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.
