Biology in the News Explained

There is no cure

Why has the word “cure” continued to be bandied about when it comes to cancer? It leaves the general impression that even though we know there are different types of cancer, they are all united by a grand mechanism and once we unlock the key to that mechanism, our troubles will be over.

But the fact is that the more we study cancer, the more complicated it gets. It’s been decades since we were promised an imminent cure by well meaning researchers, but although treatments have advanced, it is becoming clearer that a wide-encompassing cure is about as likely as a cure for the common cold, for much the same reasons: cancer is not one disease, but a catch-all term that we use to describe hundreds or thousands of variant conditions (not all of which are actually fatal). Even two cancer patients with similar pathologies (based on what we currently know) can have hugely different outcomes, for which we have no adequate explanation. The fact is, cancer treatment, though becoming somewhat more sophistocated, is still largely a guessing game.

One way to understand this is to realize that cancer is caused by a large variety of genetic issues interacting with a large (and unreplicable) suite of environmental conditions. The BRCA genes alone, which have been implicated in hormone-mediated cancers such as breast and prostate cancer, have over a thousand known mutations, most of which we do not understand. (Of course it doesn’t help that a single company, Myriad Genetics, has received a patent on these genes, which means no one is allowed to study them without their permission.) That is, it is possible for someone with a BRCA mutation never to get cancer, or to get it very young. What happens depends on the particular mutation and its complicated interactions with any potential carcinogen the person has ever been exposed to.

Researchers are getting better slowly at tailoring treatment to specific pathologies, but make no mistake, there is a long way to go. One problem that delays progress is inertia in the medical establishment to change treatment regimens that have become established dogma. Although doctors are quick to pick up on a new drug that seems to be effective in medical trials – the pharmaceutical companies make sure they are informed of every one – they are much slower to stop using a drug that has been shown to be ineffective for patients with a particular pathological profile, because there is not an equal profit-driven push in the other direction. Quite the opposite, in fact.

Two examples: It is now fairly definitive that anthracyclines (such as Adriamycin) are only effective in breast cancer patients that are positive for the HER2 receptor (Slamon & Press, 2009):

Over the past 15 years, a substantial amount of clinical data from multiple individual studies has indicated that the incremental benefit from adjuvant anthracycline-based therapies is largely restricted to the HER2-positive subgroup of human breast cancers.

But you can be sure that many oncologists will continue to encourage HER2 negative women to take these potentially dangerous drugs.

By the same token, it was also established years ago that CMF chemotherapy adds no treatment value on top of hormone therapy for hormone-positive breast cancers (Ejlertsen et al., 2006). Yet, one oncologist at a top cancer center was offering it a year ago (and perhaps still is) as a reasonable option to women with this pathology.

This is no help to progress in cancer treatment. But continued talk of a “cure” is no help to patients, who ironically can have both overly pessimistic and overly optimistic views of their prognoses. They can be overly pessimistic because when many people hear the word “cancer,” they imagine an automatic death sentence. They can be overly optimistic because after they have endured an often-hellish treatment, they may be under the impression that the cancer has been eradicated, when in fact it is impossible ever to know if this is the case.

Instead of swinging between these mythic extremes, we need to change the culture of how we think about cancer, in the same way that we need to change the culture of health care in general in order to end up with an American system of sustainable, universal health care. Overscreening and overtreatment have become the norm as we have headed farther and farther along the path of for-profit medicine. Fear of the word “cancer” and use of the word “cure” dovetail nicely with the medical profit motive as we continue on our unsustainable course toward a healthcare train wreck. Nearly 50 individual treatments of prostate cancer to save one life is great for charity fundraising and pharmaceutical business but lousy for our health.

The fact is, we all have cancer. Our tumor-supressing proteins are constantly working to keep it from reaching a pathological level, but for many, many reasons, most unknown, the system often fails and cancer then spreads to an alarming degree. But most of us should be thinking in terms of management of a condition with the potential to cause us problems in the future, similar to the way we manage diabetes, rather than hysterically reaching for the knife every time a few cancer cells are discovered by our increasingly sensitive scanning technology. Some recommend not being screened at all in order to avoid unnecessary worry, but wouldn’t it make the most sense for many of us to go ahead and screen, but then think in terms of monitoring instead of treatment as a first step when pre-tumorous cancer is detected?

It will take a lot of effort to change the healthcare-for-profit, magic-pill-for-everything-as-long-as-you-can-pay culture we have dug ourselves deeply into. But if we don’t, Americans will go back to dying from what are currently considered easily preventable and treatable Third-World diseases, in addition to the confounding diseases of wealth that we pour so many billions into now.

References

Ejlertsen, B, Mouridsen, H.T., Jensen, M., Bengtsson, N., Bergh, J., Cold, S., Edlund, P., Ewertz, M., de Graaf, P.W., Kamby, C., Nielsen, D.L. 2006. Ovarian ablation compared with cyclophosphamide, methotrexate, and fluorouracil: Similar efficacy from a randomized comparison in premenopausal patients with node-positive, hormone receptor-positive breast cancer. J Clin Oncol. 24:4956-4962.

Slamon, D.J., and Press, M.F., 2009. Alterations in the TOP2A and HER2 genes: association with adjuvant anthracycline sensitivity in human breast cancers. Journal of the National Cancer Institute 101(9):615-618

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2 Responses to “There is no cure”

  1. gourmet says:

    I had stage IIA breast cancer (multi focal, ER+, Her2-, grade III). My onc said that after surgery and chemo, I’m probably cured. What does that mean?

  2. biotunes says:

    It means that your doc is truthful. Your doctor knows simply that there was detectible cancer before, and there isn’t now, but there is no current way to detect a few cancer cells that could be circulating around in your system, and could possibly end up stopping somewhere. To put that in perspective, everyone has some cancer cells in their body, as I mentioned in the article.

    The difference between people who have not been diagnosed with cancer and those of us who have is that we have the knowledge that our risk is greater – not just for the cancer we already had, but for future cancer – i.e., since you have had progressive estrogen-positive breast cancer, you are also at greater risk than average for future ovarian cancer. That is something you need to be sure to discuss with your doctor.

    Also, surely you were put on hormone therapy (tamoxifen or an aromatase inhibitor) after chemo, which keeps hormones from stimulating cancer growth. This is both because there’s no way to be sure you are “cured,” and because even if you are, you have proved to have a higher risk for a new hormone-positive cancer, and the drugs will help prevent either a new one or a recurrence of the old. (It is true, however, that some recurrences of breast cancer in women who have been on hormone therapy are now hormone-negative, which means those drugs won’t help anymore.)

    It’s all very complex, and everybody is different, but we all need to better understand the limits of what is actually known and can be done, for treatment decisions to make sense. That’s why I think throwing the word “cure” around is misleading and unhelpful.

    Best of luck to you ( I have almost the same pathology as you).

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