The controversial title of today’s post is only there to match the title of an article in Newsweek magazine entitled precisely We fought cancer…and cancer won. The premise is that in 1971 POTUS Nixon signed the National Cancer Act to make the conquest of cancer a national crusade, in effect, declaring war on cancer. Almost four decades (and several thousands of millions of dollars/euros/pounds/etc) later cancer is responsible for even more deaths in the US (and presumably other developed countries) than it was at the beginning of the war (of course one should take on account the increase in US population and life expectancy). Thus Newsweek’s reason to declare the we have lost the war.
The reasons the article points out to explain this defeat are numerous: Cancer is complex, cancer is an smart and cunning enemy (even potentially, more than one enemy). Researchers are too academic and concentrate in elegant academic research that might or might not have an impact on potential therapies. Researchers have concentrated in curing cancers in mice (after developing tumours in them) but not enough in curing humans. Too much money has been invested in safe research (let us study one more gene) and not in things that could be more revolutionary and help save lifes (we need more maverick’s in Bethesda, not just Washington DC). Also we have been focusing too much on cures and too little on prevention.
While I personally can understand and see some truth in most of these criticisms I think that one fundamental problem is that of seeing the fight against cancer as a war that can either be won or lost. Using the comparison with the war against terror is likely to lead to misunderstandings but, in my view, is a struggle in which the goals should be long term and victories will be not epic but more (hopefully) a continuous stream of incremental steps that should push cancer out of the list of worries of the immense majority of people.
There is still plenty of room for improvement in the way research is done and the article rightly points to some issues (albeit in a maybe unnecessarily pessimistic way). One of the issues, the over reliance of animal models with a tenuous connection to the way cancer progresses, could be helped, according to the podcast included in the online version of the article, with the use of computer models. I can say I agree with that.
Some theoretical work to put together all the threads of research collected in the past (and which will be produced in the future), some emphasis on the environment that leads to cancer, an understanding on the (somatic) evolutionary process that is behind cancer progression coupled with changes in our lifestyles and a better dialogue between PhDs doing research and MDs … there are still plenty of options to try before we conclude that the fight against cancer is lost.
Hi David,
NO – WE ARE NOT LOSING! As you note there are more people and they are older now than back when Nixon declared this war. However, against that background, there will be less cancer deaths in the US this year than last and less last year than the year before – so we seem to be doing something right, albeit slowly.
I like the incremental steps analogy, slowly evolving our way to successful treatments. In reality I think we have a chance, as I’ve said before, of turning a lot of cancer into a chronic condition that people can live with.
In relation to the comment about “safe” research – it’s true, but it’s impossible to get anything that’s not very safe funded in the present environment. The NIH, including the NCI, is gun shy (certainly at the level of study sections). They have been hammered by the myopic view of science fostered by the present administration – fortunately in another 18 days we might have someone elected who actually understands that science has a value to society. Of course given that the current morons have flushed the whole economy down the pan it might be difficult to deal with the mess. Anyhow – bitter asides apart – there is little appetite for risk in science right now, which is unfortunate, since the safe stuff is essentially boring – it’s the crazy stuff, as we all know, that makes the interesting breakthroughs.
Hi Simon,
Thanks for your (very passionate) reply to my, admittedly, provocatively titled post. As you know it does not reflect my personal opinion. I guess that the curiosity to see the opinion of cancer biologists like you took the better of me.
I think the article raises some valid points but neglects to recognise some of the advances, probably because the progress has been to incremental for big headlines.
Unfortunately I can’t share your optimism about the potential for change after the next US elections, I think that, as you mention, with taxpayers having to shoulder 700 thousand million dollars (and this might only be the beginning), a major financial crisis and two wars, there will be little appetite to give the NIH and the NCI the money that could be used to make a difference.
Also a new administration might not imply a new system of funding in which approaches based on alternatives to the tried and tested let’s study this gene or this pathway may be explored.
I think that the Newsweek article describes the current state of cancer research and treatment very well. One topic touched by the article is the disconnect between basic and clinical research. The June 11 issue of Nature had several articles about translational research (e.g. Translational Research: The full cycle by Heidi Ledford), and this problem is relevant not only to cancer research.
Another topic is how we do clinical research, and the article mentions the advances in the treatment of cancer in children as a positive example. Working as a single group that coordinates the clinical research, treating as many patients as possible in clinical trials and focussing on small steps are some of the methods that also worked in adult cancer.
Which brings me to the last topic: the current system relies on rewards for individual people (in the form of papers and grants). This is often counterproductive, as it promotes small and uncoordinated basic or clinical science projects that just duplicate each other and add little new knowledge.
Many of us who are still staggering on today would not be doing so had we been born 10 years earlier.
I don’t like these war analogies, and confess to not having read this Newsweek article, but nobody should be under any doubt that we are increasingly understanding more about the basic mechanisms, and about treatments and management of this collectin of diseases under the umbrella title of “cancer”.
Intersting blog! and this entry caught my attention. The article in Newsweek made me wonder what the main point of it was – to increase funding for cancer research, stating that “we” are not doing right things" or to just blatantly point out that the “war is lost and cancer is a threat to us all, all the time”?
I agree with you as in the futility of seeing it as a “war that can be lost or won” since cancer after all is a fairly “common” outcome with age. And maybe it isn’t one of those things we can concur. However, looking at the rate of saving children with cancer – the survival rate for specific deadly sorts have increased from almost nothing to more than 80% since the 60ies. If that is not “on the way of winning” I am not sure what constitutes the victory?
(I know, 100%, but that seems rather harsh as a cut off when evaluating the efforts that have been put in, since we seldom have seen 100% success rate in anything. It doesn’t mean that we won’t keep trying, but it is crucial to point out that looking at in that way we will never be able to say that we won the war. And therefore one of the reasons I don’t like the analogy….)
I would like to have a bit more of the discussion between the PhDs and the MDs and the “public” to conclude that since cancer is such a complex disease that can arise in so many different forms but rather that we all should be “attentive” about out own bodies and look out for symptoms. The mammograms/breast cancer awareness is one, prostate cancer screenings another. I have to admit that I was a bit surprised about all the talk about colon cancer screenings if you are above 45 years old here in the States when I moved here. It made me wonder if that is “the next variant of cancer” we will hear about and make ribbons to and all the other awareness that we’ve had with the previous forms?
And maybe look at alternative ways of looking at cancer, both reasons and treatment? As previously stated, it has both been linked to both genes and environmental causes – although often in combination.
Martin: I agree that the issues presented in the article are real (I don’t agree with the conclusion in the title though).
I also agree that more collaboration between researchers (as in the case of children’s cancer) would help. Still, coming originally from a different discipline I would say that research in Cancer involves large groups of people, be it in writing papers or applying for grants. I’ve see people preparing for big grants involving lots of people from different institutions and with different expertise and I am not sure that lack of incentives for intergroup collaboration is missing.
Maxine: I guess that the war analogy appeals some types of people. In any case war seems to be the word chosen four decades ago to describe the aim of ending cancer, in my institution they just talk about curing cancer. From Newsweeks point of view the question is have we cured cancer? and the answer is no. I would have liked them to come with a more nuanced question but can’t complain to the answer.
Hey David,
This is off topic, but I just discovered that your site is 40% evil, see
PZ Myers is at 41% so you only have a little catching up to do!
Now it’s time to stop procrastinating and get back to writing another grant. Further to your comment above, one must have an inner optimist (or at least a serious stubborn streak) to keep banging on in this line of work right now.
David – altough as mentioned it is far too oversimplistic to call all cancers “cancer” as if there were one disease (and one treatment, which is what a lot of people who don’t know any science and/or are untouched by the disease personally think), I do think that some cancers are very well treated. An increasing number of people who have been diagnosed with cancer are dying of something else. (And of course, as pointed out above, more people are being diagnosed via early interventions, etc.)
Some cancers are found late and are rapidly lethal, but in other cases some real progress is being made.
I agree that animal models are not directly translatable to the clinical situation, but in many cases, animal models are the best we have got – and there is a great deal about basic science we have learned from them. From these insights who knows what knowledge will ensue? There was a good article recently by Philip Hunter on the paradox of model organisms in biology research, see here for an excerpt and a link.
I still maintain that whatever one may say about the “war” having been won or not, anyone who is going to get or who has cancer is going to do better nowadays than they would have done when Nixon declared the “war”.
Nixon’s claim, with all its grandeur, came at a time of great US hopes. A decade earlier JFK had hoped that1
They did, before the decade was out, so a war declaration to Cancer, two years later, was probably in tune with American enthusiasm. Putting this in perspective, I suppose Nixon may be forgiven for the use of the word ‘war’.
I enjoyed reading the article that David brought to our attention (thank you, David!), and just like those of you who commented already, I am not too happy with its seemingly defiant message. Also, there was no single mention to the potentially revolutionary therapeutic advances that may arise from cancer stem cells, which were in the news very recently, indeed at pretty much the same time as this Newsweek article came out.
One concept that this article seems to convey is that if one’s idea is out of the mainstream thinking, peer review will axe it, which leads to research being too conservative. Good thing is that we have exploratory funding programs that will fund high-risk projects, as long as referees behave accordingly when scoring those grants. May be these programs should receive more attention?
1 You can hear it in the trailer of the magnificent documentary In the Shadow of the Moon
By the way, my English blog is 25% evil.
My Italian blog, on the other hand is 39% evil. PZ Myers, beware!
Åsa: Thanks for your comment. You raise a good point about what the aim of Newsweek’s article could possibly be. It is sure not about giving up on cancer or about raising more money. I think they are asking for a change in the way we look to tackle cancer: emphasis in less academic research (gasp!), more collaboration and emphasis on prevention, not just cure.
It is a good point you raise that communication between not just PhDs and MDs but also patients should be important although personally, just trying to have a meaningful communication between researchers of all kinds (theoreticians, cancer biologists, oncologists, pathologists, etc) should be a step forward.
Maxine: I am with you in that animal models are necessary and in my post was only reproducing what I read in Newsweek. Once challange we face is to know with a better level of precision how do we differ from them and what can we learn from them that could be used to learn about cancer in humans.
Massimo: Thanks! I am also quite interested in cancer stem cells although I must say that I am a bit sceptical about the promise they hold. Also I would not hold such a negative view on peer review: I am sure that there is room for improvement but still looks to me like a better option than, say, a governmental committee taking decisions about which science is viable and worth exploring.
Simon: Funny, mccain.com is significantly more evil than obama.com…
David and Maxine: in my modest opinion sometimes the animal model reveals unappropriate because we are not able to replicate exactly what happens in human pathology. I’m always surprized by the fact that some mutations (like Ras) that in human promote cancer (some kind of) in mouse don’t. In human cancer, genes mutation can promote cancer as a second hit after other apparently unrelated patholgies or as a consequence of unknown epigenetic modifications. Thus, probably, the difference between mouse and man doesn’t solely rely on the difference in the genome or species . In fact, unexpected results may be due to the fact that we are studying “real” human cancer, developed as a consequence of N causes (both genetic and epigenetic), using mouse model that usually replicate only ONE of these N causes. I hope that it’s clear enough!!
Agreed, Martin, pancreatic cancer is not a cancer that has a decent chance of a good prognosis.
Martin: Regarding pancreatic cancer you are right, there is not a cure yet. Anyway, as far as I know, the fact that mutations of Ras in mouse model didn’t result in pancreatic cancer leads researcher to better understand its basis and correlate pancreatitis episode with pancreatic cancer. It’s true that understanding of biology of cancer doesn’t necessarily lead to a cure but it’s a required step for its discovery (excluding serendipity!! of course)
These are important points. My personal view is that it is difficult to extrapolate directly from any single model to human disease. Clearly cells in culture are vastly different in terms of morphology and gene expression profile from cells of the same type in vivo – however we can still use them to generate useful data – we just have to be careful about interpreting what the data say and about extrapolation to the disease in question. Likewise mice are not humans, however they do represent an important model system that can be exploited. As already noted in previous comments, there are many important differences from humans, notably including their much greater propensity to develop stromally-derived tumors and relative resistance to carcinomas as compared to humans. This may perhaps be related to their relatively much longer telomeres. (The fact that they have tails is a more obvious but still important difference as it gives us something to grab – clearly an intelligent designer pre-planned for biomedical research).
I think that work on a variety of models, and the clearer overall picture that this provides is something that will move us forwards. This makes communication not just clinician to scientist (as noted above), but also between scientific disciplines, critical to drive research forwards towards a more focused end. Some models, such as mathematical and in vitro models can be interrogated much more rapidly than others. It is sad for rapid progress, (but perhaps it is good for society) that the most important model of all – disease in the patient – is the slowest way to test any approach, but ultimately is the only one that matters.
I am wondering also if we are trying too hard to look at an “average” of specific diseases, a typical prostate tumor for example. As a result we could be missing the important individual differences that result in Mr. X dying two years after his diagnosis while Mr. Y with a histologically identical tumor is alive and well twenty years later. I would think that aspects of host differences could be modeled mathematically (David?) as these approaches become more rigorous and accepted representing an addition to the “omics” type approaches in providing a way to start moving towards personalizing therapies.
Simon, very good observations, do I guess that the best thing we can do is to learn the limitations of the animal models and improve them (transgenic?).
In my view theoretical/mathematical/computational models are very good tools in which to first explore the potential implications of the differences between individuals (with otherwise similar histologies). They probably are up to the task as long as there is sufficient biology behind them to formulate the right hypotheses and seed the models with realistic approximations of the cells and the tumour microenvironment … and as you know there are few things us, math-biologist, like more than giving you. cancer biologists, even more work to do :).
David It is a good point you raise that communication between not just PhDs and MDs but also patients should be important although personally, just trying to have a meaningful communication between researchers of all kinds (theoreticians, cancer biologists, oncologists, pathologists, etc) should be a step forward.
Oh, I know what you mean. The “intra-discipline” talks that to some people outside of “natural/medicin” science sounds like we are all in one discipline… but in real life, not so much.
I must say that after reading everyone’s comments I am tempted to go with “maybe we can be sure on the fact that we aren’t sure on much. And that cancer is a word that means a lot of different diseases, both in how they present, treatment and cause”. Then again, I guess it is not really bringin the discussion forward by saying so?!
I was brought back to this discussion yesterday when I read Nature about the ALS mice and the correlation (and non correlation) between genes and expression and mice and man. (yes, an old issue since I am falling behind….)
Hi Åsa, thanks for comming back to this post and sharing with us this Nature’s news feature. I agree with you that (even though we have plenty of facts) we are not sure about much of the things we know and (what to say) the ones we don’t know about cancer. Then again it could be that, like in a puzzle, we reach the point in which we have places enough pieces that the pictures starts to become clear. Still, it would probable pay to produce more pieces with the cell-cell cell-environment theme as opposed to the pathway/gene biased approach so we can end up having a cure for the different kinds of cancer and not just one for a specific type of genetic mutation.
David, your blog is one of the relatively few science blogs that actually talks about science (what I called research blogging) . I think we need more blogs like that.
Martin, thanks for your comment. I’d be happy to see more blogs discussing science, as blogs seem to me like a good channel in which to speculate about science and scientific results away from the (necessary) constraints of academic journals. Having said that, I enjoy enormously the blogs in NN (like Gobbleygook) that might deal a bit less with science per se and a bit more with science life and the life of scientists.
Apparently Richard picked up the ball and started a similar discussion on his blog.
Hi Martin, Yes I noticed. Richard has a point with his stress on prevention but given that cancer is bound to occur regardless of how much you watch your diet or how far you plan to live away from telecom. towers I still don’t see how research would be superfluous…