Nonclinical Societal Issues Create Problematic Intersection With Cancer Prevention

Maurie Markman, MD

It would be difficult to overstate the current degree of angst felt by members of the scientific, medical, and public health communities in the United States.

Among these problematic issues are recent rulings from the Supreme Court that many say fail to consider their impact on public safety and health¹; the recent court decision regarding an individual woman’s rights to determine her own reproductive health; the ongoing increasingly intense legal maneuvers to potentially remove from standard-of-care clinical use a pharmaceutical agent (mifepristone) long approved by the FDA as being both safe and effective; and specific state legislative efforts to firmly control local public health agency initiatives, including vaccination strategies. These and other recent events threaten to seriously diminish the well-established and generally positively viewed role of both scientific and clinical expertise in health-related public policy.

Confusion is rampant regarding how clinicians should deal with rapidly changing interpretations of state-related regulations concerning ectopic pregnancies, problematic miscarriages, and other medical conditions where a pregnancy may impact a woman’s life because of the presence of existing or newly discovered serious comorbid medical conditions (eg, cardiac, pulmonary dysfunction). Despite being optimized to improve clinical outcomes for the patient and consider the welfare of the fetus, well-established, effective, and previously accepted practices related to the management of cancer in the presence of a pregnancy may need to be altered based on interpretations of the differing regulations. However, little guidance is available for how these alternative approaches will impact either the fetus or the mother.^2,3

And finally, one must inquire: Will an error in medical judgment regarding local regulations/laws result in criminal or civil penalties for the woman, her doctors, other members of the health care team, or the institution?⁴

Unfortunately, few answers are available to guide the medical community.

Another challenging area for those involved in science, clinical medicine, and public health are the broad societal discussions of the impact of climate change.^5,6 Clearly there is a role for scientific organizations including in the cancer domain in this arena.⁷ For example, the establishment of policies, such as those aimed at avoiding extensive travel to large national or international meetings, may reduce the travel-related carbon footprints.⁸

However, caution should be advised when individual scientists and societies consider an advocacy role beyond their specific expertise. As noted by Naomi Oreskes, the Henry Charles Lea Professor of the History of Science and Affiliated Professor of Earth and Planetary Sciences at Harvard University in Cambridge, Massachusetts, and a well-recognized commentator on the history and practice of science, “The public actually may be eager to hear from scientists who advocate policies that fall within their realm of expertise.”⁹ However, based a survey her team conducted in 2021, she noted: “What members of the public did not endorse, for the most part, were political protests by climate scientists. Perhaps this is because [individuals] made a distinction between scientists as experts—with a capacity to make well-informed recommendations—and scientists taking specific political stands, which might mark them as political, rather than intellectual, actors.”⁹

The point to be emphasized here is that it would potentially be most unwise for this community to view society’s historic, highly favorable, view of scientists and the scientific enterprise as being unshakable and permanent.

Unfortunately, it is increasingly appreciated that the federal, state, and local government’s far-less-than-optimal attempts to communicate a coherent public health message regarding evolving data during the COVID-19 pandemic negatively impacted the objectivity and societal value of the scientific establishment. One quite disturbing result is the percentage of individuals (approximately one-fourth) who in 1 survey responded that they “believed harassing or threatening public health officials because of business closures was justified.”¹⁰ Perhaps not surprisingly, those individuals who “trusted science not much or not at all” where considerably more likely to support such activities against these dedicated public servants.¹⁰

With this experience in mind, is it any wonder a survey in 2021 of public health workers found that 44% reported “they were considering leaving their jobs within the next 5 years for retirement or other reasons,” and of this group—approximately 19,000—“76% began thinking about leaving since the start of the COVID-19 pandemic”?¹¹

Also concerning is that the scientific community is at least partially responsible for effecting society’s view. Items stemming from the establishment include the continuing unsettling mystery related to the origin of the COVID-19 pandemic and the possible role of an unintentional but devastating laboratory mishap,¹² the safety of certain viral research funded by the US government,¹³ and the lack of transparency by American scientists for funding they have received from foreign countries.¹⁴ Other areas of concern could be added, but the point has been made.

Today, though we are witness to the enormous individual and societal costs associated with cancer and its care,¹⁵ we are also aware of very specific strategies that have the unequivocal potential to prevent the development of malignant disease (eg, tobacco, alcohol, and weight control, human papillomavirus vaccination). However, if a large segment of society simply fails to believe the messages being delivered by the clinical scientific and public health communities because of a fundamental lack of trust in the messenger, the distressingly painful results will not be difficult to calculate.

How can the scientific establishment, at all levels, maintain or, were required, regain the trust of society?

Maurie Markman, MD, is president of Medicine & Science at Cancer Treatment Centers of America, a part of City of Hope.

References

1. Auerback JN, Sharfstein JM. The Supreme Court’s new direction and the public’s health. JAMA Health Forum. 2022;3(7):e222978. doi:10.1001/jamahealthforum.2022.2978
2. Christian NT, Borges VF. What Dobbs means for patients with breast cancer. N Engl J Med. 2022;387(9):765- 767. doi:10.1056/NEJMp2209249
3. Silverstein J, Van Loon K. The implications of the Supreme Court decision to overturn Roe v Wade for women with pregnancy-associated cancer. JAMA Oncol. 2022;8(10):1394-1395. doi:10.1001/jamaoncol.2022.3785
4. Cohen IG, Murray M, Gostin LO. The end of Roe v Wade and new legal frontiers on the constitutional right to abortion. JAMA. 2022;328(4):325-326. doi:10.1001/jama.2022.12397
5. Peters E, Salas, RN. Communicating statistics on the health effects of climate change. N Engl J Med. 2022;387(3):193-196. doi:10.1056/NEJMp2201801
6. Solomon CG, Salas RN, Malina D, et al. Fossil-fuel pollution and climate change–a new NEJM Group series. N Engl J Med. 2022;386(24):2328-2329. doi:10.1056/NEJMe2206300
7. Agbafe V. Berlin M, Butler CE, Hawk E, Offodile Ii AC. Prescriptions for mitigating climate change- related externalities in cancer care: a surgeon’s perspective. J Clin Oncol. 2022;40(18):1976-1979. doi:10.1200/ JCO.21.02581
8. Oreskes N. Science needs to shrink its carbon footprint. Scientific American. July 1, 2022. Accessed March 27, 2023. bit.ly/3KeM0Qw
9. Oreskes N. The public wants scientists to be more involved in policy debates. Scientific American. September 1, 2022. Accessed March 27, 2023. bit.ly/40CuESW
10. Topazian RJ, McGinty EE, Han H, et al. US adults’ beliefs about harassing or threatening public health officials during the COVID-19 pandemic. JAMA Netw Open. 2022;5(7):e2223491. doi:10.1001/jamanetworkopen.2022.23491
11. Hare Bork R, Robins M, Schafer K, Leider JP, Castrucci BC. Workplace perceptions and experiences related to COVID-19 response efforts among public health workers- public health workforce interests and needs survey, United States, September 2021-January 2022. MMWR Morb Mortal Wkly Rep. 2022;71(29):920-924. doi:10.15585/mmwr.mm7129a3
12. Kaiser J. Bill would bar NIH and CDC from funding lab research in China. Science. 2022;377(6603):248. doi:10.1126/science.add9089
13. News at a glance: NIH grantees lax on foreign detail. Science. June 9, 2022. Accessed March 31, 2023. https://bit.ly/3GA4iJN
14. Chen S, Cao Z, Prettner K, et al. Estimates and projections of the global economic cost of 29 cancers in 204 countries and territories from 2020 to 2050. JAMA Oncol. 2023;e227826. doi:10.1001/jamaoncol.2022.7826