Is the war on cancer an ‘utter failure’?: A sobering look at how billions in research money is spent
Justin Sullivan/Getty Images “This
thing called a war on cancer … has been an utter failure with
metastatic cancers,” estimates John-Peter Bradford, 70, author of a book
about his own experiences as a patient. “We have to try different
things, and we have to try them differently.”
The side effects John-Peter
Bradford endured four years ago as he underwent radiation therapy and
surgery for throat cancer were, he says, “barbaric.” Still, the potent
treatment worked, eradicating the tumour and saving his life.
As his family confronts the shock of another, more advanced
malignancy today, however, the Ottawa management consultant is
agonizingly aware that many cancers remain incurable, despite 40 years
of hugely expensive research into the disease and how to treat it.
“This thing called a war on cancer … has been an utter failure with
metastatic cancers,” estimates Mr. Bradford, 70, author of a book about
his own experiences as a patient. “We have to try different things, and
we have to try them differently.”
National Post GraphicsClick here to see up to date data on cancer rates in Canada
His sobering view is not exactly embraced by the disease’s most
public face: cancer charities and hospitals, which still confidently
promise to “outrun cancer,” while exhorting donors to walk, cycle or
even play road hockey “for the cure.”
Yet some scientists believe the quest for an antidote to the world’s
number-one health risk is indeed being lost, even as research costs
surge well past $100-billion.
Though the per-capita cancer mortality has fallen, the total number
of deaths continues to soar, as the rate of new cases also climbs. Jim
Watson, the Nobel-winning discoverer of DNA’s double-helix structure,
caused a minor sensation recently by arguing that curing most metastatic
cancers — cancers that spread in the body — remains more daunting than
ever, while researchers pursue scientific dead ends.
Lamenting a “conservative” research establishment that he suggested
is reluctant to take scientific risks, he urged scientists to follow
new, unexplored, yet more promising directions.
Of all the much-hyped and pricey new cancer drugs entering the market
— the most tangible results of so much research — a few have worked
wonders, but the benefits in many cases are minimal, some doctors
complain, with serious side effects downplayed.
“It’s been a very, very chaotic process of looking for cancer cures,
and it’s not been tremendously successful,” said Jack Siemiatycki, a
prominent cancer epidemiologist at the University of Montreal, who
suggested that there is little co-ordination among the myriad cancer
labs and clinics. “There have been successes, but it’s a modest success
story.”
Michael Pollak, an oncologist and internationally recognized
treatment researcher across town at McGill University, maintains that
cancer science has, in fact, made great strides in the last 40 years.
But even he admits that well-meaning scientists often leave patients
with an exaggerated sense of their achievements.
“The researchers are always announcing fantastic progress and
breakthroughs — and the patients are still getting sick and dying,” said
Dr. Pollak. “The people who are announcing cancer breakthroughs, I’d
like them to walk through the cancer ward. … You see all these thin and
kind of desperate patients.”
The “spectacular” volume of knowledge accumulated about the disease
is one of science’s great accomplishments, said Dr. Ian Tannock, an
oncologist and researcher at Toronto’s Princess Margaret Hospital. Asked
about his cancer centre’s own slogan “conquer cancer in our lifetime,”
though, Dr. Tannock is more cautious. He said he doesn’t believe that
widespread cures will come in his or his children’s time on earth,
foreseeing a series of small advances, but no dramatic breakthroughs.
The results of modern cancer research are typically measured from the
date in 1971 when Richard Nixon, then U.S. president, launched what was
dubbed the war on cancer, with many likening it at the time to
America’s triumphant drive to put a man on the moon. And the massive
dollars assigned by the U.S. since have been mirrored on a smaller scale
in other countries, including Canada.
Yet that era’s great expectations were hopelessly naive, argues Dr.
Benjamin Neel, head of the Ontario Cancer Institute and an American
whose medical training began in the same era.
Launching a war on cancer in 1971 “would be sort of like Kennedy
trying to put a man on the moon in the 1600s,” he said. “We had no
fundamental understanding of the disease.”
Since then, though, scientists have managed to draw a detailed map of
how cancer works, identifying genetic anomalies that allow cells to
multiply uncontrollably and resist the natural death that comes to
normal cells. Dr. Neel calls it a springboard of knowledge that should
lead to something closer to cures for even the most stubborn cases,
sometime down the road.
“I don’t think there has been a single better, more efficient
expenditure of public money,” he said of the research into the science
behind cancer. “Far from being embarrassed, we should be trumpeting
those successes.”
In the U.S. alone, the National Cancer Institute (NCI) — created by
the Nixon administration more than 40 years ago to help fight the war —
has doled out close to $100-billion in funding, with hundreds of
millions more raised and spent by cancer charities and hospital
foundations.
The numbers in Canada are smaller, even when put on a per-capita
basis, but still impressive. Total cancer-research spending here in 2009
was $545-million, according to the Canadian Cancer Research Alliance,
with the biggest chunk ($132-million) coming from the Canadian
Institutes of Health Research, this country’s counterpart to the NCI.
More than 60% of the cancer money goes to work on biology and
treatments. By comparison, a recent study put total spending on research
into cardiovascular disease — Canada’s next-biggest killer — at under
$100-million, a fifth as much.
Despite definite patches of hope, though, the statistics remain grim,
with an estimated 186,000 Canadians newly diagnosed with the disease in
2012 and 75,000 deaths. Even after the effect of an ageing population
is filtered out, data show the rate of new cases per capita has been
rising, albeit slightly, now at 456 cancer patients per 100,000 people.
While the overall number of deaths is 50% higher than two decades
ago, the good news is that the mortality rate per capita — again after
removing the effects of a greying population — has dropped to 184 per
100,000, from 243.
But here’s the catch: Much of that reduced lethality, is due
primarily to one thing, and it has nothing to do with medical
breakthroughs but, rather, the precipitous drop in the smoking rate that
prevented legions of people from even getting sick with cancer in the
first place.
“I think the most important cancer research of the 20th century by
far was the discovery of the smoking association,” said Dr. Siemiatycki.
“It wiped out one-third of cancer.”
An American Cancer Society study last year suggested that overall
cancer mortality would barely have shrunk at all after the early 1990s
if not for the huge societal shift away from tobacco.
Dr. Deirdre Meldrum, Dr. Roger H. Johnson, Mr. Vivek Nandakumar/ Arizona State University Three-dimensional
images of a cell as it progresses from a normal cell to an invasive
cancer. From left to right: normal cell, metaplastic cell, dysplastic
cell, invasive cancer cell.
For some patients struck with certain cancers, it’s true that the
prognosis is decidedly better now than four decades ago. Childhood
leukemia, a virtual death sentence in the 1960s, now has an 80% survival
rate; Hodgkin’s disease is all but curable, while some of the major
adult cancers, like breast and prostate, can be successfully treated
now, if caught early enough.
Still, many advances have come through better screening programs —
improved mammography for breast cancer that can detect a tumour while
it’s still small — and better use of the same tried and true treatments
of surgery, radiation and chemotherapy, with the latter two attacking
cancerous and healthy cells almost indiscriminately.
“We still tend to treat cancer today with, in some cases, many of the
same tools we used 40 years ago,” said Sian Bevan, research director of
the Canadian Cancer Society.
Those traditional treatments, honed over the decades to reduce the
damage to normal tissue, were what saved Mr. Bradford. Yet they still
come at a heavy cost. He lost his sense of taste and can no longer
create saliva. Much of his throat was removed.
In a recent book lamenting the limited progress against cancer,
Margaret Cuomo, a New York radiologist, also notes that radiation can
actually cause more malignancy later in life, citing the case of Robin
Roberts, the Good Morning America host, whose 2012 public bout with
cancer may have been triggered by treatment for a breast tumour five
years earlier.
The drive in drug development now is to narrowly target the genetic
mutations that give cancer cells their deadly characteristics, ideally
avoiding widespread harm to healthy cells. There are certainly some
success stories.
For the one-fifth of breast-cancer patients who have the HER2
protein, the drug Herceptin, in combination with surgery and
chemotherapy, has helped make the disease virtually curable when found
early enough, said Dr. Tannock.
Gleevac, another targeted drug, has “completely transformed” chronic
myelogenous leukemia from a certain death sentence to usually
survivable, said Christine Williams, research vice- president at the
Canadian Cancer Society.
Bruce Dickinson of St. Catharines, Ont., who suffers from
myelofibrosis, a rare blood cancer, credits the fact he is still alive
today to the new drug Jakavi, which has stabilized his
fast-deteriorating health. But the 60-year-old relies on manufacturer
Novartis to provide it free, on a humanitarian basis, since the $7,500
monthly price is almost four times the income he and his wife receive
from disability benefits.
The agency that assesses oncology medications for the provinces,
recently recommended the drug be covered under government plans, but
only if the price was cut to make it more cost-effective, noting that
Jakavi’s ability to extend life remains uncertain.
Along with such breakthroughs, meanwhile, have come a slew of new,
targeted treatments with less glorious results. Many are approved based
on extending patients’ lives by just weeks beyond existing treatment
courses, or not at all, and, as Dr. Tannock and colleagues have shown in
a series of recent studies, they often feature serious side effects
that come to light well after hitting the market.
And their price tags are typically sky high. A group of oncologists
at New York’s Sloan-Kettering Cancer Center recently refused to
prescribe Zaltrap for late-stage colorectal cancer, noting in a New York
Times op-ed piece that its $11,000 monthly cost was twice that of an
older drug, Avastin. Yet both had the same, modest effect, extending
survival by 1.4 months on average.
But even Avastin itself is “a great disappointment” in treating
cancer, in Dr. Tannock’s estimation, despite being the world’s
ninth-highest-selling drug in 2012, raking in $6-billion in sales,
bolstered by extensive, mostly positive media coverage.
Those extra few weeks or months afforded by new drugs, while seeming
insignificant from a distance, can be important to patients, stressed
Dr. Bevan at the Cancer Society. On the other hand, some are surprised
by the modest benefits after hearing of great breakthroughs, said Dr.
Pollack.
“If you’re a patient, six months is appreciated, but it’s not exactly what they had in mind,” he said. “They want a cure.”
Tyler Anderson/National Post Dr.
Ian Tannock, senior cancer researcher at Princess Margaret Hospital,
poses for a portrait in Toronto, Ontario, March 7, 2013.
On a February day in 1956, surgeon Evarts Graham handed a chest X-ray
to a colleague, not mentioning its origin. The verdict? Metastatic
cancer, inoperable.
The image, as it turned out, was of Graham’s own chest.
“The trouble is, that I smoked for 50 years,” he wrote to a friend.
Dr. Graham’s death two weeks later was tragically ironic. As
documented by oncologist Siddhartha Mukherjee in his book The Emperor of
All Maladies, the American physician had earlier spearheaded one of the
seminal studies showing a powerful link between smoking and lung
cancer.
The impact of that discovery still resonates, as critics like Sholom
Glouberman, founder of the Patients’ Association of Canada, argue for
much more work on the prevention of cancer, despite an image less sexy
than that of seeking a cure to the devastating disease.
A new drug with minimal life-extending abilities will earn extensive
publicity, noted Dr. Eva Grunfeld, a University of Toronto
family-medicine professor.
However, she said, “you don’t get much fanfare” about the
cancer-related benefits of losing weight, though evidence indicates
obesity not only makes getting the disease more likely, but curtails
survival once someone has it.
“The most effective way of stopping cancer is to work at the prevention end,” said Mr. Glouberman.
Jack Siemiatycki, a University of Montreal epidemiologist, argues
that an urgent priority is finding more causes. If someone developed a
drug that had the same impact on cancer incidence and deaths as has
plummeting smoking rates — which has been almost entirely responsible
for the drop in cancer mortality since the 1990s — the researcher would
undoubtedly win the Nobel Prize, he said.
Yet he has calculated that just 1% of research funding now goes to
identifying new carcinogens, while the number of Canadian
epidemiologists doing that kind of research could fit in a small room.
And most of them are at, or near, retirement age.
Such research often begins with large “observational” studies — such
as the recent Interphone project that looked for a link between
cellphone use and brain tumours — followed, when evidence of an
association emerges, by more exacting trials.
No cause will turn out to be nearly as important as smoking did,
Prof. Siemiatycki acknowledged. Research since, however, has uncovered
the connection between human papilloma virus and cervical cancer —
leading to the first vaccine that can prevent cancer — as well as the
risks of sunlight, indoor-tanning beds, asbestos, radon gas and alcohol.
Still, knowing the contributing factors of cancer does not always
lead to concrete action, notes Dr. Benjamin Neel, head of the Ontario
Cancer Institute.
About 17% of Canadians still smoke, obesity is epidemic and indoor tanning remains a $1-billion industry.
Of course, trying to defeat cancer at the molecular level is a
challenge like few others in medical science, despite a history of
laboratory discoveries — from Frederick Banting’s insulin to Fleming’s
penicillin — that were able to vastly transform the treatment of other
illnesses.
It has turned out, for starters, that cancer is actually as many as
300 different diseases, with qualities that make them uniquely difficult
to eradicate. Disease-causing bacteria, by contrast, are foreign
invaders whose biology is sufficiently different from normal human cells
that it is possible to kill them without harming the patient, noted Dr.
Pollak. Cancer cells — a case of the body’s own internal biology gone
awry — are so similar to normal cells, that most of the weapons that
obliterate them also endanger healthy tissue, he said.
Plus, cancer patients have as many as 100 million cancerous cells,
and each one must be dispatched to prevent the disease roaring back,
much like a few neglected weeds multiplying on a front lawn. “The prize
[in oncology] for almost succeeding is not that large,” said Dr. Pollak.
The challenge has proven all but insurmountable when cancer spreads
beyond its initial site, Dr. Watson points out in his recent article in
the journal Open Biology.
Once metastasized, the major adult cancers remain incurable; the new,
targeted drugs “only temporarily hold back the fatal ravages” of lung,
colon and breast tumours that have spread, he wrote.
He advocates shifting money away from developing therapies designed
to stop genetic triggers for specific cancers, and toward uncovering
ones that attack features common to various malignancies. Potential
targets include a protein called Myc, which he said may be an essential
feature in many incurable cancers.
He complained, though, that researchers, rather than trying to “aim
big,” are assaulting the disease on a “never-frantic, largely five-day
working week.” The biggest obstacle to progress, Dr. Watson added, is
“inherently conservative research establishments” averse to
experimenting with innovative ideas.
Dr. Pollak recounted how Dr. Watson, the field’s elder statesman,
visited him recently in Montreal and essentially argued for inventive
research that, while quite likely to fail, has a shot at producing truly
transformative results.
The McGill professor said he agreed there should be more of that kind
of high-risk, high-yield science in the mix. Funding bodies meting out
limited dollars tend to discourage scientific gambles, though, rewarding
those who propose building incrementally on previous findings, rather
than bolting off in new directions, he said.
The competition between labs to achieve some sought-after goal first,
while healthy in many respects, also risks leading to duplication of
effort and secrecy that may not aid the greater good, said Dr. Pollak.
Dr. Neel said Dr. Watson is right that individual targeted cancer
therapies will have limited impact on their own, but predicted the
future of treatment will involve using several types of drugs that
attack different aspects of a cancer, much as chemotherapy is employed
now.
And Dr. Watson does not have an entirely spotless record as a
scientific prophet. He predicted in 1998 that new drugs that curbed
blood flow to tumours would result in a cancer cure within two years;
once tested on humans, the medications had only minor benefits.
But if science is making only tentative steps toward overcoming
cancer’s worst cases, fundraising campaigns continue to offer a far more
reassuring vision, signalling to potential donors that conquest is
imminent. “Cancer can be beaten … conquer cancer … end cancer … a future
without breast cancer” are among the hopeful messages. No one doubts
the importance of generating research dollars, but some critics question
the marketing approach.
“They have no right to talk about [curing cancer],” said Sholom
Glouberman, founder of the Patients’ Association of Canada. “I think
it’s more than a bit misleading.”
Dr. Neel maintains that it’s possible that within two decades that
significant treatments will emerge even for those now-incurable,
metastatic cancers, though he predicts the end will come via a series of
small victories: “with a whimper, not a bang.”
In his Pulitzer-winning book, The Emperor of all Maladies, oncologist
Siddhartha Mukherjee is generally optimistic about the fight against
cancer, but disavows the notion that a penicillin-like cure is imminent —
or might ever come.
“Much of the battle will remain the same: the relentlessness, the
inventiveness, the resilience, the queasy pivoting between defeatism and
hope … the arrogance and the hubris.”
As his family again struggles with cancer, Mr. Bradford is
understandably more blunt, calling on science to emerge from its
“bubble” and recognize that it needs to aggressively pursue new ideas.
“Is the war on cancer going too slowly?” he said. “I’d say it’s like
Afghanistan. There’s no way to win the way they’re doing it now.”
tblackwell@nationalpost.com
National PostLabels: Biology, Disease, Health, Medicine, Science
Dr Benjamin Black, who is treating Ebola patients in Sierra Leone
