Cancer Medicine 2013: Why I Am Getting Out Now
In
1971, when Dr. Kleinerman and I were first dating, she asked me what I was
going to be.
“A
medical oncologist”, I said.
She
roared with laughter and said, “you’re no oncologist”.
As
I have come to learn in the ensuing 42 years, it’s a good idea to listen to
Coach K of Pediatrics.
Genie
was right. I am no oncologist and once I left the NCI and came to Anderson and
met real oncologists, I realized how right she was. In fact, she’s the one who
made the big contribution to the care of cancer patients, not I. I played
around in a molecular pharmacology lab for 20 years, never making a dent in the
cancer problem. My only real work of note in cancer is trying to help the rest
of the faculty do the work from my position as vice president. No regrets, but
that is the truth.
Now,
finally, I am entering a job for which I am uniquely suited that will have
little if anything to do with the cancer problem. Some might say my timing is
way off because now, finally, we can make an impact on cancer. The current
President of MD Anderson is among those extolling the virtues of this unique
moment harkening back to what he believes was a similar moment in the early
1960s in the history of space exploration.
Respectfully,
I believe he is completely in error and that there couldn’t be a better time to
get out of oncology and into community health care delivery as I am attempting
to do.
For
me, the decision is easy. Here’s why:
First,
I really have nothing unique to bring to the oncology table any longer. The
biochemistry and molecular pharmacology that filled my life for 20 years has
been supplanted by attempts at reductionist science to identify genetic markers
within human tumors that will dictate their appropriate therapy. Even a cursory
reading of the cancer biology literature would suggest this to be folly. Cancer
is a systemic disease of both malignant and normal tissues (e.g., immune system
and microvasculature) that is more likely a product of systemic dysfunction
akin to end-organ failure in cardiac or kidney disease. These genetic signs in
the explanted cancers are as likely to be effect as cause. We are most
definitely NOT at a moonshot moment in the history of oncology. At least, not
yet.
As
for my other role as an administrator, I believe that I have had enough of
that, thank you. Besides, the last thing the administration of MD Anderson
wants is the involvement of the faculty.
Second,
we are doing way too much for and to cancer patients without having discerned
what actually works. How many men have undergone costly proton therapy for
primary prostate cancer without any evidence that it is superior in any way to
conventional radiotherapy? And when have we used “the patients want it” as an
excuse to administer untested treatments? What ever happened to ethics? Hell,
even the insurers have caught on as the Wall Street Journal recently reported
as many are no longer reimbursing for proton therapy of prostate cancer. If we
spent half as much on treatment research and did some comparative effectiveness
research and outcomes studies on what we already do, we could probably pocket
enough to fund thousands of RO1 grant applications. How? By not doing what
doesn’t work!
Third,
where we actually know what to do right now, we aren’t doing it. Why do we
still allow the consumption of tobacco products at all? Tobacco is far more
lethal and costly than most of the illicit drugs whose importation the DEA is
chasing all over the southwest trying to stop. Let’s incentivize supermarkets
to get fresh produce into underprivileged and economically disadvantaged areas
of Houston. Let’s teach kids in school how to eat, cook, exercise and NOT START
SMOKING. We can prevent 90% of lung cancer 30 years from now, right? Let’s.
Fourth,
health care is still a right to me. ObamaCare changes nothing of importance
other than perhaps getting some people insurance who had none before. Whether
they actually acquire health care is another matter. It’s great that the ACA
pays for preventative screening for cancer, but who’s going to pay for the
treatment if something is found? And, who’s going to service the Medicaid
population in this regard?
Fifth,
the support for clinical cancer research is in the control of the pharmaceutical
industry. These corporate giants have fealty to their stockholders only. The
companies have vested interests in the outcomes of the studies. The government
and the academic centers simply do not have the funds to pay for the most
important type of research of all. How shameful is this! There has to be a
better way to assure the dispassionate examination of new therapies without
academia being on the take from big pharma or worse trying to imitate the worst
of their behaviors by building drug companies on campuses historically dedicated to truth not profits.
That
goes double for the FDA. Get them off the dole from pharma by having Congress
support their activities and eliminate the users’ fees and the folks with
conflicts of interest from all FDA panels.
Finally,
I believe academic medicine as I have known it for the past 40 years is over.
The business model of charging high prices for clinical care under the illusion
of superior quality to defray the cost of research and education will fade as
smaller and more efficient providers and systems deliver better outcomes at
lower cost because they do not have to support the overhead of a place like
Anderson. Air conditioning buildings that look like ocean liners costs a great
deal and nothing that occurs in that mid-campus building will cure anyone.
Frankly,
I can’t think of a better time to get out of the cancer business. It is being run by people who view
money as the solution to all problems. They confuse hard work for hard thinking
(Max Perutz’s quote about something James Watson never did). And they are reinventing
the wheel at the genetic level by pushing a reductionist view of a disease
process that they don’t really understand in animals let alone in people. For
those of us who have heard the countless promises that the cancer breakthrough
is right around the corner or advocacy of the latest technology that logically should alter
oncology practice, it’s the same old song.
The
cancer problem is not one of a lack of expenditure. Like all scientific
problems it will take brilliant insight combined with tireless effort to make
any headway at all. That’s science. The journey to the moon was not a
scientific challenge but a financial and political one. As the recent Kennedy
tapes revealed, he just wanted to beat the Russians. Cancer is still in the
realm of science a place where the right direction to take is far less
predictable and money alone will not be enough although it’s a good start if it
isn’t wasted.
At
the end of a truly wonderful film, North Dallas Forty, based on the novel by
Peter Gent about a fictional professional football team bearing an amazing
resemblance to Gent’s Dallas Cowboys, the main character, a receiver played by
Nick Nolte, has been let go by management. As he meets his quarterback (Mac
Davis) one last time, he is tossed a football. He lifts his hands and then
allows the ball to hit him in the chest and fall. He’s out.
Me,
too.
