It’s tough to keep track of all the chemicals and the behaviors that will give you cancer these days.  Since the 1980s when indoor smoking was banned in most work places, office workers have become accustomed to seeing coworkers take breaks throughout the day to stretch, walk outside, breathe the fresh air, and then dump carcinogens in their lungs with a cigarette.  Whose health outcomes are more promising: the person sitting at their desk all day or the one who took breaks, but smoked?  Researchers are hard at work to unveil this mystery and, at least so far, they say both lose out.

“People spend 9.3 hours per day on their derrieres, eclipsing even the 7.7 hours they spend sleeping,” WIRED Magazine reported in 2013 under the headline In Silicon Valley, Sitting is the New Smoking. “Their sedentary lifestyles contribute 10 percent of the risk of breast and colon cancer, 6 percent of the risk of heart disease, and 7 percent of the risk of type 2 diabetes.”

ABC News reported more bad news earlier this year.

“And research also shows that even if you hit the gym or the jogging path every day, sitting is bad for you.”

The ABC article was based on a meta-analysis of 4 million lives published in the Journal of the National Cancer Institute. It found that the risk of colon and lung cancer increases by over 5 percent per two hours per day spent sitting per day.

Coffee Was The New Smoking in the 1980s

Before sitting became the new smoking, coffee held that honor due to a failure of research design.

“The classic example is the research that showed that those who drink coffee are much more likely to get lung cancer,” Genomics Professor David Veenstra said at the 27^th Annual AMCP Conference last week in San Diego during a talk on the importance of comparative effectiveness research (CER). The poor health outcomes of smokers, who tend to drink more coffee, were mistakenly associated to coffee drinking and the 1980s news was teeming with headlines like “Coffee Causes Cancer.” 

Coffee was not in fact the new smoking, but was blamed for tobacco’s risks due to a poor research design comparing health outcomes of coffee drinkers against those that do not drink coffee. As soon as researchers segregated smokers from both groups, the link between coffee and cancer went up in smoke.

In the pharmaceutical CER world, a poor research design can lead to mistaken beliefs about medications and therefore lead to poor health outcomes and weak sales, which is why I attended two sessions at AMCP on CER and how manufacturers can effectively engage in it to contribute to public health.

Why Sit When You Can Surf?

It was a quick jaunt down to San Diego from San Jose for the HIRC team where we headed straight to Mission Beach for a surf lesson. (Luckily for HIRC employees, HIRC’s commitment to health doesn’t stop at communicating the priorities and needs of health plans to pharmaceutical companies; we live it and breathe it as demonstrated by our awesome opportunities to surf, run, and engage during the conference.)

Conditions were “blown out” (surf lingo for windy) but the sun was out and we each got plenty of opportunities to paddle, “pop up” (get to our feet) and ride waves before collapsing, exhausted, at the Marriott for an early night. Despite soreness of muscles we didn’t know we had, the next morning before dawn we redeployed our weary bodies and joined about 150 others for a charity 5K before heading to the conference where, after all that activity and whether it was good for us or not, sitting was a welcome refuge.  I headed straight to a comfortable seat for a one-hour discussion on research challenges in CER.

Challenges for Payers and Manufacturers in CER

With the exception of very large plans, payers typically lack a systematic approach to evaluating medicines and interventions, said head of the Science Payer Group at GlaxoSmithKline, Omar Dabbous.  

Dabbous outlined a few ways for manufacturers to develop CER that payers will utilize:

• Base it on the payer’s data

• Offer complete transparency throughout the research process

• Make the research actionable

“Make it applicable to real world data,” Dabbous said, which is most trustworthy if it is transparent and, critically, based on the lives managed by the payer. This transparency requires a paradigm shift among manufacturers that are generally more concerned with propriety, for instance, during the research process.

Patient-Centered CER

The top contributor to the growth of actionable CER over the last 5 years, Dabbous said, was the development of the Patient-Centered Outcomes Research Institute (PCORI). PCORI, a CER funding agency that includes all health care stakeholders from the development of the research question to the real world implementation steps, has five aims:

1. Address system level issues
2. Critically evaluate different treatment options
3. Address issues of disparities
4. Accelerate the CER process with superior data infrastructure
5. Disseminate the findings

PCORI executive director Joe V. Selby, MD, MPH, who spoke at the other CER session I attended, explained the types of projects PCORI funds, the mission that drives their projects forward, and the engagement PCORI seeks from manufacturers and other stakeholders.

“Organizations that can move public opinion need to be involved from the beginning,” Selby said. Along that vein, he was notably eager to get industry players in the room who were interested in partnering with PCORI, and avid that clinicians in the room should apply for funding.

The studies PCORI funds are not always disease-specific but they are always patient-centered, Selby said. Therefore a study between two treatment regimens to maintain A1c levels would not interest PCORI, whereas a study to minimize side effects or symptoms would.

“It’s got to be quality of life centered—mortality, functionality—outcomes that matter to patients.”

This nuanced version of CER is one difference between NIH’s CER funding and PCORI. Another is the emphasis on translation of the results to the real world. The impact on public health and the involvement of patients as engaged stakeholders rather than clinical subjects are critical to PCORI’s mission, Selby said.

Is the Solution Right-Brain CER?

The keynote speaker, graffiti artist and business strategist Erik Wahl, was a surprising addition to an otherwise clinically and analytically heavy agenda. I made my own CER study comparing the effectiveness of left-brain, analytical sessions throughout the day against Wahl’s right-brain approach, painting Bono, an eagle, and Einstein upside down on stage to the tunes of U2 while discussing the big picture challenges health care stakeholders are facing today and asking the audience to learn how to utilize the right brain for problem-solving.

Trying to apply a right-brain approach to a left-brain world can be challenging, and certainly isn’t always appropriate (Wahl pointed out he would prefer his heart surgeon stick to the left brain while holding a scalpel) but the holistic approach to care that PCORI is advocating and supporting through CER seems like it’s off to a good start by redefining the role of patients as stakeholders in the research design.

So Is Sitting Going to Give Me Cancer or Not?

A few decades after the “coffee gives you cancer” debacle but just a couple years since “Sitting is the New Smoking” became a common headline, the answer remains unclear: does sitting itself cause tobacco-like health outcomes, or is there a correlate that needs to be teased out?  Could it be, for instance, that spending all day in left-brain analysis mode causes cancer? Would a monk or nun who sits in meditation all day suffer the same poor health outcomes as a software engineer in Silicon Valley? 

Until robust research that can segregate those who sit all day in front of a monitor activating left-brain analytical neurons from those who sit in quiet contemplation activating right-brain holistic neurons, only time will tell if sitting causes cancer.  Until then, I’m going for regular walks and maybe requesting a stand-up desk.