The “war” on cancer: are we “winning” or “losing” or what?


Clifton Leaf is a cancer survivor. He is also the Editor-in-Chief of Fortune magazine. And he has long argued that we may not be making the most astute decisions about how we are trying to find “the best” and “the rightest” ways to diagnose, treat, and manage cancer. You might be interested in his book entitled The Truth in Small Doses: Why We’re Losing the War on Cancer — and How to Win It, originally published in 2013.

One of the points that Mr. Leaf has made frequently over the years is that it all depends on how we define and then measure “success”. And this was a point he made yet again in a presentation at the ESMO 2018 Congress in Munich over the weekend (see here for a commentary on the UroToday web site).

Here are just a few of the key points that Mr. Leaf is well known for making:

  • Yes, it is true … the 5-year relative cancer survival rates from 1973 to 2013 have risen significantly, but …
  • This rise in the 5-year survival rates has been driven to a great extent by the fact that we have got better and better at diagnosing cancer early (and the earlier you diagnose a cancer patient, the longer he or she is going to live, even if you do nothing).
  • For patients being diagnosed with later, more advanced stages of cancer, the 5-year survival rates really haven’t changed anything like as much.
  • The number of drugs in development for the treatment of cancer (just in the US) went from 399 in 2005 to 1,120 in 2018, but …
  • The number of drugs developed per each US$1 billion invested has dropped from about 80 in 1950 to < 1 in 2010, and …
  • There is a direct association with this loss of return on investment and the rising costs of  cancer care.
  • The average monthly cost of treatment with a cancer drug now exceeds the average (median) monthly household income.
  • Over the past 15 years, the average number of life-years lost per person dying of cancer has increased (most especially for those diagnosed with cancer in childhood).

To quote Dr. Thenappan Chandrasekhar of Thomas Jefferson Univerity, here in Philadelphia, who commented on Mr. Leaf’s presentation for the UroToday news system:

This was a very sobering talk regarding the overall cancer burden and progress we have made as a field. Perhaps we need a change of focus — rather than extremely expensive treatments for a small population of patients, we need better strategies for prevention and interventions that can impact a larger swathe of the population!

Your sitemaster personally believes that what we need is a much more equal level of focus and investment on three different issues:

  • The development of effective, safe, and affordable treatments for those unlucky enough to be diagnosed with (or who progress to having) aggressive and metastatic forms of cancer
  • The development of effective, safe, and affordable treatments that prevent or control progression of cancers that are diagnosed early
  • A complete re-thinking of the processes that might be available to prevent or at least limit the likelihood that people get diagnosed with cancer in the first place (and your sitemaster is not talking about things like whether you cell phone may increase risk for cancer; rather, he is talking about the foods we start eating as infants, our general level of health and health education, and the levels of pollution we seem to be willing to live in and with)

Whether such an approach is even possible given the current levels of emphasis on the development of treatments intended to cure late stage forms of cancer, and the related profitability of the entire cancer enterprise (not just the biopharmaceutical industry) is, of course, open to considerable question.

7 Responses

  1. I’m not so sure there is enough money in curing cancer for the “experts” to be much interested in it, unless they become the ones suffering with the disease.

    DS

  2. Speaking as a layperson (not a doctor), but a someone who follows cancer research closely, I am very surprised that both Clifton Leaf, and your sitemaster’s comments on the above subject say nothing explicit about the importance of diagnosing cancer (or pre-cancer) early through much reported advances (if in progress) on liquid biopsies as well as other gene markers that can catch cancer early. IMHO, these diagnostic tools would be far more successful in “winning”, or at least advancing the war against cancer than drugs and other treatments that are often unaffordable, have limited treatment efficacy measured by whatever standard, as well as some unpleasant, and even very risky, side effects..

  3. Dear Daniel:

    I can’t speak for Mr. Leaf, but exactly how one diagnoses cancer early wasn’t the subject of the above commentary. Diagnosing most cancers relatively early is now relatively simple (using all sorts of differing methods, including liquid biopsies in some cases).

    The critical question then becomes whether a patient diagnosed with what are often low- and very low-risk forms of cancer actually need treatment at all, and if so, when. We know that in several types of common cancer (prostate and breast cancers in particular), there has been a long history of over-treating people with such low- and very low-risk forms of these disorders — with profound, consequent, and unnecessary impact on their quality of life.

  4. I don’t want to appear semantic, and I don’t think I am being, but your story began as follows: “Clifton Leaf is a cancer survivor. He is also the Editor-in-Chief of Fortune magazine. And he has long argued that we may not be making the most astute decisions about how we are trying to find “the best” and “the rightest” ways to diagnose, treat, and manage cancer.”

    With all due respect (especially to a website and sitemaster that is one of the best of its kind — I read it all bulletins as I have a strong history of prostate cancer in my family. In addition, my first wife died of stomach cancer and my best friend of 51 years is dying of mantle cell lymphoma — and this this is an issue I feel passionate about). I see the word “diagnose” above and not just the words “treat” and “manage.”

    Thus I think my comment is fully on point and I am rather baffled by your response to be quite honest. I don’t have to say that the earlier cancer can be diagnosed the better it can be treated. To put my point in another way, and with no space to develop it, I think when it comes to cancer there is an institutional cultural bias (that is also reflected in the way cancer research is funded, driven as it is, to a significant extent, by Big Pharma) on treatment and expensive treatments at the expense of funding techniques for early diagnosis.

    When my wife was dying almost exactly 11 years ago to this day, we went to see a leading expert at OHSU who confidently predicted that, “in a few years we will have a blood test for cancer.” (His actual sentence word for word.)

    This has not turned out to be the case and my file on liquid biopsies indicates that the projections that it will are 5 to 7 years hence. I mean isn’t, or hasn’t, one of the holy grails of prostate cancer research been to find a blood test that would show prostate cancer in its early stages, and one that will measure the aggressiveness of a prostate cancer tumor. But unless I have missed something on your site over many years we are not there yet by some way.

    Yet, you say in your response to me: “Diagnosing most cancers relatively early is now relatively simple (using all sorts of differing methods, including liquid biopsies in some cases).” With all due respect I am dumbfounded by this assessment as it does not accord with the huge amount I have read on this subject, and I ask for proof or clarification. (Yes, I concede that early screening can catch a few cancers, but only a small minority of cancers.

    With respect to prostate cancer, and to an extent other cancers, I could not agree more with this site and your line that active surveillance is a good or the best strategy in most cases. I salute you and your colleagues for this advocacy and in your fight against an institutional culture that favors (ed) instant radical treatment.

    But the issues of diagnosis and treatment are, needless to say, totally different ones, though they are lumped together in this story as I think my opening para shows.

    Professor Dan Cornford

    Davis, CA

  5. Dear Prof. Cornford:

    I am sorry to hear about the death of your first wife.

    It appears that we are talking about two very different things.

    You are clearly (and correctly) passionate about the need for new tests that can be used to diagnose specific types of cancer early and simply, with a very high level of accuracy. I am also passionate about the need to develop such tests. But this a lot harder than you appear to understand. For example, there is no known characteristic of prostate cancer that is a universal indicator of risk for this disorder. So finding such a test in a case like this is extraordinarily difficult. I don’t know if you know about the work of the Canary Foundation, but they have been pouring money into research of exactly the type you are referring to for a decade now. So have others (including those with commercial interests).

    I have no idea whatsoever why the person at OHSU told you there might be “a blood test for cancer within a few years” 11 years ago. If I had known that you were told that 11 years ago, I would have told you that the person in question was delusional. We now have multiple new tests that measure potential types of risk for many types of cancer (prostate cancer included), but they aren’t definitive … and even the fact that we can use liquid biopsies to identify the presence or absence of expression of specific genes does not necessarily correlate with risk for diagnosis with clinically significant types of cancer.

    Conversely, however, our ability to identify and diagnose the presence of many specific forms of cancer far earlier than it could be done 20 years ago is considerable. This is true for breast cancer, prostate cancer, colon cancer, lung cancer, multiple myeloma, and even forms of cancer that we didn’t even know about 20 years ago. But this still needs to be done by using multiple different tests in order to carry out an appropriate work-up and identify the correct diagnosis (and then decide what needs to actually be done). So when I (and Mr. Leaf) say that we are much better at diagnosing cancer early than we were 20 years ago, we are not suggesting that this is either easy or that can be done with a simple test.

    Because of this I would humbly submit to you that the issues of diagnosis and treatment are actually not “totally different ones” at all (except in a theoretical sense). In fact they are inextricably linked together in the case of the majority of cancers (and other diseases too). The exceptions are the (usually relatively rare) disorders that can be diagnosed on the basis of a single and often inheritable genetic defect (e.g., sickle cell disease, cystic fibrosis, hemophilia). With the correct background information, these disorders can, indeed, be diagnosed with great accuracy and relatively quickly. Alas, I know of no form of cancer that can be diagnosed on the basis of genetics alone.

    I haven’t tried to count up all the new forms of test that are now available to assist in the early and accurate diagnosis of prostate cancer (as opposed to the situation in the mid 1980s, when we didn’t even have the PSA test), but it is at least a dozen and probably more. Alas, not one of these tests is both specific for or selective for even a single one of the multiple subtypes of prostate cancer (at least 25 according to the Prostate Cancer Foundation).

    On a more positive note, I remain convinced that appropriately trained dogs seem to be able — by smell alone — to spot risk for certain cancers (bladder and prostate cancer specifically included), and much better than any medically available test at present. The problem is that no one seems to have been able to develop a clinical equivalent of a dog’s nose, which tells us that we still have a way to go before we can harness the olofactory skills of dogs as a mechanism for diagnosing specific disorders. We would all like simpler answers to some of life’s most complex questions … but actually finding such answers is not as simple as we might like to believe.

  6. Because of the potential harm and questionable benefit associated with PSA testing and screening — and subsequent risk for over-treatment, as of 2018 the US Preventive Services Task Force (USPSTF) is recommending the following:

    — Men aged from 55 to 69 should decide for themselves after discussion with their doctors.
    — For men over 70, no screening is recommended.

  7. Dear JJ:

    I would point out that this set of recommendations from the USPSTF is still controversial, and takes no account of key risk factors such as family history, ethnicity, and exposure to known risk factors (which range from cadmium to Agent Orange). For a rather more detailed analysis of a distinctly “grey” issue, we would suggest that people read this commentary.

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