Is control better than cure as a goal for cancer research?
Maxine Clarke
Tuesday, 16 June 2009 08:15 UTC
Patients and politicians anxiously await and increasingly demand a ‘cure’ for cancer. But trying to control the disease may prove a better plan than striving to cure it, says Robert A. Gatenby in a Nature Essay (Nature 459, 508; 2009). According to Professor Gatenby, the ‘war on cancer’ continues to be driven by the implicit assumption that magic bullets will one day be found for the disease. Yet lessons learned in dealing with exotic species, combined with recent mathematical models of the evolutionary dynamics of tumours, indicate that eradicating most disseminated cancers may be impossible. And, more importantly, trying to do so could make the problem worse. He is not suggesting that cancer researchers should abandon their search for more effective cancer therapies, or even for cures, rather that they should address the possible benefits of an uneasy stalemate in appropriate situations. “Even now, many oncologists agree in principle that therapeutic strategies aimed at controlling cancer could prove more effective than trying to cure it. But the idea of killing not the maximum number of tumour cells possible but the fewest necessary will be difficult for both physicians and patients to accept in practice. Certainly in a war that is steeped in the tradition of magic bullets and all-out attacks with high-dose chemotherapy, such an approach may seem defeatist. However, in battles against cancer, magic bullets may not exist and evolution dictates the rules of engagement.”
Updated 16 June 2009 08:16 UTC
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An active and healthy lifestyle is the most efficient ways to prevent cancer. This is the best prevention modern science can make, but as leading a healthy lifestyle is often a question of choice, this is the best we can do and ways to cure cancer are still as important as ever.
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Is that so, Eva? For example, are there figures showing that athletes are less likely to get cancers? There are certainly associations between cancers and lifestyle factors, but a great deal is unknown about why and how people get cancers. And there are other factors involved beyond lifestyle choices.
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Actually, the most efficient way to prevent cancer (though perhaps the most difficult) is to not grow old, as age is the #1 risk factor for any cancer type ;)
However, the subject of this article is on treatment, rather than prevention, and it nicely elucidates they way many are beginning to think of cancer treatment. In fact, Judah Folkman was spruiking this idea for many years.
I don’t think it’s a defeatist concept at all.
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and I’m hurriedly trying to find the data to back-up my assertion above ;)
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I think that it is really a bit of a semantic trick at this point. We, in the Scientific Community (and I speak as a former researcher in the fields of cancer prevention and early diagnosis) need to back off of the WoC talk. Cancer is a disease that has a difficult to establish root cause (in most cases) and a complex maturation. To think that we can “cure” has been a bad frame of mind to put people in all along. When you talk to patients who are “cancer free” many do not think of themselves as cured but as survivors and we mark survivorship in years. This noting the passage of time is important because it recognizes the fact that oncologists and scientists have a difficult time determining who will not have a relapse (that is it is hard to determine with 100% certainty who is cured). So, re-framing our approach doesn’t mean we are necessarily shifting treatment tactics so much as maybe we are being more honest with those who are suffering from this disease. Now, will funding agencies want to take this more cautious and, I believe, realistic approach? That is hard to predict a lot of money rides on the fact that people have come to believe and hope that a cure does exist and will be found.
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Well said, Craig. “Living with the sword of Damocles” is how many experience it – for the rest of their lives.
Or perhaps to put it another way, ask any oncologist or insurance company about what they think about a particular person who is “cured” from a cancer.
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Interesting, relevant video interview with Nobel Laureate and President of Rockefeller University Paul Nurse on better collaboration between doctors and scientists:
http://bigthink.com/on/the-healthcare-revolution
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I think Maxine was right to chellenge the lifestyle hypothesis. The World Cancer Research Fund report ‘Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective‘ has 537 pages and over 4,400 references. Hardly any risk ratios are bigger than 1.2 and, in my opinion, the evidence for causality is often exaggerated.
While it is true that the results are compatible with the conclusion that a large fraction of cancer is a result of diet and other lifetsyle factors that conclusion depends on all the risk factors being as found (not exaggerated by the Ioannidis effect) and, crucially, that all are causal.
Certainly there is some reason to think that environmental factors matter, particularly the data on immigramt Japanese in the USA. But after looking at the WCRF report I think that it is compatible with the view that these environmental factors are proving to be remarkably elusive and have not yet been identified clearly.
Sometimes I think we should say “I don’t know” rather more often.
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Yes indeed, David, try telling a young child with terminal leukaemia or other cancer about “lifestyle factors”.
Craig is correct, though that the article at the post here is more to do with what to do about a cancer when someone has got it, rather than with how they got it in the first place. Not that this isn’t an interesting topic.
I suppose that one aspect of Prof Gatenby’s argument is how does the oncologist predict which patients (or cancers) will be susceptible to the “long term survival” strategy and which not – as so little is known about most cancers on the level of an individual patient (assuming not much specific biological information for that particular patient and tumour).
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Sometimes I think we should say “I don’t know” rather more often.
Yes, not so often to believe that we are not capable to know more… :) Scepticism must not be extreme.
I think that David and Maxine are right – science and medicine still knows about etiology of cancer as unsufficient as about its pathogenesis. So the change of strategy from cure to prophylaxis is unlikely to be too efficient. There is only one way. Scientific investigations of cancer must become more effective. Rather it is necessary to change the strategies of scientific investigations of cancer and the strategies in field of interactions of medicine and science investigating problem of cancer. There is a lot of different investigations, scattered to all parts of the world. It is necessary to integrate them to see the problem in the whole. Of course, the international organisations (such as International Agency for Research on Cancer) try to do it, but it seems their role remains rather “bureaucratic”, than really scientific. They collect the result of investigations, but not to integrate them, i.e. they create sort of “library”, but not the whole reconstruction/model/“picture” of the problem.
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