THE TRUTH IN SMALL DOSES: At long last

Happy, and beautiful

Okay, I have stalled long enough.  It is time for me to explain why I think that The Truth in Small Doses, by Clifton Leaf, is so important.  In my view it is indisputably a classic; the most important book that I have read since I stumbled on Ted Irving’s Paleomagnetism and its application to (a bunch of things I can’t remember), back around 1959.  Leaf, to me as an ignorant outsider dabbling in cancer research, is the equivalent of Irving, to me as a general geologist getting turned on to paleomagnetism and tectonics.  Yes, Leaf is that good.  Please read his book, and take it seriously.

Like me, Leaf is not a biologist.  He claims that he almost flunked biology in high school.  Heck, that’s nothing,: I didn’t even TAKE biology in high school.  I took physics: biology was for girls, and sissies.

Not only isn’t Leaf a biologist, he isn’t any kind of scientist, nor even a science writer.  At the start of his cancer crusade he was an editor of a business magazine, for Heaven’s sake.  Outsider he may have been, but outsider he is no longer: even someone as fundamentally ignorant as me can tell he knows plenty.  And he lays out what he knows, and what he thinks, plainly, eloquently and – at times – even amusingly. 

Leaf came to his cancer crusade naturally, if tragically.  He lost his mother to a rare intestinal cancer after a long fight, and he himself had to confront Hodgkin’s lymphoma at age fifteen.    He has devoted much of his  energy to the study of the “cancer culture” for the past decade.  He seems to have become well respected in oncology and cancer research circles.  He also has written various articles on cancer, but the best result of all this study and effort is this book.

Now, having burned through nearly 300 words just introducing the subject, I am going to enumerate what I believe to be the most important points in the book.  Then I will read it again and see what I got wrong.

In the first chapter he makes the case that we are NOT winning the war on cancer.  In fact, in his view we are barely holding ours own.  To me, this is the weakest part of the book.  He makes this claim in spite of the fact that most commentators; even many wearing white coats and bearing distinguished titles, evince joy about our progress, and even moderate exuberance.  True, they would admit, more Americans die of cancer every year than the year before, but that can be explained by a growing and aging population.  If rates are compared – “deaths per 100,000” usually is used – much of the apparent increase is erased.  Similarly, if one allows for an aging population – by “correcting” to a standard population, things look better yet.  Leaf criticizes this later procedure on the grounds that the “standard” used can become out of date.  (The standard used currently is the year 2000; often the standard is not changed – while the age structure of the population evolves – for up to 30 years.)  In several passages that I find puzzling, Leaf concludes that things are getting worse, not better.  My thinking is that things are getting much better in some areas and a little better in others.   However, many cancers most, perhaps - still have us stumped.  Overall we are making progress, but at a miserable and, frankly, disgraceful pace.

Why is this? asks Leaf.  Here are his main arguments:

1)      We should be concentrating on prevention and early detection, and not so exclusively on cures for advanced disease.  Pick the low-hanging fruit, he might say.  My view: easier said than done.

2)      The existing machinery  for parceling out Federal research dollars is inexcusably slow, cautious and bureaucratic.  It is based on “peer review”, much like the process we geologists must use to get funded.  However, geology is a luxury; mankind could get along without it quite handily.  Cancer, on the other hand, is a serious subject; one we cannot fluff.  Apparently the earliest  Congressional bill initiating the War on Cancer (1971) called for a separate institute, run by a sort-of  “Cancer Tsar”,; someone empowered to allocate funds, enforce collaboration, keep egos under check; generally run the show like a business.  Elsewhere I have suggested Bill Gates for the job (which, of course, does not exist.)  Steve Jobs might have been even better.  This concept was deep-sixed by a combination of turf-protecting elder statesmen of oncology, and of course Republicans and other small government types shuddering at the thought of yet another Federal agency.  It was decided to simply add cubic kilometers of money to existing granting programs; to smother cancer in money.  This hasn’t worked.

3)       Leaf makes a convincing case, bolstered by many interesting examples, about how the present system stifles creativity, slows progress, and encourages ”incrementalism”; defined roughly as the tendency to creep ahead cautiously, fearful of the adage “first, do no harm”, thereby producing expensive, minute improvements in existing therapies – and not the breakthroughs we so obviously need.  As a stupid, overblown, made-up example:  Imagine that you are a young untenured Assistant Professor at some medical school.  What do you want out of life?  Well, of course you want diseases in your area of expertise to be conquered; for Heaven’s sake, who wouldn’t?  But of more immediate relevance, you want to get a nice grant, thereby demonstrating that you are worthy of elevation to the distinguished rank of Associate Professor, with tenure.  That way you can support your family and maybe even buy a house and a car.  So, what are you going to do?  You are going to submit a “safe” research proposal, that’s what.  You are going to suggest trying something that everybody knows works on cancer A, to cancer B.  Or you are going to show that substituting atom X for atom Y in an existing therapeutic drug will make it work 6% better.  You are going to do something safe.  What you would really like to do is to follow an educated hunch you’ve had for years, that injecting garlic juice into a solid tumor will cause it to wither and die.  No peer-group panel will fund you for that – but, if you could spin a good, scientifically compelling yarn, Steve Jobs might.  Bottom line: the workings of the existing machinery of cancer research stifle creativity.  I take this to be undeniable.

The final chapter is short and vague; in it he seems to be telling us what to do about the mess we’re in.  He writes about “preemption”, which I take to be synonymous with "prevention”.  He also mentions early detection, which obviously should go hand-in-hand with preemption.  There are many cancers for which early detection plus preemption has been shown to work: lung cancer, cervical cancer, even to some extent, breast cancer.  For ovarian cancer you can have your ovaries and fallopian tubes removed after you have hatched your family.  However, many cancers arise from routine genetic “mistakes”, and – so far- you can’t preempt that.  That’s why we need to continue to fund research on cures, and especially work to understand the basic biology of cancer.  The recent work on epigenetics and micro-RNAs (discussed in several previous blogs) offers hope for a  much better future.  But that is quite enough: if you have read this far, please go and buy a small gold star and apply it to your forehead.  I am proud of you.

I may return to this topic in the future.  Be warned.