Cancer rates are rising in the young, Researchers have identified a focal point for the forces they suspect of driving up cancer cases in young people: the gut. They are searching people’s bodies and childhood histories for culprits.

Brianna Abbott, writing in The Wall Street Journal, tells us rates of gastrointestinal cancers among people under 50 are increasing across the globe.  In the U.S., colorectal cancer is the leading cause of cancer death in men under 50 and second for women behind breast cancer. Each generation born since the 1950s has had higher risk than the one before. 

“Everything you can think of that has been introduced in our society since really the 1960s, the post-World War II era, is a potential culprit,” said Dr. Marios Giannakis, a gastrointestinal oncologist at the Dana-Farber Cancer Institute in Boston.

Robert F. Kennedy Jr., President-elect Donald Trump’s pick for Health and Human Services secretary, has pointed to ultra-processed foods and chemicals in medicines and the environment. Cancer doctors share some of his suspicions about diet and exposure to contaminants such as microplastics, shards that make their way from packaging or clothing into our bodies through water and food. They are scrutinizing those and other potential hazards including “forever chemicals” and even light.

“We’re all concerned and want to do something quickly and act quickly, but we want to do so based on sound science,” said Dr. Andrew Chan, director of epidemiology at Mass General Cancer Center in Boston.

His team has found connections between early-onset colorectal cancer risk and obesity, consuming a lot of sugar-sweetened beverages and physical inactivity.  But those studies don’t prove a direct cause. Chan’s team is expanding its work to incorporate studies that track more people and analyze blood, tumor and stool samples. They will scour the results for potential carcinogens, then expose mice to them and see if cancers develop. They plan to first focus on obesity and alcohol, said Yin Cao, a cancer epidemiologist from Washington University School of Medicine in St. Louis, who co-leads the work with Chan.

Excessive alcohol use is linked with risk for early colorectal cancer, studies show, along with diets high in fat and added sugars. One study found people who ate more ultra-processed foods had a greater risk of precursors to colon cancer.

The group plans to test ways to lower risks, including whether prescribing weight-loss drugs including Ozempic can help prevent colorectal cancer. Another trial will assign some participants a healthier diet and study whether changes in the bacteria and pathogens in the gut, called the microbiome, affect their risk.

“There’s an  interplay most likely between the things we eat, the bacteria in the gut, and what those bacteria produce,” said Dr. Jordan Kharofa, a gastrointestinal-cancer specialist at the University of Cincinnati Cancer Center, who isn’t involved in the study.

Kharofa and other researchers have uncovered links to diets high in sulfur, which results from consuming lots of liquor and processed meat and few fruits and vegetables. Gut bacteria can turn that sulfur into hydrogen sulfide, which could inflame the colon and raise cancer risk.

 But some patients don’t fit that description at all. “They are very, very health conscious, and then they come into your clinic and they’re 33 and they’ve got stage-four colon cancer,” said Dr. Marwan Fakih, a gastrointestinal oncologist at City of Hope in Duarte, Calif. “There’s no question we’re missing something.”

Some researchers are looking at antibiotics, which disrupt the microbiome. One California team analyzed medical records and failed to find a solid link to broad-spectrum antibiotics, but the early results suggest long-term use could increase risk.

“We don’t have all the answers yet,” said Jane Figueiredo, a professor of medicine at Cedars-Sinai Medical Center in Los Angeles. “There might not be a magic bullet.”

All of this makes us realize there is much we still don’t know about the causes of cancer and therefore much we need to learn. Perhaps it makes sense to take another look at our diets and the processed foods that we consume, as Kennedy suggests.

The recent cold-blooded murder of the UnitedHealth insurance executive has prompted a debate about the pros and cons of healthcare insurance. No one in their right mind should advocate murder of anyone, let alone because of a grievance with the healthcare industry. But it is good to better understand the healthcare system we live in, especially as it compares to alternatives in other countries.

There is no one better to assist us in that discussion than John C. Goodman, a healthcare economist who writes for The Independent Institute. Recently he reviewed and compared the healthcare system of Canada with the U.S. But before we compare different healthcare systems, we need to better understand problems that all healthcare systems face.

Three Problems in All Systems

Goodman says there are three problems with the doctor-patient relationship in all developed countries – regardless of the way the payment system is organized:

First, when a third party is paying the bill, neither the doctor nor the patient has any incentive to apply the kind of cost/benefit analysis that is normal in the purchase of any other good or service. In considering whether to obtain an expensive test (an MRI scan, e.g.), the incentive is to consider only the benefit. Since cost is irrelevant to the patient, a tiny benefit—no matter what the cost—is viewed as desirable.

Second, in a fee-for-service arrangement (such as exists in both the U.S. and Canada), the more services doctors perform, the higher their incomes. So, just as patients have an incentive to over-consume, doctors have an incentive to over-provide.

Third, there is malpractice liability, which is especially a problem in the U.S. A doctor who orders an unnecessary MRI scan faces no real penalty. But no matter how improbable, there is always a chance that a scan not ordered will fail to detect a problem that grows worse through time. Our legal system, therefore, provides incentives for too many tests and too many procedures, compared to a system in which costs would have to be justified by comparable benefits.

These are called perverse incentives in the language of economists. If they are not checked in some way, medical care becomes unreasonably expensive. That means higher premiums or higher taxes, depending on your healthcare system, or both. How do we check these perverse incentives?

The Canadian System

Canada checks these incentives by limiting resources. The typical Canadian general practitioner, for example, does not have radiology equipment and must send patients to a hospital for simple x-rays. The hospitals, in turn, operate under global budgets that limit spending, no matter what the level of demand. In other words, they put profits before patient care. This can happen in any healthcare system.

Canada ranks 25^th of 29 countries on the number of MRI scanners per person. As a result, the wait for a scan is almost three months, and the wait until final treatment is more than six months. The government has decided to prevent overuse of MRI scanners by severely restricting the number of scanners that are available.

Canada’s system of limiting heath care resources and forcing doctors to ration care has many undesirable characteristics. The system favors high-income over low-income patients. It favors white patients over racial minorities. It favors city dwellers over rural residents. It favors the politically connected over those without connections. Arguably, there is more inequality in access to health care in Canada than there is in the United States.

You might suppose that in countries that impose rationing, such as Canada and the U.K., doctors are forced to be more efficient—prioritizing resources so that the most promising procedures are done first. But studies by the RAND Corporation found that this isn’t so. In Canada and Britain, for example, scholars found just as much unnecessary care (as a percent of the total) as they found in the United Staes.

Then there is fraud, which is a special problem in government-administered programs. In Medicare and Medicaid, for example, fraud is estimated to consume at least $100 billion a year. Hospital upcoding (claiming a higher level of patient severity in order to obtain a higher insurance payment) is another problem. One study estimates that increased upcoding (relative to a decade earlier) was associated with $14.6 billion in hospital payments. Although doctors are the biggest critics of claim denials, hospitals are by far a bigger problem.

The Pre-Authorization Problem

As a doctor, I can tell you that pre-authorization is the bane of practicing medicine. It slows down your treatment of the patient and sometimes prevents you from doing what you know is needed. But there is a role for pre-authorization to hold doctors accountable for their treatment decision-making.

Goodman explains: “An important tool private insurers use to avoid unnecessary spending and inappropriate care is to require preauthorization for a particular drug, therapy, or procedure. Doctors tend to regard these procedures as burdensome and irksome. Yet only 7.4% of requests by patients in Medicare Advantage and Medicaid managed care plans are denied. Moreover, in the vast majority of appeals (83.2%), the initial denials are overturned.”

It’s easy to think other countries have better healthcare, but the facts don’t support that claim. All countries with government-provided healthcare (socialized medicine) suffer from the same problem: rationed care. If you can’t get in to see the doctor, or the government won’t allow the treatment he recommends, your “free healthcare” isn’t really free.

The public seems to understand this. Despite occasional complaints, more than two-thirds of Americans rate their health insurance as “good’ or “excellent.” And that holds for all kinds of insurance: employer plans, (Obamacare) marketplace plans, Medicare and even Medicaid. Even among people who say they are not in good health (and who, presumably, need medical care), a substantial majority give positive ratings to their health plans. Only a tiny percent rate their insurance as “poor.”

The U.S. Surgeon General, Dr. Vivek Murthy, says drinking alcohol can cause cancer – even in moderation. In fact, he is calling for all alcoholic beverages to carry warning labels to inform the public of the danger, much like cigarettes were required to do many years ago.

“Alcohol is a well-established, preventable cause of cancer responsible for about 100,000 cases of cancer and 20,000 cancer deaths annually in the United States,” Dr. Vivek Murthy said in his advisory issued Friday. “Yet the majority of Americans are unaware of this risk.”

Laura Cooper and Brianna Abbott, writing for The Wall Street Journal, tell us “An act of Congress would be required to change the existing warning labels on bottles of beer, wine and liquor. Today, federal rules require only a warning against drunken driving and drinking while pregnant, as well as a general warning that alcohol “may cause health problems.”

Alcohol consumption is the third leading preventable cause of cancer in the U.S., after tobacco and obesity. The link between alcohol consumption and cancer risk has been established for at least seven types of cancer, including breast, colorectum, esophagus, liver, mouth, throat and voice box, Murthy said.

The Distilled Spirits Council, a spirits industry group, pointed to recent research from the National Academies of Sciences, Engineering and Medicine concluding that men who consumed two drinks a day and women who consumed one drink a day had lower all-cause mortality rates than people who never drank alcohol. The same report also found a link between alcohol consumption and breast cancer risk. “Many lifestyle choices carry potential risks,” and the government should consider the entire body of scientific research, the spirits council said.

Obviously, this council has an inherit bias since they represent an industry that profits from the sale of alcohol. But are there differing opinions on this issue in the scientific literature?

Allysia Finley, also writing for The Wall Street Journal, says yes. She says, “Surgeon General Vivek Murthy has done more to politicize science and erode trust in public-health leaders than anyone other than Anthony Fauci. Dr. Murthy was at it again on Friday with a headline-grabbing report that recommends alcohol be distributed with cancer warnings.

She notes two weeks earlier the National Academies of Sciences, Engineering and Medicine released a congressionally mandated review of the recent evidence on the health effects of moderate drinking, or up to one drink a day for women and two for men. Its more than 200 pages of findings run counter to Dr. Murthy’s 22-page report, though they got scant attention in the press.

The academies found insufficient evidence to support a link between moderate drinking and oral, pharyngeal, esophageal, laryngeal and other cancers. It did find a slightly higher risk of breast cancer with moderate drinking but also a lower risk of death generally and from cardiovascular disease specifically compared with never drinking.

Finley says, “More government is Dr. Murthy’s prescription for every social and public-health ailment. Given this record, why would anyone take his latest warning about alcohol and cancer seriously?”

Since I was in medical school in the 1970s, we have known that excessive use of alcohol is related to certain cancers such mouth, throat, esophagus, liver, colon and breast. Yet there has been little evidence it is correlated with occasional to moderate alcohol usage. In fact, occasional use of alcohol, especially red wine, has been associated with reduced cardiovascular risk. This new surgeon general report is a deviation from this prior information.

If this is really more about political ideology than science, I would expect some pushback from the medical community in the near future, especially after the inauguration of our new president. Let’s wait and see.