Jun 29 2007

Why Havent We Cured Cancer?

Below is a recent e-mail I received. It reflects a widespread belief, and is frequently invoked by the CAM community to promote bogus therapies. The relevant section of the e-mail is as follows:

“To the question: while I don’t believe in conspiracies, we have been treating cancer using the same 3 methods (chemotherapy, radiation, and surgery) for at least the past 30 years, despite the billions of dollars which have been spent on research. I feel that there isn’t an incentive to find a cure. There is too much money at stake, and jobs depend upon the research and treatment. Your thoughts, and keep up the good work.”

There are a number of common misconceptions in this question:

A Cure for Cancer

Cancer is often referred to by non-experts as if it were a single entity – one disease. In fact it is a category of diseases, also referred to as neoplastic diseases. Neoplasms result when a single cell mutates so that one or more of the normal mechanisms that restrict cell growth are disabled. The cell then reproduces without restriction, forming either a solid tumor or a blood cancer like leukemia.

The many types of cancer differ in important ways. They are classified by the cell type that gave rise to the cancer (liver cell vs brain cell, etc), the grade of the cancer, which refers to how aggressive the cancer is and relates to the type of mutation that caused the neoplastic transformation, and finally the stage of the cancer. Stage refers to how advanced the cancer is: is it localized, has it spread locally, has it spread to the lymph nodes, has it spread to distant tissue (called metastasis). Each type, grade, and location of cancer is a different disease (whereas stage refers to how advanced the disease is).

There probably will not be a single cure for cancer anytime soon (not with current technologies), just as there is no one treatment for all infections.

The War on Cancer

It is easy to understand why the public would have the sense that advances in cancer treatment have not been keeping pace with scientific advances in general or with the expectations for cancer specifically. But in reality cancer treatment has been steadily progressing, reflected in a slow but steady improvement in survival for most cancers and also the trend for less radical or destructive treatments. Some cancers, like the various types of breast cancer, are mostly curable if they are caught early enough. Other cancers, like pancreatic cancer or glioblastoma multiforme (a type of brain cancer) have seen little improvement in outcomes.

Again, this is similar to other advances in medicine. We have eradicated some infectious diseases, like small pox, while others, like tuberculosis and malaria, are stubbornly persistent.

The notion that the billions of dollars in research should have produced more effective treatments then we currently have, if not an outright cure, is naïve. It is not based on any assessment of the science. Cancer is a very difficult nut to crack. The challenge is to find ways to kill some cells in the body – cancer cells – with minimal effect on all the other cells in the body. Meanwhile such treatments are a race against time, especially for aggressive cancers, for cancer cells (by definition) rapidly reproduce and spread. Cancer cells may even mutate further, becoming more aggressive or even resistant to treatment.

Researchers have made tremendous progress and have been very clever and innovative in their approaches to cancer treatment. We are learning more and more about what makes cancer cells different from non-cancer cells, and with each new advance in our understanding cancer researchers think of new ways to exploit this knowledge to fashion new treatments – even entirely new treatment approaches. Constantly rethinking the problem of cancer is what has led to the steady progress we have made and continue to make.

So the unstated premise in the question, that we should have made more progress by now if the effort were sincere, is false. It is similar to those who believe that we could have a synthetic fuel by now were it not for the big oil companies silencing any such research. The reality is that gasoline is a cheap and efficient fuel, highly combustible yet stable over a range of temperatures necessary for convenient storage and use. Coming up with a gasoline alternative that compares favorably in all of these respects has proven very challenging. No big oil conspiracy needs to be invoked to explain the lack of success so far.

Slash, Burn, and Poison

The three standard treatments for cancer are surgery to remove solid tumors, radiation therapy to kill cancer cells, and chemotherapy to disrupt one or more mechanisms by which cancer cells survive and multiply. Each of these technologies have steadily improved over the last century, becoming more and more targeted and effective.

Critics of scientific medicine have promoted the notion that standard medicine is over-reliant on these methods and does not give adequate attention to other modalities. I disagree with this in general – I think that the various treatment modalities are given the attention they deserve based upon both evidence and our understanding of basic biology.

With regard to cancer specifically, if one is going to charge that other modalities are being ignored, then what those alleged modalities are needs to be specified. There are no magic treatments out there.

CAM proponents offer only dubious alternatives. Often the modalities they offer are entirely fake – for example manipulating non-existent energy fields, purifying imagined and unidentified toxins, and even fake “psychic” surgery. Often the treatments are drug therapies, but this fact is obscured by jargon, such as calling the drugs “natural.” The only difference between CAM drug therapies and standard drug therapies is that the CAM therapies don’t work.

Another treatment modality offered as an alternative is nutritional. Nutrition is an important part of standard cancer treatment, to help maintain general health and weather the side effects of the treatment. But there is no evidence and no theoretical support for the claim that vitamins or supplements alone can affect the course of cancer. Such claims are often combined with the claim that such treatments “boost the immune system” so that the immune system can fight the cancer itself. The assumption is that an optimally functioning immune system should be 100% effective against cancer, but there is no basis for this assumption. The immune system is not perfect, and cannot be made so by nutrition alone.

The Incentive to Cure

Cancer cure conspiracy theories often hinge on the claim that there is no incentive to find a cure for cancer. But again this is based on an overly simplistic and extremely flawed concept of the medical community. Despite the popular image promoted by critics, the pharmaceutical industry does not control medicine. The healthcare infrastructure has many independent components. The motivation of each would need to be considered separately.

While it is true that pharmaceutical companies make their decisions largely, even entirely, on the net effect on their profits, this does not mean they would not want to find cancer cures. (Again, just for emphasis, it is highly unlikely that a single cure for all cancer will be found anytime soon, but here I will refer to as a cure any highly effective treatment or cure for any type of cancer.) As patents for existing drugs expire, companies are always looking for the next new treatment. Any company with a new effective cancer cure would make billions.

What about treatments that cannot be patented? These would still be highly profitable – although only about 20% as profitable as a patentable drug. A drug company would not lose money on such a treatment, however. Also, the PR value to a company for curing cancer cannot be underestimated.

Even if we assume the worst case scenario from the perspective of the pharmaceutical industry – that one company has identified a potential treatment that cannot be patented and which they determine would not be worth the development costs – this would lead only to that company not developing that drug. They would not, however, be able to prevent their competition from developing it. They would also not be able to prevent academic cancer researchers from getting an NIH grant to research the new drug.

This brings us to cancer researchers and their institutions as entities separate from the pharmaceutical industry. The motivation to find a highly effective cancer cure is tremendous. Every cancer researcher wants to work in the lab that cures cancer. Every academic institution wants to have their name forever associated with curing cancer. The benefits would be enormous – literally fame and fortune. Research dollars would flood any lab on the trail of a cancer cure. A university with such a lab could easily raise funds to open a new cancer center and become a world leader in cancer treatment. The notion that there would be no incentive on the part of researchers and institutions to cure cancer is, to be polite, incredibly out of touch with reality.

Another factor to consider is that cancer treatments do not come out of the blue. They derive from basic science knowledge about how cancers function – what makes them different. This basic science knowledge is transparent, in the public domain, published in journals and discussed at meetings. Therefore, everyone in the field knows about any potential new treatment approach. Potential new treatments cannot be ignored, let alone hidden.

Another unstated premise in the e-mailer’s question is that a new cancer cure would have a disruptive effect on the cancer treatment industry; that it would suddenly displace current research and treatment. This is highly unlikely.

First, with regard to research, any new treatment would be an outgrowth of existing research, it would not invalidate or disrupt it. In fact, new discoveries lead to the need for more research. And further, because cancer is not one disease but many diseases, any new cure would need to be studied for every type, grade, and stage of cancer. A new treatment could potentially spawn decades of clinical research.

For the same reason it would take time to displace existing treatments. Therefore any new treatment would just become another part of the constantly evolving repertoire of cancer treatment. There is no reason to assume it would be any less profitable to oncologists than existing treatments. But if it were, that is something that would not even become apparent until after the new treatment was researched. In the face of evidence for improved outcome with a treatment, oncologists could not avoid giving the new more effective treatment for both ethical and legal reasons.

Conclusion

The overall reality is that the standard of scientific medicine is not a monolithic entity, controlled by any one institution, agency, or industry. It is a complex and dynamic set of many forces and interests. It is ultimately driven by science, which is a transparent and public process, and prevents any big brother type of control (this is partly why it is so important that healthcare be based upon science).

Cancer is a very difficult type of disease to treat, and the public has a very distorted view of the nature of cancer and of medical scientific progress in general. This has led to unrealistic expectations of progress in curing cancer, which then in turn leads to thoughts that cancer research is somehow not working.

I find the same to be true in medicine in general – the public thinks of scientific progress in terms of dramatic “breakthroughs.” Media hype feeds this misconception. The reality is that medical scientific progress is largely a series of very small steps, with a cumulative effect of slow steady improvement in treatments. We have not cured Alzheimer’s disease, ALS, Multiple Sclerosis Parkinson’s disease, and many other diseases as well. But treatments are slowly improving. Slow steady progress does not make good headlines, however, so the myth of miracle medical breakthroughs will likely continue to be promoted by the media.

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