of money they get for these products, but they could make up for it with additional volume, she said.

The fact that it might not hurt the company’s profits doesn’t mean the move is “a bad thing,” said Craig Garthwaite, a health economist at Northwestern University’s Kellogg School of Management. “We wanted list prices to go down, we have now gotten those prices to go down. That is a good thing.”

Emerging field of evolutionary medicine could address range of health conditions

UCLA researchers say the approach could help tackle cancer, antibiotic resistance, food-related disorders

Peer-Reviewed Publication

UNIVERSITY OF CALIFORNIA - LOS ANGELES

Evolution has helped many members of the animal kingdom adapt to overcome or resist a range of medical issues that scientists are trying to solve in humans.

The giraffe, for example, has a gene that protects the heart from being damaged by blood pressure that would be high enough to ruin a human heart. Elephants possess multiple copies of a gene, one that’s common in mammals, that makes them highly resistant to cancer. And naked mole rats seem almost immune to aging.

Now, scientists in an emerging field of study are studying the evolution of those and other traits to better understand the origins of human diseases — and to pursue cures for conditions that seem intractable.

In a paper published Feb. 28 in Frontiers in Science, an international team of scientists led by two UCLA evolutionary biologists lays out a research plan for “evolutionary medicine.”

Evolutionary medicine applies insights from ecology and evolution to inform, direct and improve biomedical research, public health measures and clinical care. Observing that there are likely countless disease-resistance mechanisms among the vast diversity of life on Earth, the authors argue for the need to systematically search out those mechanisms, uncover their physiological bases and use those findings as the foundation for new clinical treatments and improved public health policy.

“Our bodies and minds evolved in one environment but are living in another — and that mismatch causes disease,” said Dr. Barbara Natterson-Horowitz, the paper’s first author, a cardiologist and evolutionary biologist at UCLA and Harvard University. “Evolutionary mismatch underlies many forms of heart disease, cancer, reproductive disorders and even mental health challenges.”

Conditions like those often are treated as lifestyle diseases; current interventions tend to place the responsibility for treatment on the patient — calling for exercise and dietary changes, for example. However, changing health behaviors doesn’t always work.

“It’s not about treating diabetes when a person gets it at 40, but about making the investment during childhood,” said Daniel Blumstein, a UCLA professor of ecology and evolutionary biology and a co-author of the paper. “Policies that promote interventions early in life can have an immensely positive effect on future health and welfare.”

The paper presents four broad areas in which insights from evolution and ecology could bring the biggest benefits to human health.

• Identifying evolutionary and developmental mismatches with human behaviors could lead to new interventions for obesity, Type 2 diabetes, cardiovascular disease, allergies, conditions related to gut health and mental illness.
• Studying infectious disease epidemiology, such as the evolution in virulence and transmissibility of viruses, could help prevent or stop future pandemics.
• Improving understanding of human development in an evolutionary perspective, could help solve problems in growth, reproduction and aging.
• Learning more about the evolutionary tradeoffs that influence human behavior could inform efforts to promote habits that improve health and longevity.

“Understanding our collective human evolutionary history can help us forecast future public health burdens,” said Molly Fox, a co-author of the paper and a UCLA assistant professor of anthropology and of psychiatry. “Across the animal kingdom and the fossil record, we can draw from a vastly larger pool of information than traditional epidemiology to understand how environments and lifestyles shape the basic processes underlying disease.”

An evolutionary approach could also help guide the development of drugs that don’t induce bacteria to become antibiotic-resistant — interfering with bacteria’s ability to evolve, for example, or using viruses called phages that could infect bacteria and cause them to become more susceptible, rather than more resistant, to treatment.

The authors also describe a possible evolution-inspired approach to overcoming chemotherapy resistance in people with cancer: treating the cancer like an organism undergoing extinction.

“The idea is that an effective way to eradicate a population is to first critically reduce its size with an ecological catastrophe — like the meteor strike for the dinosaurs,” Blumstein said. “And then kill remaining individuals with a second disaster — like the famine that followed the meteor.”

“Extinction therapy” would translate that principle into a clinical strategy. Patients would receive a high dose of one cancer drug to reduce a tumor’s size, as in current protocols. But before drug resistance has a chance to arise, the first treatment would be replaced by another to kill off the remaining cancer cells.

“Knowledge from the wild can inform our understanding of human health,” said Natterson-Horowitz, adding that her own thinking on the subject changed during her time as a medical consultant to the Los Angeles Zoo. “Biodiversity in the natural world can be a powerful source of insights that can accelerate biomedical innovation.”

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JOURNAL

Frontiers in Science