Part 3: Glory—Is cancer beating cardiovascular disease?

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New York, NY - With the noble goal of raising awareness and reducing death and suffering from the second most common cause of death in the developed world, the American Cancer Society has been a success by any yardstick. Its signature events attract participants in droves. US communities hosted more than 5100 "Relay for Life" events in 2010, drawing in 3.5 million people, and an additional 220 "Making Strides Against Breast Cancer" events, attracting more than 800 000 participants. In 2010, its fundraising events, as well as contributions and bequests, brought in more than $903 million. For its success, the American Cancer Society is listed as one of the world's most successful nonprofit groups.

Total monies raised in 2010 by the AHA, American Cancer Society (ACS), Susan G Komen for the Cure, Lance Armstrong LiveStrong, National Children's Cancer Society (NCCS) from fundraising, contributions, bequests, etc.

Other prominent cancer organizations also boost visibility for different forms of the disease and in so doing raised millions of funds in 2010, among them the Susan G Komen for the Cure foundation ($421 million raised), the Lance Armstrong Foundation ($48.2 million), the Prostate Cancer Foundation ($40.2 million) the National Children's Cancer Society ($18.7), and countless others. In fact, the US Better Business Bureau lists more than 25 registered and "accredited" charities devoted to cancer; for heart disease, it lists just one: the American Heart Association (AHA).

So when it comes to winning over hearts, minds, and wallets, cancer is a tough act to beat. The AHA's primary public-awareness activities are its "Heart Walks," held annually at different times of year in different locations. According to numbers provided by the AHA, last year's events attracted roughly a million participants to 350 events. Total public support in 2010, from Heart Walk participation and other fundraising events such as the AHA's Heart Ball, Go Red for Women luncheons, and Workplace Giving programs, plus other contributions and bequests, was $509 million. That's nothing to sneeze at, but it's just 55% of what the American Cancer Society alone pulled in that same year.

Dr Donna Arnett

Just why cancer, as a cause, seems to have so much more public resonance, generally, than cardiovascular disease is difficult to explain, although many people interviewed by heartwire said the same thing.

"I think, rightly or wrongly, people are more afraid of cancer, even though cardiovascular disease and stroke are the number-one and now number-four causes of death and have been for a very long time," says incoming AHA president Dr Donna Arnett (University of Alabama at Birmingham). "It is interesting; I don't understand it."

The fear factor

Earlier this year, a survey conducted by insurance company MetLife called "What America Thinks" found that 41% of responders named cancer as the disease they feared most; only 8% named heart disease, and another 8% feared stroke. Surveys of women conducted by the AHA have repeatedly shown that many women believe cancer to be their number-one cause of death, not heart disease.

Others note that most people believe heart disease, for the most part, claims men and women toward the end of their lives, whereas cancer strikes down people in their prime or earlier. And indeed, Centers for Disease Control and Prevention statistics show that cancer is the more common cause of death in people under age 65, while CVD deaths move past cancers to be the number-one cause of death in people age 65 or older. On a website devoted to breast-cancer awareness, however, the CDC notes that heart disease, not cancer, is the number-one case of death in women over age 40.

Some projections also suggest that age cut points for heart disease deaths are creeping downward, due to mushrooming rates of obesity and diabetes and lower levels of physical activity in kids and young adults.

Just desserts?

Dr Thomas Bersot [Source: University of California, San Francisco]

That speaks to another important difference in attitudes toward cancer and heart disease. Despite the fact that morbidity and mortality would be reduced for both diseases if people committed to lifestyle changes, there's a pervasive sense that many people who have heart attacks got what was coming to them after years or decades of undisciplined eating, smoking, inactivity, or stress: modifiable risk factors that they themselves failed to take in hand.

The fact is, says Dr Thomas Bersot (University of California, San Francisco), "We have treatments for cardiovascular disease, especially if people would pay attention to lifestyle issues, [although] there are not good ways to induce people to change behavior. And I think that many people view heart disease at a policy-making level, as something that can be dealt with if people could just change their lifestyles."

He continues: "There are many, many kinds of cancer, with different sets of risk factors and different mechanisms of initiation of the malignancies, as opposed to heart disease, where it's pretty much the same for everybody." For most cancers, their myriad etiologies are less well understood, making their occurrence seem so much more random and unjust. The physical manifestations of cancer symptoms and treatment also have a powerful effect on the public consciousness, whereas cardiovascular disease, with the exception of end-stage heart failure, is by and large a hidden disease.

"People will say, at least if you die of a heart attack, you're gone, that's it. But people worry about wasting away with cancer, losing their hair, all the things that can happen to them," agrees American College of Cardiology (ACC) CEO Dr Jack Lewin.

A more compelling story

There's no getting past the fact that the battle against heart disease has advanced by leaps and bounds in recent decades, whereas cancer has had more modest and sporadic gains. And that fact in itself seems to have an effect on the public psyche.

Every year, the National Institutes of Health (NIH) director testifies before the US S enate to present its funding needs for the institutes that make up the NIH. In the segment of his 2011 funding request entitled "How far we've come," Dr Francis Collins cited "the area of cardiovascular disease" as having made "some of the most impressive gains" of the mid-20th century.

Cancer, by contrast, fell under the section "How far we have to go," with Collins noting that cancer "still claims the lives of more than 500 000 Americans annually—about one every minute."

Dr Clyde Yancy

"So globally, it looks like there is dissimilarity in our ability to treat and prevent these major diseases, with some more successes in CVD vs other causes of death," Dr Clyde Yanc y (Northwestern, Chicago, IL) points out. "But we haven't cured anything—that should be very clear."

In fact, heart disease is rarely couched as something that can be cured so much as prevented, whereas the quest for a cancer "cure" has long been a compelling story. A recent survey of 48 different US media outlets over an 18-month period, conducted by the Pew Center's Project for Excellence in Journalism, found that cancer received the most media attention of any one disease: 10.1% of total health coverage. By contrast, heart disease was a distant third, with stories on cardiovascular disease making up just 3.9% of news reports over the survey period.

Dr Christopher Milne [Source: Tuft University Center for the Study of Drug Development]

Dr Christopher Milne at Tuft University's Center for the Study of Drug Development, whose research probes trends in drug research, development, and approval, says it's conceivable that the ability of nonprofit groups, media attention, and other public forces to raise the profile of a particular disease may influence research, funding, and ultimately drug development.

The National Cancer Institute, for example, "has always been good at getting publicity to some degree for what they've been doing," he says. And leveraging the level of publicity also achieved by the nonprofit groups likely also carries some weight. "There is perhaps a stronger advocacy on the part of cancer patients, from what we've looked at in terms of advocacy; the cancer groups are one of the strongest, and that counts when [government bodies] are trying to divvy up that sizable chunk of money every year."

Dr Jack Lewin [Source: American College of Cardiology]

Without question, agrees Lewin, "people are more frightened of cancer than they are of heart disease, and that really does influence the emotionality of how much money the NIH gets, and how Congress is always ready to rush and give cancer more money than they'll give heart disease almost any time."

Yancy, likewise, choosing his words carefully, says he also thinks members of the Senate tasked with carving up the NIH pie are, at some level, more persuaded by the outlying needs in cancer than they are by those in cardiovascular disease.

"Some of that is political will, and if the political will is—correctly—the perception that cancer is a very compelling problem and that we haven't won that war, that progress has been slow, then one response to that would be in fact to drive more research energy toward answering that question."

With all their heart

When asked, the AHA always circles back to the point that heart disease is the number-one killer, claiming 598 607 lives in 2009. Malignant neoplasms were the cause of death for 568 668 people that same year. Those heart-disease death rates declined 3.7% from the previous year, and cancer deaths just 1.1%.

But if, for heart diseases, there are fewer drugs in development, less money for research, less notoriety in the public imagination, it's conceivable that some of the momentum that has driven heart-disease deaths down in recent decades could be lost.

Dr Barry Franklin [Source: Beaumont Hospital]

And that will cost not only lives, but dollars: according to the AHA, CVD is the most expensive diagnosis in the US, costing more than three times more money each year, in direct costs, than cancers. According to National Heart, Lung, and Blood Institute numbers, total heart disease costs were $324.1 billion in 2010, while neoplasms were $102.7 billion^[1].

Dr Barry Franklin (Beaumont Hospital, Royal Oak, MI) chairs the AHA's advocacy committee: he, too, can't quite make sense of the numbers. "Each day we lose 2300 people to heart diseases and stroke—that's pretty sobering, when you consider that that's what we lost on 9/11. I don't think the average lawmaker has a clue!"

Of the $35 billion dollars the NIH has been allocated for 2012, roughly $1.7 billion has been earmarked for heart disease and stroke, he points out. "In 2006, we spent over $100 billion dollars on angioplasty and bypass surgery, and we're fighting to get $1.7 billion for research over the next year in cardiovascular disease—you see where I'm coming from? And when I hear people saying we want to cut the research budget, it just doesn't make sense to me. Lawmakers need to get a better hold on what the ramifications are of cardiovascular disease."

Professional help

Some observers point out that the professional societies and nonprofit organizations could take a closer look at their own organizational structures to understand the disparities between cancer and heart disease in the public consciousness.

In cancer, the American Society of Clinical Oncology (ASCO) serves as the professional society, publishes a journal, and hosts the annual meeting, as well as advocating for practicing physicians. By contrast, the formidable efforts of the American Cancer Society are devoted 100% to the public, "helping people stay well, helping people get well, by finding cures, and by fighting back." The American Cancer Society raises money for research, but there's no distracting physician-education or journal-publishing component, and it has its own powerful patient-advocacy branch, the American Cancer Society Cancer Action Network, that "is working every day to make cancer issues a national priority."

By contrast, the roles of the ACC and the AHA are a little more blurred.

Both have as part of their missions improving "heart health"; the AHA is a registered charity, focused on public education, patient advocacy, heart-disease prevention, and research. The ACC is the professional society focused on practicing physicians, their education, clinical-practice standards, appropriate use of therapies, and advocacy.

But both cardiology organizations have physician membership components, both publish journals, both are involved in guideline development, and both societies organize annual scientific meetings.

"Where I see some difference [between oncology and cardiology] is that with the cancer organizations there is a little clearer separation of the roles: the cancer society doesn't get into the patient-care part of cancer much at all, and the AHA and ACC overlap a bit more," Lewin admits. "But they are more similar than dissimilar."

Of note, the AHA spent almost 13% of its budget on professional education and training and 16% of its budget on fundraising. By contrast, the American Cancer Society spends no money on professional education but 21% on fundraising efforts.

Getting the word out

Asked whether he wished the AHA had a different structure or had done something better or differently to match some of the American Cancer Society's successes, Franklin is adamant.

"I think the AHA has done a very, very good job in getting the word out that coronary disease is our number-one killer and cancer is typically number two. I think the leadership of the AHA—and I've been a member for 30 years—has been absolutely exemplary in getting the word out."

Franklin points to a recent AHA fundraiser in Detroit, where the economy is "depressed as hell," as an example of the AHA's success.

"We just had several thousand people walking in the Detroit Heart Walk and we raised $1.4 million dollars a month ago. That's not chump change, and that's in the Detroit area! . . . If we're behind, we're rapidly catching up," he insists. "To me: there may be reasons [why heart disease is lagging behind cancer] but is it something the AHA isn't doing? I don't think so."

Lewin also praised the AHA for the advocacy and awareness work it's done over the decades, as well as the ACC, particularly in areas like smoking cessation, although he acknowledged: "There are always missteps and always room for improvement."

But Lewin also makes the bold prediction that despite cancer's public profile and all of the strides being made in oncology, cancer will surpass heart disease as the number-one killer in the developed world in the next 10 years. That said, even in the US, the rising tide of heart disease among minority and lower-income groups, as well as what Lewin calls "the global pandemic of cardiovascular disease," should prompt cardiologists and heart-disease activists alike to look to the American Cancer Society for inspiration.

"I think we really ought to pay attention and copy some of the things they're doing, because they've been really good at engaging the patients and patients' families, and telling stories, and really grabbing people emotionally to contribute and participate. And part of it is the scary nature of cancer, even though heart disease should be scary as well, in my view."

Maybe, says Lewin, "we've been resting on our laurels a little bit, because we've been so successful in reducing morbidity and mortality from heart disease that we're saying, gosh, we're doing so great, what's the problem? The reality is we still have a long way to go, and there is a whole lot more to do."

Heartwire from Medscape © 2011 

Cite this: Part 3: Glory—Is cancer beating cardiovascular disease? - Medscape - Aug 18, 2011.