Elsewhere on NN, Anna Cath takes issue with the framing of cancer as a ‘bioterrorist’. Personally, having sat through another hour-long talk on jun and fos, I’m going to take issue with the framing of cancer as something to be cured.
We have been trying to find a ‘cure for cancer’ for more than thirty years. We don’t have a single cure, and nor are we likely to, because ‘cancer’ is a word that describes many, complex and different conditions. We might then suppose we could come up with multiple cures–but after thirty years of serious research we don’t seem to be getting anywhere: the increase in long-term survival after radio- or chemotherapy is still disappointingly low. The state of affairs with regard to therapy was brought home forcibly to me this week: today was the funeral of a member of this department. She died on Monday night, of pancreatic cancer.
Why is this happening? Why is this still happening?
When you look at the genesis of cancers they all follow pretty much the same pattern. A mutation in a gene causes a protein to go wrong, which in turn releases the brake on cellular proliferation. There are numerous oncogenes, myriad pathways, all telling the same sad story.
But there was a telling moment in the seminar when the speaker justified his research (he’s working for CRUK, after all) by overviewing a transcriptional regulation pathway and talking about ‘pharmaceutical opportunities’. If we could find a control point in a cancer cell that differed from normal cells, and use it to turn the cell ‘off’, that would be an obvious place to throw a drug. Much effort and money has been expended in trying to understand different cancers, so that we might be able to do just this. And, actually, we don’t seem to be getting very far.
The problem is that we’re trying to do the equivalent of reducing the number of people killed in road accidents by building faster ambulances and more hospitals. This is completely arse-backwards. The only way to significantly reduce cancer mortality is to prevent cancer, not to cure it. There are attempts to do this–eat less meat, more vegetables, stop smoking–but not only are they rather half-hearted we don’t even know the mechanisms by which lifestyle and diet cause cancer (except for smoking and exposure to known carcinogens), so how can we advise people what to do?
So shouldn’t we devote more effort into researching causes rather than cures? So that we can treat the source, not the symptom? I think so, but here we run into trouble. There is intense political and economic pressure to not find out what causes cancers. I could say that drug companies have no interest in curing cancer, because they want to sell drugs–but that would be a cheap shot and might mark me out as a nutter. But I think it’s fair to say it’s easier to point to thousands of scientists working on a maze of twisty biological pathways, all alike, and say we’re doing something, rather than examine our manufacturing processes and the like. When the companies that support the Pink Ribbon campaign might actually be contributing to breast cancer, wouldn’t it be best just to keep quiet?
If the incidence of cancers in the developed world is increasing, what does this say about our lifestyle, and about the products that our consumer society insists on having? Even if there is no link, wouldn’t it actually be a good idea to find out?
Is it time to say that cancer research–as we know it–doesn’t work? Is it time to divert the majority of scientific effect towards identifying and preventing–or repairing–that initial mutation?
Hear hear. Of course, as a statistician (and hence someone closely connected to epidemiologists) I am biased, but as you point out we know a lot of the things that could help. I suspect the solution lies in politics and social policy (i.e. encouraging people to eat well, exercise etc.), rather than in more science.
Thanks for the great post Richard. I think something else to throw at least some of these resources at would be palliative care and the hospice movement – for those who ran out of time waiting for a cure.
The problem with cancer research is that they try to understand cancer.
What they need to do is to try to cure cancer.
I remain in favor of cancer research because of the very large number of things we have learned about how cells work by studying it. I also am not sure it’s fair to say that there have been no improvements in cancer treatments in the past thirty years — do you have a reference for that? I was just at a talk that was describing some of the advances and successes for some a number of cancers, particularly with combination therapies. I will try to find the papers that this speaker was referring to.
I don’t think Mark is right—we do need to understand cancer, just for the sake of understanding. Which is what Jenny says. But if we want to reduce cancer, well, maybe research into cancer is not the best way?
Would you mind if I draw attention to this post by David Basanta at his Nature Network blog? He asked a similar question, Richard, and there is a subsequent conversation at the link provided, including my own thoughts on this.
Of course I agree with you that “cancer” describes many diseases, some of which are much more treatable these days than when Nixon declared his war in the early 1970s. Many people nowadays are diagnosed with a cancer but dying of something else. Pancreatic cancer is a sad exception, and not the only one.
Chemotherapy is a necessarily blunt instrument rather than targeted precisely at a particular patient’s cancer (almost all the time), it is about overall statistics. It helps some people but not others, and so most people who have a cancer decide it is better than nothing. Similar arguments apply to radiotherapy: it is improving all the time thanks to research; and it helps a lot of people if not all.
I agree that we should apply efforts to prevention, but there are so few clear-cut associations, and even when they are, many people take no notice (I am thinking tobacco here.) Environmental factors are factors, but nobody knows how significant in each case, and how these interact with that person’s genetics and other “environmemtal” factors outside that individual’s personal control.
At Nature we get many Correspondence letters submitted that state arguments along the lines of “why are we spending all this money on sequencing the genome of the malaria parasite, which helps nobody at the moment, when we could be spending it on simple practical applications that would prevent more people from getting malaria?”. (Mosquito nets, and cue argument about DDT spraying but you get the picture.) I think the answer is that we have to do both. The world does not work in this way (take money from one style of approach and spend it on another). If we had cancelled the malaria parasite genome project at an early stage, that money would not have been spent on practical prevention measures, but on some other research programme, or not on anything to do with science or health. Our systems of dealing with disease as an entire entity from molecule/gene to person in an environment are not joined-up in this way.
When we don’t know the answers, we have to do everything I think – look at basic mechanisms which may or may not turn out to be relevant; look at lifestyle factors which are probably never going to be all the story; look at education which is never going to be effective for everyone; look at anything that might help at least some people. Obviously, resources are limited, which slows it all down.
_ … and might mark me out as a nutter._
Richard, the first step towards a cure is realizing that you have a problem. Fortunately you’re among friends here (Jennifer, pass the syringe. Yes, the big one with the evil-looking blue liquid in it).
But seriously, I think Jenny is right in that by studying cancer we have learned, and continue to learn, a great deal about how cells work, things we might not have done but for the goal of ‘curing’ cancer, however elusive that might be.
But there is an evolutionary perspective here, too. I suspect that to cure cancer we’d have to find a cure for death itself. There are good evolutionary reasons why people grow old and die, all to do with the increasingly well known trade-offs between longevity, reproductive output and resource allocation. Organisms are not built to last forever, and cancer is just one of the ways of stopping them doing this.
One thing that interests me is why it is that certain species tend to die of different things. Whereas cancer is what kills people eventually, if they don’t die of something else first, what tends to kill cats (sorry, Bob, there’s no easy way of saying this) is renal failure. One of our cats, Marmite, aged 12, is suffering from advanced renal failure, and her life has been improved greatly by a special diet designed for elderly cats in that state. I’m sure it’ll get her in the end, but her lot has been much improved of late.
So my point is that whereas we might not be able to cure cancer, we can and should do our best to alleviate its symptoms, put off the evil day of reckoning, and improve the quality of life of cancer sufferers. Yes, lifestyle is a part of this, but so are drugs.
Drug companies know that their best markets are people who have a chronic condition from which they are not likely to die in the immediate future, but still requires medication.
As an aside, I once toopk my psoriasis to see a skin specialist (the psoriasis came with me as it was unable to go on its own). The specialist said that being a dermatologist was great – his patients never really got cured, but then they didn’t tend to die, either.
Good points I think, Henry – though people do get cancers prematurely, which is particularly tragic. In these cases it is not part of the “natural” death/ageing process, it is some massive cellular mistake which also strongly justifies investigation for that reason, as well as the reasoning you so aptly provide.
I’d also add to Richard’s links to companies supporting cancer campaigns but themselves accused of “unhealthy possibly shock horror cancer-causing products and activities”. The same “malaria parasite genome” argument applies, I think. If those companies withdrew their support from cancer campagins, they would spend it on something else (maybe advertising, maybe on swimming pools for their executives); if they stopped supporting cancer research/awareness, they would not stop doing those “nasty, potentially cancer-causing” activities.
Or, to put it another way, would you ban smokers from raising money for cancer charities?
Hello Maxine and Henry
thank you for your thoughtful comments.
Maxine, the lack of clear-cut associations is a reason we should concentrate on researching them, do you not think? You say ‘we have to do everything’, and I don’t disagree: however, there is a limited amount of money in the pot (as you actually say).
Henry, I’m sorry if I gave the impression we shouldn’t be doing basic research, finding out how things work (and break). Anyone who has known me for more than five minutes should know my feelings on the matter.
well, you know, I’m not so sure. having seen the pain and suffering that are the side-effects of cancer treatment, I’m wondering if it’s not better just to provide the patient/relative/friend with morphine on demand and allow them to die with respect and dignity?
I have no answers, only questions.
Damn. Maxine, there is an argument that companies that support the Pink Ribbon campaign, for example, make money on the deal through increased advertising revenue. And there is something very fishy about giving away (or selling) items that are carcinogenic in support of the cause (in support of ‘awareness’, which is a caviling word).
I did some digging for a review I wrote last year. There are references therein.
Jenny, I was saying not that there haven’t been improvements; rather that they have been disappointingly small for the effort put into it.
@ Maxine
people do get cancers prematurely, which is particularly tragic. In these cases it is not part of the “natural” death/ageing process, it is some massive cellular mistake which also strongly justifies investigation for that reason, as well as the reasoning you so aptly provide.
With you all the way, Maxine. Sorry I appeared to ignore your earlier comment – I didn’t – I think we posted our comments at about the same time.
@ Richard: having seen the pain and suffering that are the side-effects of cancer treatment, I’m wondering if it’s not better just to provide the patient/relative/friend with morphine on demand and allow them to die with respect and dignity?
Yes, well, it might come to that, but in the old days they used to ‘cure’ migraines by making small holes in peoples’ skulls to let the demons out. Now we need such cures like a loch im kopf, because thanks to science, we have aspirin, ibuprofen and codeine. So perhaps, in the Great Golden Future, we might have chemotherapy that doesn’t work on the whatever-doesn’t-kill-you-makes-you-stronger principle. It might not ‘cure’ cancer, but it will make it manageable – much in the way that HIV infection is more manageable than it used to be, twenty years ago.
Sure Henry. But what about now, and what do you really think is the most likely outcome?
Sorry, I should be asking a cell biologist…
Now? Yes, you should really be asking a cell biologist. As we all know, cell biologists have the attention span of a mayfly, whereas we palaeontologists bat eons around like footballs.
Sorry, you were saying something?
(I on;y pretend to be a cell biologist. I mean, I’ve solved NMR structures. Better ask Jenny: she’s hardcore).
Sorry, you were saying something?
Not me, guv. You were hearing the voices again, won’t you? Just have a nice lie down, dear, and you’ll feel better. (Nurse? NURSE!)
Really interesting chat here – I echo Henry & Maxine’s sentiments in many ways, but I’d like to offer this point of view:
Mutations occur throughout our life-span, they accumulate as we age and all sorts of earlier functions stop working – either as part of the senesence process or otherwise. I think talking about “natural” death/ageing processes is a bit misleading, it gives the impression that you want to exclude cancers as being natural. If mutations are natural, so (unfortunately) are cancers.
That’s a good point Mike.
But as (life-)scientists, part of what we try to do is stop natural processes so that people suffer less and live longer. Mutations are natural, but that’s no reason to stop trying to prevent or mitigate them.
What we’re doing— all of us who are scientists—is unnatural. It’s part of what makes us human.
Jenny, I was saying not that there haven’t been improvements; rather that they have been disappointingly small for the effort put into it.
Your definition of ‘disappointment’ might depend on your perspective. The patient on Gleevec who earns one or two or five years of life might well disagree that the large amount of effort that went into this molecularly targeted therapeutic resulted in something disappointing. Aside from these extra years for many, many patients, there is also the leap in understanding we, as cancer researchers, gained in understanding how cancers respond to being targeted in that fashion, and the inspiration that this drug provided in people trying to design other targeted therapies for particular cancers based on the known molecular details. I think it’s far too soon to decide that such targeted strategies are a failure, or will be in future.
And how normative is Gleevec?
(not being contrary, I’m honestly interested. I meant it when I said I had more questions than answers!)
Nobody mentioned the pharamceutical industry yet. And what a shame that is. I love portraying them as evil.
Needless to say, this particular industry has no interest in curing cancer. It does have an interest in selling expensive therapies. Huge advertisement budget of course. Not so much research. No research in anything that could be cheap and effective. Combine it all and we can start form a basic notion on why there aren’t more effective therapies available in the treatment of cancer.
Combine that with a huge field of cancer research where there isn’t a real incentive to cure cancer either. Why would they? Once cured there won’t be any possibilities for grant applications any more in this area.
Or am I now being cynical, paranoid, biased, and opinionated at the same time?
Of course I am, but maybe there is a tiny kernel of truth here.
Everybody acts in their own interest and there doesn’t seem to be a ‘real’ interest in curing cancer in any of the groups involved besides the patients. But they are not involved in the process of curing cancer´with maybe a few exceptions.
Remember how Christopher Reeves suddenly started promoting stem cell research after he got an immediate interest?
I think that there are possibilities to ‘cure’ cancer. We are just not really motivated to look in the right places. So it is taking a lot more time than is necessary.
Needless to say, this particular industry has no interest in curing cancer. It does have an interest in selling expensive therapies. Huge advertisement budget of course. Not so much research. No research in anything that could be cheap and effective. Combine it all and we can start form a basic notion on why there aren’t more effective therapies available in the treatment of cancer.
I’m curious if you’re basing this comment on personal experience, Mark.
I’ve actually worked in collaboration with a giant pharmaceutical company on a cancer drug I helped design (now in Phase III last I heard) and I don’t completely recognize this portrayal. I will say more, but would like to hear about your experiences first.
Is it cheap and effective then?
Sorry, do you need a definition of Phase III?
laugh
(sorry, carry on)
No. Do you need a definition of the word and?
@Mark: Or am I now being cynical, paranoid, biased, and opinionated at the same time?
Welcome to the club, it’s called
Groucho Marxbeing a scientist.Keep it civil, people.
Mark, you were asked a question.
As it hasn’t finished its trials AND it has not been assigned a price, I’m still not sure how you expect me to answer that question.
I would like to understand how you expect a company to develop a product that can take 10-15 years and millions in R&D investment to do so without trying to make a profit. The shareholders would never allow it. And what is wrong with them recouping some of their outlay?
yes, I answered it with a question: is the drug in question then cheap and effective.
This because my position was that in general the pharmaceutical industry has no immediate interest in developing a cheap and effective cancer therapy.
Whether I have personal experience in the pharmaceutical industry isn’t going to change the logic behind the position. The appeal to personal experience is merely a standard forum technique to win a debate. A modification of the authority appeal.
It’s not really interesting to be honest. If I learned anything over the years, it is that I know nothing am mostly wrong, and even if I am right it means nothing.
I do know about the application of logic and reasoning though.
I would like to understand how you expect a company to develop a product that can take 10-15 years and millions in R&D investment to do so without trying to make a profit. The shareholders would never allow it. And what is wrong with them recouping some of their outlay?
So you are supporting my position. Companies have no interest in finding a cheap and effective cure. Simply because no profit can be made on that principle.
Richard: And there is something very fishy about giving away (or selling) items that are carcinogenic in support of the cause (in support of ‘awareness’, which is a caviling word).
I agree with this sentiment. I know I am a strange outlier kind of a person (eg don’t watch “factual” TV/listen to radio etc), but in my support of charities I do it by bank standing orders/direct debits etc. I never wear ribbons, pins or other “I’m a wonderful person because I gave some money to a cause” badges. I know how much of my earnings I give to various charities and I am comfortable in that knowledge.
So if these companies just gave the money to whatever charitable or other worthy cause, that would be finer by me than what they do now, which is to make a bit of money for themselves by positioning themselves as caring and all of that.
That having been said, I don’t think anyone would want to turn them away, although there are of course many instances of people and organisations turning down what they perceive as “tainted” support. I don’t think this applies to medical research but I don’t know.
Mark,
As a scientist you should know that evidence trumps pre-conceived notions. There is no logic in your argument, merely prejudice.
I’ll grant that companies have no interest in ‘cheap’ cures: because (even absenting the moral obligation to produce a return for their shareholders) they have to pay the scientists who work to discover and develop those pharmaceuticals. ‘Effective’? Again, your prejudice is showing; not your logic.
That read a bit weirdly. Tobacco industry is of course an example. But I think that tentative and extrapolated associations of companies with an end-effect (eg cancer) are not cause for turning away support.
Maxine, I would be honored if you would consent to marry me.
Oops! Bit of crossing in the post there! My “that read a bit weirdly” comment applied to my own previous comment, not to Richard.
Well, if we accept that companies (including pharmaceutical companies) are ephemeral, shareholders come and go, economies boom and bust, etc. etc. etc… then a pharma. could still make a profit from developing and selling a cure.
It would have a shelf life, but as we’ve seen with a variety of other disease causing organisms (MRSA anyone?), nature has a way of ensuring the pharmas can then move on to develop other drugs that will ultimately be just as ineffective yet profitable.
Richard – OK, I’ll put you on the wait list.
Mark et al. – Disagree that pharma companies aren’t interested in a cheap “cure for cancer” – which doesn’t exist anyway because as pointed out by several people at the top when this debate was a bit more measured, cancer is not one disease but many. If a drug company found a cheap treatment for one of these cancers, my bet is that it would be delighted, because there would be innumerable knock-on benefits for the company.
Man, it’s hard to keep up with the high comment rate here.
Mark, think of the massive amounts of free advertising the (unrealistic) headline “Phake Pharmacom comes up with cure for cancer” would develop.
Come on Mike, are you man or paleontologist?
Maxine, it’s that bloody Gee character, isn’t it? He’s dead.
The margins of this comment box are not large enough to include all my comments, let alone references for them all, so I’ll try to boil them down to a thick gluey mass.
(1) As you say, cancer isn’t one disease. Understanding how to prevent “cancer” is not likely to be any simpler than coming up with a “cure” for cancer.
(2) That said, a fair bit is understood about how cancer starts, and I think what we know suggests there may not be any way of preventing for a large amount of cancer. The errors that lead to cancers arising are built in to the system; fixing them would require far more fundamental changes to our cells than is plausible.
(3) That said, there is an excess of cancer that is probably preventable, from environmental causes, and reducing that might drop cancer rates by half (wild-assed guess).
(4) For all the futility in cancer treatment, all in all, there are some subsets of remarkable improvement. Treatment of childhood cancers has improved spectacularly over the last, oh let’s say 20 years. Some other subsets of cancer have gone from high mortality to probably curable. Unfortunately the most frequent forms of cancer, by and large, aren’t in those subsets, but the lesson is that it is possible to cure (some kinds of) cancer.
(5) Basic research has actually led to some insights that, I think, are likely to lead to significant improvements in cancer treatment over the next decade.
We get numbed by the constant barrage of press releases proclaiming dramatic new advances that we know perfectly well are nothing of the kind, but I think there actually have been a handful of genuinely big breakthroughs in understanding — even though they haven’t led to direct treatments yet, I’m optimistic that they will, in the foreseeable future.
My own gut feeling puts angiogenesis inhibition in that category still (and I’m aware of its relative futility in humans so far), and though I’m biased as an immunologist I think the recent demonstration of long-lasting equilibrium phases of developing cancers is a huge conceptual advance, as well.
Thanks for that, Ian. It’s the kind of analysis I was hoping for.
I’ll bring out one point though: is improvement in treating childhood cancers meaningful on a twenty-year timescale? That’s almost impossible to answer, I guess.
Dr Turing told me I are machine
Whether I have personal experience in the pharmaceutical industry isn’t going to change the logic behind the position. The appeal to personal experience is merely a standard forum technique to win a debate. A modification of the authority appeal.
Actually, I was genuinely interested in whether you, personally, had ever worked with industrial scientists on cancer cures, expensive or otherwise. Companies are made of people, and those that I worked with had a passionate interest – both the scientists and the management team – in developing cures for cancer that could be as financially accessible as possible. This is why many of them were working there in the first place. I didn’t recognize your description of the pharmaceutical industry from my own experiences, so I was curious to know about yours. It was not, I assure you, some rhetorical trick. If you have no such experiences, and are basing your statements on feelings, rumors, stereotypes, second-hand accounts or other non-direct evidence, then just say.
I was mostly responding, initially, to your statement that “this particular industry has no interest in curing cancer” and that they didn’t invest much in research. Both of these statements are not universally true as I am aware of several examples to the contrary. This is all I wanted to say. I personally think it’s irrelevant if great cures actually cost what they’re worth. If you don’t want to buy them, then don’t. In the meantime, how is this industry hurting you personally? If you don’t like the current set of players, you could always feel free to set up your own pharma dedicated to developing new cheap, effective drugs. (Although it might not be as easy as it sounds.)
Recently I was explaining to people outside of cell biology how our research gets funded. Or rather, I was explaining why the cancer society funds my research, even though I am not “curing cancer”. The first line in the grant application has to be something along the lines of “cancer is bad!” otherwise it won’t get funded. An oceanographer once told me that they do they same, but the first sentence is “global warming is bad!”.
You can’t just do basic research and get money without linking it to something awful, and people expect scientists (especially molecular biologists, geneticists, etc.) to be actively curing diseases. That’s not how it works, and I like it that way, but I wish there was a way to just be honest about it and say “Look, we just want to figure out how stuff works, and antibodies are crazy expensive. Give us money, okay?”
that they didn’t invest much in research. Both of these statements are not universally true as I am aware of several examples to the contrary.
I assume now that you have firsthand knowledge on the distribution of the advertisement budget of the pharmaceutical industry and their research budget if you claim they do invest a lot in research.
Please share.
this particular industry has no interest in curing cancer
And indeed that is what I still claim. They are after all only there to please the shareholders are you so nicely stated yourself. Pleasing shareholders has no direct causal relationship to curing cancer. Profitable therapies have.
If you have no such experiences, and are basing your statements on feelings, rumors, stereotypes, second-hand accounts or other non-direct evidence, then just say.
Low rethorical trick: I based my argument on logic and general knowledge.
If you don’t like the current set of players, you could always feel free to set up your own pharma dedicated to developing new cheap, effective drugs.
If you had tried to follow my original argument then you could have formulated your own answer to this question.
It is all a matter of interest. I have no interest in curing cancer. And I proposed that most parties involved in ‘curing cancer’ have no real urgent desire to ‘cure’ cancer either. You still have failed to address this basic premises.
And I don’t think anyone is really interested in me or my secret desires to cure cancer and spread happiness through the world.
And I proposed that most parties involved in ‘curing cancer’ have no real urgent desire to ‘cure’ cancer either. You still have failed to address this basic premises.
If you truly believe that the majority of people researching cancer have no interest in curing cancer (because when you use words like “the industry” and “the company”, you are ultimately talking about the people that comprise these organizations) then we have simply been interacting with different sets of people. That’s fair enough. I can only speak about those groups and companies I’ve been involved with, and not for every group. But there are exceptions out there, so you one-size-fits-all assessment of the entire industry does not seem entirely fair. But you are entitled to your opinion, of course. I don’t have the time or energy to argue any further on this point — I’ve got some cancer to cure.
Eva, interestingly in Britain, there are some funding bodies that won’t accept applications for grants that seem too applied — they are devoted to basic research. I’m not sure how widespread these sorts of bodies are, but I think it’s a terrific idea to ring-fence some money for this. (And it’s funny watching my colleagues struggle to put in grants without any reference to disease!)
Jenny, I was saying not that there haven’t been improvements; rather that they have been disappointingly small for the effort put into it.
I am not sure I agree on this. It all depends on how you look at it of course.. . I mentioned over at David’s post have we lost the war on cancer that Maxine linked to too.
If we agree that cancer is a complex disease and not really one disease and then look at the different outcomes of all these diseases we can see that there have been some enormous break through in certain areas. And that the awareness and detection rate are up in several others. As example, survival rate from the brain cancer medulloblastoma has risen from 10 percent in 1962 to 85 percent….
Of course it is obvious that not all cancers are curable and not all are researched about either but I think it is key to look at it as more than just cancer – especially since it sounds like “the measles” which is not really the same thing.
And I am not sure that anyone has looked at (easy review) what has come out of the “other research in the name of science/cancer in this case” as in a spill effect on other diseases . Sometimes I wonder if that would be a good thing to do?! Usually one sees that when the Nobel Prize was handed out in the early times – when one early discovery was the core thing in an applied thing later on, although it wasn’t really clear at the beginning.
Great points, Asa. I share your positive outlook. I started researching cancer in 1989 and from this perspective looking back, a lot has been accomplished that we can be proud of.
I have heard all these “big pharma don’t want to cure cancer” arguments before. Twice now they have gone hand-in-hand with “you guys know the cure for cancer, you’ve all taken a vow of secrecy and are being paid lots of money by the government to keep it that way”. One incident ended when I told the person how much money I was making as a postdoc and how I doubt you could find a single scientist who would keep the discovery of a lifetime, Nobel prizes, worldwide adoration etc. secret. The other incident ended with the person being kicked out of the party after he started to verbally assault me and then threatened to physically assault my husband for coming to my defense.
As Jenny has mentioned, there have been amazing strides in treating particular types of cancer with targeted drugs, e.g. Gleevec. Herceptin for HER2+ breast cancer is another example. Understanding more about the basic nature of these cancers was a necessary first step towards developing these therapies. The two drugs I mentioned made little difference to the average cancer survival rate, but a huge difference to the subset of patients with specific types of cancer. This is the way that most cancer researchers I know are thinking these days.
BTW Richard, I’d love to know who gave the talk you referred to. I did my PhD in a CRUK lab, on Jun and (peripherally) Fos – see recent post!
Sorry for the consecutive posts, but I knew I’d read something recently that is relevant to Asa’s point of a “spill effect on other diseases”
From the BBC : “A drug developed to treat leukaemia may be a powerful new weapon against multiple sclerosis, researchers say.
Alemtuzumab appears to stop progression of the disease in patients with early stage active relapsing-remitting MS – the most common form of the condition.”
(And it’s funny watching my colleagues struggle to put in grants without any reference to disease!)
Cancer is ba-err..b-b-biology is awesome!?
Upon a more careful read-through of the post I found an omission!
“we don’t even know the mechanisms by which lifestyle and diet cause cancer (except for smoking and exposure to known carcinogens)”
And UV radiation! From the sun! (Unless you considered the sun a carcinogen… I tend to think of it as a giant light-and-heat-source rather than a carcinogen.) Richard, you’re in Australia, it’s almost summer there, the ozone layer is damaged right over your head, and you have the phenotype of someone with practically no physiological defense mechanism against UV radiation – don’t forget this one!
I can’t say exactly where – too tired – but somewhere, the discussion seems to have gotten confused about ‘cancer cures’ vs. ‘cancer treatment’. I am responding to the initial topic, the cures. I also need to say that I do not have any knowledge or experience in or with cancer research or the pharmaceutical industry – just an opinion. If that is necessary to say.
Jenny – your comment on starting one’s own company to Mark reminded me of The Institute of OneWorld Health, a non-profit pharmaceutical company started precisely by someone from the pharmaceutical industry who wasn’t happy with ‘the current set of players’. From the founder’s story on their website:
In the spring of 2000, I was chatting with a cab driver about my work. When I told him I was a pharmaceutical scientist he burst into laughter and said, “You guys have all the money.” It wasn’t the response I normally received when I spoke about my career, but I realized he was right. The pharmaceutical industry did have all the money and did make all the decisions about which drugs to develop — and we made those decisions based on the bottom line, the profit margin.
So it seems that the founder, Victoria Hale, had the kind of experience Mark was talking about? I absolutely, 100% believe you when you say that the people you were directly involved with, who were either doing the research themselves or funding it, were enthusiastic about what they were doing without any other agenda. But that doesn’t mean that there was no agenda higher up in the ranks (I’ve been in a similar situation myself).
And I still think, as Richard mentioned waay back up there in his post, that maybe thinking a little less about high-tech drugs, and a little more about prevention (and again, palliative care), would be a great thing.
If anyone seriously thinks I’m saying that we shouldn’t research cancer, or treatments, then I’ve failed in my intention.
More when I’ve woken up properly.
I don’t think anyone is saying that, Richard!
@Mark:
And we know that ‘general knowledge’ trumps evidence.
To be less sarcastic: You’re just making stuff up.
@ Richard: Maxine, it’s that bloody Gee character, isn’t it? He’s dead.
Possibly, but only for tax purposes. Please don’t tell anyone, there’s a good chap.
@ Cath: Alemtuzumab
Sorry, I simply don’t believe that this is the name of anything that even a marketing droid could have come up with. It’s even harder to pronounce that Batrachochrytium dendrobatidis. Were I asked by some random passer-by what ‘Alemtuzumab’ meant, I’d have no end of options, like … er … um …
an anagram of a breakfast cereal;
a fifth-magnitude star in Orion;
a daemonic name rejected by H. P. Lovecraft for being too silly;
The name of Osama Bin Laden’s Granny (no, not Doris, the other one);
The sound of impotent rage almost made by Richard Grant when I
cheatedbeat him at arm-wrestling, but quickly suppressed when he realized Anna and Jennifer were watching. And Maxine, too, and we know how he feels about her.@ Eva: The first line in the grant application has to be something along the lines of “cancer is bad!” otherwise it won’t get funded. An oceanographer once told me that they do they same, but the first sentence is “global warming is bad!”.
That’s a very important point. very often, as an editor, I come across papers on some specific facet of the world that use as justification that such-and-such will be important in understanding large-scale biodiversity loss, or that climate change will affect the distribution of this-or-that species. Authors seem to think (stop right there, Grant). and more than that, they seem to think that even if the flinty heart of Gee won’t be swayed by the magnitudes of the specific advances they might describe, then I’ll go all gooey at the thought of climate change in a general way. It is then that I roll my eyes and try very hard not to reject the paper straight away.
And it’s not just me. My colleagues who deal with (ahem) ‘real’ biology, rather than frogs-and-buttercups stuff, always sigh when they get to the end of a paper about the ability of growth factor FRIP to interact with ligand TRAP and release calcium from intracellular stores, and find a sentences such as ‘this has obvious therapeutic implications’.
EDITOR: Mine neither, matey. Now Go Away.
EDITOR: Not from this angle you aren’t.
Word on the street is that the grant didn’t get funded because we didn’t have a disease state for the gene.
But this is Australia, where sheep are scared and words matter.
“Were I asked by some random passer-by what ‘Alemtuzumab’ meant, I’d have no end of options, like … er … um …”
it ends in -mab and is therefore clearly a monoclonal antibody.
Either that or an explosive sneeze.
Yeah, but you still haven’t
irisedflagged a meaning for the ‘Alemtuzu’ part.Trying to confuse dyslexic amphibians?
I’m going to try to steer this conversation away from Gee and his bevy of sozzled Canadians…
First, no one denies that (some? OK) anti-cancer treatments are successful. That’s fantastic, and shows that the money we’ve thrown at the research isn’t wasted (quite apart from the benefit to basic research argument, with which I have lot of empathy).
Second, it’s obvious Pharmas are in it for the money. In case anyone hadn’t noticed, that’s how our civilization operates. But they are not in it for the money alone—if they were, they’d do something less risky. A lot of treatments (not just anti-cancer) come out of startups that in turn are spawned by academic labs. Research is expensive, clinical trials more so. The way the regulatory bodies operate (which I think is a priori no bad thing) you have to have a shedload of cash to progress to clinical trials. The only way to do that is to partner with big pharma. Upper management are businessmen—they don’t care what they produce, I guess: but the scientific direction has to be made out of a desire to cure, because (despite what the nutjobs say) drugs that do not have a beneficial effect are not going to make it in the marketplace. That’s why we have fucking Phase III trials. Even if you are in it for the money alone (as I say, that would be dumb), you have to want to cure in order to make that money.
Third, the scientists do it out of a desire to find out how things work. When Axel (there you go, Cath!) said ‘pharmaceutical opportunity’ I wondered if I could see $$ signs in his eyes. That sounds cynical, and could be taken that way: but the truth of the matter is that you need a disease state to get funding. I’ve discovered this anew last week. But Axel does the research because he’s interested in finding out how things work, and probably because he does want to cure cancer to boot.
Fourth, the companies (*not* the pharmas) that support things like the Pink Ribbon campaign produce stuff that is laden with carcinogens and other environmentally unfriendly greeblies (those pink-lidded water bottles? The plastics in them? Ouch). They make a ton of money from advertising revenue, goodwill from being associated with the campaign; and continue to contribute to the problem. They have no interest in stopping cancer, because stopping cancer might mean they have to stop or change their manufacturing processes…
which leads me to the question I posed.
Is (and if the answer is ‘no’ that’s fine—I intended to start a discussion, not peddle my own agenda) concentrating on a cure at the expense of finding the cause detrimental to people’s health? Eva makes my point for me by mentioning UV: there are very few known causative mechanisms. DNA replication is tricky, which is why we have DNA repair mechanisms, and randomly they go wrong, and we get cancer. But what proportion of cancers are directly due to some interaction with our environment? We do not know.
Should we try to find out? Even if it means diverting (some? Most?) money away from searches for cures (which, I emphasize, is important)? Despite the successes, I find the survival rates still disappointingly low, given how clever we are at other things. I don’t think we should stop trying: I wish we could do better.
So, I ask, is it not better to try to prevent the cancers occurring in the first place?
Is that, actually, too difficult? I don’t know. That’s why I posed the question.
I want to know what caused the cancer that killed Gina on Monday night.
I know lots of people looking for causes too. e.g. the International Cancer Genome Consortium is planning to sequence multiple examples of specific cancer types to look for recurring mutations that might suggest cause as well as pharmaceutical targets.
I read a blog called the “Assertive Cancer Patient” that is written by a long-term metastatic breast cancer patient. She has a very interesting take on “breast cancer month” and the sea of pink merchandise.
Sorry, The Assertive Cancer Patient.
Unlike Henry I am chemically unenhanced (for now) – honest! It is still not 5 o’clock here!
Cath—do you think that the ICGC is a good idea, given for example that BRCA1 and 2 are responsible for only about 10% of breast cancers?
The recurring mutations that they will find are going to be in things like kinases and repair enzymes. They will be pharmaceutical opportunities. But they won’t tell you what went wrong in the first place, which is what I’m trying to get at, here. A mutation in an oncogene is not the primary cause.
I take your point about the primary cause, but I really do think that these genomics initiatives can have an incredible impact if applied intelligently. For example there are lots of cases of familial breast cancer where BRCA mutations can not be found. The same is true for many other cancer types, e.g. ovarian. Finding other recurring germline (not somatically acquired) mutations would enhance screening and therefore prevention.
Thinking about it I’m actually surprised that no-one has mentioned the HPV vaccine and its likely impact on cervical/penile cancer rates. Although obviously only a few cancer types have a known / suspected viral cause.
I know of lots of other ongoing / funding pending research projects that are making a huge effort to identify risk factors – diet, exercise, others that I can’t mention without explicitly identifying which PIs / projects I am involved in.
bq. For example there are lots of cases of familial breast cancer where BRCA mutations can not be found. The same is true for many other cancer types, e.g. ovarian. Finding other recurring germline (not somatically acquired) mutations would enhance screening and therefore prevention.
Eh, you see, that’s the preconception I’m interested in. Would it? If it’s familial, how do you prevent it? Gene therapy? Can we stick in a load of extra DNA repair mechanisms?
Testing when familial cancer is suspected, followed by more frequent / earlier screening for carriers, the potential for prophylactic mastectomies etc (a horrific choice that many BRCA mutation carriers have to make). Not ideal obviously but with the potential to reduce incidence.
The thing with UV and skin cancer is also that there money does go to prevention, because it is preventable, at least to a great extent. It would be ridiculous to let everyone sit out in the sun all their lives and then just develop something after the fact to cure their melanoma. The Canadian Cancer Society funded the work I did, and that is not “curing cancer”, but rather just finding out how skin pigmentation works. When our lab participated in a relay event for the CCS, they were also actively handing out sunscreen (even though it was at night), and strictly forbade smoking on the grounds (even though it was outside). But obviously something like the cancer society is not out to make money (well, not for themselves), and they are the ones who really want to prevent rather than cure.
And the point I think Richard is trying to make (yes?) is that they can currently only prevent the cancers they know how to prevent. But they’ll fund projects looking for causes, not just cures (That last link is quite possibly my favourite Onion article ever. They’ve really gone downhill lately. This is from 2001! And on topic. I am staying on topic by posting old news from The Onion.)
I wear my
sunglassessunscreen at night!Off to the pub now. Yes, I know alcohol is a risk factor. But it is almost dark, so at least my Celtic skin will be safe on the way there. Everything’s a trade off.
Yes, that’s it Eva.
Funny thing is, in Australia there is a huge emphasis on sunscreen, hats &c.; yet they still have double the melanoma rate of the UK. And vitamin D deficiency.
A bit of UV is required, it appears, to activate the endogenous DNA repair mechanisms.
I wonder if prophylactic gene therapy might be doable, Cath?
PS. Has anyone looked at potential carcinogens in sunscreen?
runs away screaming
If it’s familial, how do you prevent it? Gene therapy? Can we stick in a load of extra DNA repair mechanisms?
For inherited cancer syndromes caused by a germline mutation in a tumor suppressor gene, I think that DNA repair mechanisms and overall maintenance of genomic integrity must contribute to tumor burden and malignant progression. Of course I think this, because it’s what I work on, in the context of neurofibromatosis type 1 (NF1). However, for some inherited cancer syndromes (e.g. NF1 and tuberous sclerosis complex), there is also a haploinsufficiency phenotype, i.e. traits and disorders that can’t be explained by the standard Knudsen two-hit model.
I’m not very optimistic about finding “cures” for cancers that arise or become malignant primarily through mutations in tumor suppressor genes; I think they can be treated (of course in many cases, treatment = resection of tumor), and that quality of life and survival time for the patient can be improved. I think tumor burden, recurrence, and side effects from cancer therapies can be reduced. But cured? No, not in my lifetime.
Tumor suppressors often serve many functions, in specific cell types at particular stages, and so how can they be completely replaced or targeted pharmacologically? Take p53, as a classic example- it’s involved in apoptosis, cell cycle regulation, and base excision repair … often under different circumstances in the same cell type. Neurofibromin was first characterized as a GTPase activating protein for Ras … but there are many other GAPs, and many Ras relatives, and the GAPs are expressed differentially according to cell type and developmental stage. Neurofibromin also regulates cAMP levels in some cell types and contexts. Some of the knowledge about neurofibromin function has been used to apply existing drugs (farnesyltransferase inhibitors, Gleevec, rapamycin) to NF1 tumors. But I guess my bias is that it’s easier to inhibit an activated oncogene product, than to replace a missing tumor suppressor product; most human cancers arise and undergo malignant transformation through mutations in tumor suppressor genes (including those encoding transcription factors, signaling molecules, pro-apoptotic molecules, DNA repair proteins, miRNAs, etc), and therefore “cure” seems extremely difficult.
Cheap and effective? Old drug for new uses! 🙂
the article
the trial phase II-III
the trial phase I
Mmm, and your point is what, exactly?
Simply, we should be ready for new surprises… My friend had wife who died of breast cancer in her 37 years and left 4 children (from 4 to 12 old)… I talked with her a year before her death… I remembered my father (82) who is (up to this day) in the habit of talking about TBC (he had had TBC and had survived it to became a lung doctor) that nobody had believed (about 60 years ago) that it would have become curable. I think there must be a “magic bullet” for cancer as well as there has been “magic bullet” (antibiotics) for various microorganism-induced diseases. Perhaps, however, we are doing research too rationally without Flemings sensitivity to small, totally surprising things.
I definitely believe that proteasome inhibition is a new anti-cancer strategy (not only for multiple myeloma ). The cheap, old (actually, non-patentable), safe and broadly available drug DISULFIRAM (ANTABUSE) is probably able to do the same work like bortezomib does.
Hi Kristi, excellent reply. I was just wondering if your pessimism in curing (certain types of) cancer would change if we consider that tumour cells need to interact with their microenvironment for the tumour to be really malignant. Thus affecting the tumour microenvironment could, potentially, serve as a mean to prevent tumour growth and progression. Not that it’d be easy though but seems to me that is worth some (ongoing) research.
Wishful thinking, Boris. And you still need (expensive!) Phase IIIs.
Oh, and Fleming was a nit.
Sorry for being late to this discussion. I think we can be more optimistic about cancer cure rates. The Surveillance, Epidemiology and End Results (SEER) program is one of the best places to look for cancer statistics (at least for numbers from the United States). For many cancers, survival for 10 years equals cure, and here are the 10-year survival rates for selected cancers from the SEER database (with 1988-2004 data):
Testis 95%
Prostate 90%
Melanoma 89%
Hodgkin’s lymphoma 80%
Breast cancer 80%
Acute lymphocytic leukemia 61%
Colon and rectum 57%
Kidney 57%
Head and neck cancer 48%
Stomach 19%
Lung 11%
Pancreas 4%
Other important numbers are of course the numbers by age (it makes a huge difference whether the cancer is diagnosed in a 2-year old or 85-year old), the numbers by disease stage (localized vs. metastatic) and the changes over time (e.g. now vs. 1988).
But we shouldn’t forget that most patients with prostate cancer, melanoma and breast cancer are cured, as are the majority of patients with colon cancer or kidney cancer. And with all the talk about targeted therapies we shouldn’t forget that surgery is still the most important treatment for solid tumors and that chemotherapy cures patients with Hodgkin’s lymphoma, acute lymphocytic leukemia and advanced testicular cancer.
I personally believe that there are many different ways how cancer cure rates can be improved, from prevention, better early detection, improved treatment to basic science. And prevention is important. The number of people with newly diagnosed stomach cancer in Europe has fallen dramatically in the last 30 years. For newly diagnosed lung cancer these numbers are finally falling for men, but not women.
The relative contribution of basic science research to the improvements in cancer cure rates are difficult to measure. For me good clinical trials are most important to improve the treatment of patients with cancer, and we need good public funding for that. Drug companies are interested to find a cure for cancer, but will usually not fund clinical research for very rare cancers, with old drugs given in new combinations, or with trials that try to reduce the treatment intensity (because of concerns of long-term side effects, e.g. in Hodgkin’s lymphoma).
bq. But we shouldn’t forget that most patients with prostate cancer [] are cured,
um.. really? Is that because men die of something else before the cancer gets them?
um.. really? Is that because men die of something else before the cancer gets them?
The detection of very early prostate cancer by measuring PSA in the blood and the high age of most patients means that many men with prostate cancer will not die from the disease. But it also means that either an operation or radiotherapy can cure most patients with localized prostate cancer.
I’m still quibbling about ‘cure’. I’d like to know how those numbers in the links you gave look when you add back those men who died, and what they died of. Do bone metastases, for example, count as ‘not-prostate’ cancer?
These numbers mean that 10% of the people who are diagnosed with prostate cancer die of the disease. Almost all of those who die will have had metastatic disease, including bone metastasis. But most prostate cancer patients never develop metastatic disease.
The same is true for many other cancers including malignant melanoma. Advanced malignant melanoma is almost impossible to treat, but 81% of patients have localized disease with a 98% cure rate.
Testicular cancer is an exception, the cure rates are 99% for localized disease, 96% for patients with lymph node metastasis and 71% for patients with distant metastasis (e.g. lung, liver or brain). The main reason for this good survival is the chemotherapy drug cisplatin introduced in the 1970s.
You also have to compare these numbers to other common diseases. To take just two examples, the 10-year survival for liver cirrhosis is 34%. And only 43% of those that survive the acute phase of a heart attack also survive the first 5 years.
Thus affecting the tumour microenvironment could, potentially, serve as a mean to prevent tumour growth and progression
Hi, David- I think some of the most promising therapeutic research involves tumor microenvironment and tumor immunology. One of the biggest criticisms of mouse xenograft models, which I’ve heard many times at meetings, is that the tumor microenvironment can’t be mimicked accurately under those circumstances (different tissue location, immune system not intact, etc.). I’m certainly no expert in tumor immunology (I came into cancer research through the back door of developmental neurobiology), but I think microenvironment issues can account for much of the variable expressivity (in inherited cancer syndromes) and differential responses to treatment in all forms of cancer. With “microenvironment” I would include not only immune system, but support/stromal cell behavior, ability to remove/inactivate genotoxic agents, and DNA repair capacity.
I’m more optimistic about translational research into tumor microenvironment as applied to sporadic cancers, than to inherited cancer syndromes. For the latter, I’ve heard some interesting ideas about boosting expression of the intact, wild-type tumor suppressor gene (or reducing protein degradation) in patients, to alleviate some of the consequences of haploinsufficiency, but implementation seems a long way off.
bq. But most prostate cancer patients never develop metastatic disease.
is that because people die with rather than of the cancer?
I’m a little niggly about prostate cancer because (a) I have a good chance of getting it (being male) and (b) by all accounts the treatment sounds as bad if not worse than the condition itself.
Again, preventing the cancer sounds to me like the solution. Not early detection, but prevention (I think there’s an argument against early detection: detect early and live for 15 years on chemo, or not know about it and die 5 years sooner? Pass the morphine).
That all y’all (and thanks for the discussion) have come up with these very specific treatments and success stories does make me think they’re exceptional, rather than the rule. Discuss.
Richard, I think preventing the cancer is much more wishful aim than treating the cancer… the best preventing is to die early (or to remove persons genes).
From my own family:
mothers father: 130 kg/170 cm (not smoker), happy life according to his own stances (NO SPORT)… he died 87 years old
my father: smoker since his 13th birthday, an alcoholic, now he is 82 years old and absolutely fit
boyfriend of my she-cousin: no smoker, no drinker, 25 years old… really painful death of sarcoma
Well, the plural of ‘anecdote’ is not ‘data’, but surely even that tells us we don’t know everything about risk factors and should be devoting energy towards finding them out?
I think the most important “risk factor” is the body itself. If you have good body (it is not necessarily only about genes), you can survive almost anything, if you have bad body, you could become cancer patient even in early childhood. An, of course, psychology seems to be important…
Boris, what are you smoking and did you bring enough for everyone?
Now, I am drinking red wine (cabernet sauvignon), so I am not smoking… :
) At the same time, I am listening youtube (it is about drinking :) However, I like cigarettes (Camel) if I drink the beer; usually, I have enough for everybody :-).My father always says: it is not important how long you will live, it is important if your life is happy and deeply valuable (my father is poet 🙂
Having sat through a few basic science talks that use important diseases for their preamble …
The could be that whilst people who are ostensibly studying cancer love to burrow down into a problem of cell biology they do not like to burrow back out to the real world (organisms with diseases).
After listening to too many of these seminars in a row one day I asked the speaker that since they had used disease X to walk us into this cell biology problem perhaps they could walk us back to the disease.
The answer was essentially ‘no’.
ouch
Ha, Nathaniel – I’ll have to try that some time. In my field we get “studying incredibly common species X is vital for conservation”. It got absurd when they used this for inbreeding in Drosophila.
“We don’t know what X does, so we’re going to find out” doesn’t seem to be an unreasonable justification for researching X, at least to me.
Unfortunately, the granting agencies tend to disagree.
I like Boris’ philosophy of life.
1. Whatever doesn’t kill you, makes you stronger.
2. Giving up things you enjoy won’t actually make your life longer, it’ll only seem like it.
Dr Grant has told me that if I don’t help bring his tally of comments up to 100, he’ll do things I’d really rather not mention here, but which would almost certainly involve the copious release of calcium from intracellular stores.
In the village hall if wet (Restrictions apply).
Does this mean you’ll deinitely review Siege of Stars, Richard?
Oh, go on then, seeing you’re such a silver-tongued lounge lizard.
…surely that’s cheating?
And Nathaniel, I like that one. I’m a neuroscientist working in a pharmacology dept., and as such must sit through hours of seminars on topics I have no interest in, and often little understanding of. I often feel the same way…
I see I’m not needed anymore.
Or…
ONWARDS TO 200!
Encouraging people to eat well has been tried and it obviously isn’t a very effective way to combat cancer. It’s all to do with the risk/reward balance; unless people can see an immediate effect, they always take the short-term reward and risk the long-term effects.
Smoking for example, if people thought it could kill them within days nobody would smoke, but because the effects take years, people are willing to take the risk.
I declined to take part in your push for 100 comments, given your shenanigans last time I tried to claim the 100th comment.
HPV vaccine anyone? No-one? I think it’s worth discussing (and even on topic!)
So shouldn’t we devote more effort into researching causes rather than cures? So that we can treat the source, not the symptom? I think so, but here we run into trouble. There is intense political and economic pressure to not find out what causes cancers.
It’s a shame that pointing out an unavoidable motivation of a corporation is so chancy. My doctoral adviser would agree with you 100% since his work (and my own thesis work) is directed at finding the cause of cancers in children, particularly leukemia. Now, this is a disease state that has shown remarkable improvement in chemo/rad efficacy (somewhere greater than 80% success). However, at what cost? Another thing that he and I have been interested in is how many of these “cured” children are now at increased risk for secondary malignancy later in life? Perhaps even as a function of the treatment! After all, methotrexate, 6-thioguanine, 6-MP, cisplatin and their ilk are not the nicest of compounds…
So he is obsessed with cause. And he can’t get grant money, and is now faced with a dwindling lab.
Par for the course.
Again, preventing the cancer sounds to me like the solution. Not early detection, but prevention (I think there’s an argument against early detection: detect early and live for 15 years on chemo, or not know about it and die 5 years sooner? Pass the morphine).
Richard, prevention is probably not a realistic goal for prostate cancer, as up to 80% of men over 80 have it when you do a post-mortem exam. But to almost all of them, it didn’t make any difference, as they died from other causes and never had any symptoms from it.
I agree with what you say about early detection and that is why PSA screening for early detection of prostate cancer is controversial. And treatment indeed has side effects, prostatectomy (removal of the prostate in an operation) leads to incontinence in up to 50% and impotence in up to 100% of patients. Severe pain from bone metastasis is fortunately a much rarer event.
Cath, I attended a talk by Harald zur Hausen last week, about HPV vaccination in particular (as opposed to just being about HPV in general).
The most interesting thing in my notes, IMO, are:
-the incidence of cervical cancer is highest in those areas of the world that can’t afford vaccinations. Countries that are vaccinating their young girls right now are those in which the numbers were already low anyway.
-HzH is very much in favour of vaccination not just girls, but also boys. He gave three reasons (or maybe more, but I wrote down these three) 1. Boys can also get certain types of cancer related to HPV (penile, most notably, but there were a few other minor ones), 2. as a point of solidarity, and 3. you can’t go wrong with extra degree of protection.
(Fix typos as needed. I never see typos until after I hit “post”, or when I’m already at Kinko’s to bind my dissertation.)
Intersting. Would the vaccine be effective in males too? I mean, it takes two to tango, so we have to be 50% of the cause of the infection…
It should be – it’s the same virus. Or at least, it should be as effective as it is in girls, and exactly how effective that is isn’t entirely clear. There was a panel discussion with the lecture as well, and one of the panelists pointed out that it takes about twenty years from infection to cervical cancer, and the vaccine hasn’t been around for that long, so we simply don’t know if it will hold out.
The vaccine absolutely works in males too, but I think it will be a while before that thought permeates the general consciousness! I mean, there are enough problems getting people in developed countries to vaccinate their daughters (OMG it will make our daughters promiscuous!!11!!).
I wonder if someone like the Gates Foundation would be interested in rolling out vaccinations to developing countries. However there could well be social / cultural barriers as I mentioned above…
Eva, as always, one or two personal experiences can override my logical appreciation of the overall low rates of cervical cancer. (One scare myself (biopsy negative thankfully), similar experiences by at least 2 of my friends, one friend-of-a-friend who had a positive biopsy and then local laser therapy, one friend’s sister who had a couple of false-negative pap tests and ended up needing a hysterectomy and radiation/chemo at the age of 23). Too late for any of us to get the vaccine, but there’s hope for the young’uns to grow up in a world without cervical cancer.
Hmm, seems that NN software thinks that ! ! 1 1 ! ! is an invalid image link rather than standard internet language for an extreme freak-out.
Interesting perspective. A good one, I mean.
I think some people were assuming I meant lifestyle changes when I started talking about causes rather than cures. But this—HPV—is precisely what I’m talking about. A causative agent/event has been identified and a treatment developed to protect/prevent.
“OMG it will make our daughters promiscuous!”
That was another thing the panel discussed: it’s silly, because right now kids are already being vaccinated against that one Hepatitis virus that is sexually transmittable (I always mix up my Heps so I won’t try to guess the letter) and nobody worried about that.
Yeah.
Kids will fuck; the thought of pregnancy or syphilis or AIDS or HepB/C has had little effect on that. Why should the HPV vaccine?
Richard
I completely agree that basic scientists ought to be able to simply work on mechanisms because it’s interesting and might through a stroke of unintended luck end up being useful in human disease treatment/prevention 20 years down the road.
It sucks that you have to employ grantsmanship in order to get funding. However, one might also argue that taking money away from medical research to do basic work is a problem.
What vexes me is sitting down to a talk that has a disease of major public health importance mentioned in the title only to have that disease completely ignored past the first slide. I understand that might be necessary in the grant but it’s not necessary when you’re giving a seminar/research talk.
On the HPV issue -I find it remarkable that one of the marketing tools for vaccination that isn’t used is the pap smear.
The women in my life assure me that they’d rather not have to have them. One of the implications of widespread coverage against HPV is that our daughters may no longer need a cervical screening program as the disease may be too rare to make the program worthwhile.
Is this purposely not mentioned because dis-establishing screening for female diseases is like a third rail of public relations/politics (touch it and die)?
Nathaniel, the pap test was also discussed at the seminar/discussion I went to. It should still be continued, says Zur Hausen and say the healthcare workers. It should be complementary to the vaccination, not one or the other. Besides, as I pointed out above, it’s not yet clear if the vaccinations will last a lifetime, and the only way to check this is by routine screening, especially of women who have been vaccinated when they were younger.
That’s a very good point, Eva. It’s a post-hoc trial, really.
Maybe the vaccine will mean less frequent pap tests – that would be a good thing (I’m on an every 6 months regimen myself until I have 5 years of negative results – halfway there!).
Not all cervical cancers are caused by HPV, right? The sources I’m finding say “almost 100%”.
As far as I can tell, HPV is by far the major cause. Early age of first sexual intercourse, first birth, and oral contraceptives seem to be the other risk factors, apparently.
Screening- I didn’t express myself very clearly.
I didn’t mean to imply that I thought screening was no longer necessary in the immediate future.
The decision making that surrounds whether to screen populations is very sensitive to how common the disease is. So even though we have very good tests for some diseases we don’t test everybody for them because the disease is too rare. The reason for this is that it’s too expensive/not cost effective.
The related reason is that (no matter how good your diagnostic test is) the rarer the disease the larger the proportion of false positives to real positives. These cause unneccesarry worry/morbidity in a great number of women who do not have cancer (and there are also potentially upsides in terms of the new lease-on-life effect).
So what I am hoping is that by the time I hit the currently accepted retirement age cervical screening will no longer be needed because the disease will be far too rare. So the marketing implication is that the daughters of those currently being vaccinated will no longer need the current Pap smear screening technique in their lives. And I think that’s a very good scientific-based outcome that those involved should be mightily proud of.
It would be good to think that we wouldn’t need to screen—but as Eva points out we’ll need to keep it around to test if the vaccine is working… which means a good 20–30 years more, at least. I guess.
Like I said- Retirement age
I admire your optimism 🙂
I read through all these comments (whew, glad I had some time).
Mark, I am somewhat symapthetic to your logic, but you assume that there is a cheap and effective cure for cancer. Maybe cancer is uncureable because we have defined it operationally to broad.
To all: what does the data show? You all have a lot of opinions on this, but has anyone done a meta-analysis of the literature to tell us whether, objectively, we are any closer to a breakthrough? If not, then we all better keep working.
I didn’t read through all these comments.
Confessions aside, Olivia Judson had a recent piece in the New York Times, Cancer of the Devil , that took a different angle on cancer… and it’s potential future. Fairly appropriate for Hallowe’en, too.
Much like it’s your favorite aunt or best friend that gets cancer, whereas Uncle Albert with his piles and racist epithets keeps knocking on to a hundred and six, I’m quite upset about the Tasmanian Devil.
Why can’t koalas (nasty, scratchy, chlamydia-laden things) or cane toads get something like that?
Evolution’s a bitch, sometimes.
Early age of first sexual intercourse, first birth, and oral contraceptives seem to be the other risk factors [for HPV]
I’ve always wondered about the ‘oral contraceptives’ link – isn’t that possibly just a confounding factor: you take oral contraceptives -> you probably don’t use condoms -> you’re more likely to contract HPV?
p.s. just so that Cath isn’t the only one: me, same thing, screening once a year now. I wish they’d had the vaccine way back when..
That was my interpretation too Steffi – I suppose it’s possible that altered hormone levels could affect viral replication rates or something like that, but the correlation with not using condoms seems more likely.
I was thinking just this morning that rolling out a one-time vaccination like Gardasil would be much easier and cheaper than trying to implement screening programmes, mammograms, coloscopies etc. in developing countries. Too bad so few cancers have a (known) viral cause!
BTW if you fancy a Friday laugh about a very interesting cervical cancer screening experience, I highly recommend this post by Isis the Scientist.
ooooh, very good!! Thank you 🙂
bq. Too bad so few cancers have a (known) viral cause!
which just about brings us full circle, doesn’t it?
Henry: I like Boris’ philosophy of life.
Boris: 🙂 It is uncles Tobys (philosophy of life) from Tristram Shandy a Gentleman as well…
A raised glass of sherry to all for a thoroughly informative and stimulating post and comment thread.
Very decent of you, sir.
I’ll raise a toast to that (as it is 2140 and past my bedtime).
There’s a lot of love in this room.