Control del tabaco: cuando la economía vence a la salud

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Tobacco control: when economics trumps health

Tobacco makes a lot of people a lot of money. This mantra should be repeated often during any discussion of the epidemic of tobacco use. Today's discussion arises because WHO released a report on the global tobacco epidemic, stating that 2·3 billion people in 2012 were reached by at least one measure to reduce tobacco use, including warning labels, advertising bans, or high taxes. The report shows increases from 2010 in effective communication of the message that tobacco use is bad for health.

Gaps in coverage therefore exist for two-thirds of the world's population. 37 countries do not dissuade cigarette use with suitable taxation, and 130 have minimal or no policies covering use of warning labels. Even in countries with nominal bans and control measures, lax enforcement and corruption eviscerates their effectiveness. Increasing the number of people covered by comprehensive control measures, such as WHO's Framework Convention on Tobacco Control's MPOWER, will need strong political will.

Such political will—especially moves to restrict advertising and sale of tobacco products—is vehemently opposed by the tobacco industry on the grounds of free trade and intellectual property rights. New Zealand's ambitious plan to reduce smoking prevalence to less than 5% by 2025 and Australia's introduction of standardised packaging, which was targeted by cynical legal opposition, have set benchmarks in tobacco control. By contrast, the UK Government's decision to pause the consultation about the introduction of standardised packaging (citing sparse data, economic grounds, and fears of rises in illicit trade) is a disgrace.

Effective strategies and strong leadership are needed to influence those countries without adequate tobacco control measures. What does the UK Government's decision say, if not that economics trumps health? Despite proportional decreases in use, more people worldwide smoke now than ever before and tobacco use still kills more than 6 million every year. The UK should join Australia and New Zealand in setting an example to the countries looking to strengthen their resolve against the tobacco epidemic.

¿Por qué la oncología?

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 The Specialty of Medical Oncology

Artículo de Alok A. Khorana, MD

Why oncology? It's a question that I am often asked -- by trainees, by other physicians, sometimes even by patients or their families. Implicit in this question is the pervasive belief that cancer medicine is a "difficult" specialty. I would like to address this perception and dispel some of the myths about the treatment of cancer.

Oncology as used here refers primarily tomedical oncology, which is a subspecialty of internal medicine. A fellowship in medical oncology typically lasts for 2 or 3 years following a 3-year residency in internal medicine. The 2- or 3-year term is determined by whether you are subspecializing in hematology and oncology (3 years) or oncology alone (2 years). Hematology encompasses benign diseases such as anemia and thromboembolism, as well as a greater emphasis on malignant hematologic disorders and stem cell transplant. Surgical and radiation oncology are separate subspecialties, although many of the issues are applicable across the board to the treatment of patients with cancer. And although my discussion centers broadly on medical oncology, it is quite common (particularly in academic medical centers) for oncologists to subspecialize. The most obvious split is hematology (benign or malignant) and oncology (basically solid tumors), but multiple other areas of focus can be pursued. My own practice and research, for instance, focus on gastrointestinal cancers; similarly, other oncologists focus solely on lung, genitourinary, leukemia, or transplant patients.

So, why oncology? For me, it boils down to 3 reasons. First, it is rewarding. In contrast to the prevailing perception, the subspecialty of oncology is incredibly gratifying. The relationships that you develop with patients and their families are unlike those in almost any other subspecialty. Once a patient has a diagnosis of cancer, the oncologist serves as both a treating provider and a gatekeeper for other providers. We see the patient and his or her family members on a regular basis. As gatekeepers, our role is similar to that of primary care physicians but is much more intense, given the seriousness of the disease and the frequency with which we see our patients in a short time span. To witness the resilience and strength of my patients and their families amid the devastation of a cancer diagnosis and its implications is always a privilege.

The second reason to choose oncology is that it is challenging. The science of oncology is undergoing a major paradigm shift. For the past several decades, chemotherapy has been the backbone of treatment, but most oncologists agree that we appear to have reached the ceiling of what is possible with chemotherapy combinations. In the meantime, our understanding of cancer biology has progressed substantially and this has led to the development of so-called "targeted therapy" -- drugs designed to affect specific targets that are up- or downregulated in malignant cells. Very few actual cures have resulted thus far from the development of targeted agents, so chemotherapy or combinations of chemotherapy and targeted agents are both widely used as we transition from one generation of treatment to the next. Unlike other subspecialties such as cardiology, oncologists have not yet found answers to all or even most of the most common diagnoses. This means that many advances must yet be made, and if you choose oncology, you will be among those making them. Moreover, there are many ways to make those advances: as a basic science researcher working with preclinical models, as a translational investigator finding new biomarkers, as a clinical trialist testing new drugs, or as a health services researcher, finding ways to reduce costs or improve quality.

Finally, oncology changes quickly and constantly. Oncologists respond rapidly to new data; we are a community of early adopters. It is not uncommon for thousands of oncologists to return home on a Tuesday evening in early June and change their treatment plans for Wednesday morning. As next-generation sequencing is becoming cheaper and more usable at the bedside, oncologists are already using tumor mutational status to make decisions in real time about which drugs to use for individual patients. We are at the cusp of the precision medicine revolution.

Now, it's important to be realistic: Oncology isn't for everyone. If you are squeamish about taking care of dying patients or developing close bonds with patients and families; if you find it overwhelming to manage a myriad of symptoms at once; or if you prefer to not have your treatment algorithms change overnight, then oncology might not be for you.

But if you like science and think that it is cool to be able to use genomics at the bedside; if you are not fazed by challenges and losses; if you want to be at the cutting edge of new drug developments; and, above all, if you want to make really sick people better, do I have the right field for you.