By Intelligent Design?
I was at a fund-raising dinner recently
for a particular type of cancer. It doesn’t really matter which kind because
these dinners are all the same. Only the color of the ribbons change. Survivors
are lauded. Those who have died are remembered in various ways, mostly with
tears. The evening is always bitter sweet filled with hope and sadness. And
much of it is misleading.
The emotions are not. They’re real. The
libretto is, for the song being sung is meant to tear at your heart strings and
purse strings in equal measures and not present the true problem those fighting
all cancers are facing, whether patient or physician.
The real nature of cancer is being avidly
pursued at the molecular level. Genomics and proteomics and a host of other
“-omics” are being employed to micro-dissect the intracellular microenvironment
of the malignant cell. Other scientists are trying to understand the many
factors at work outside the cancer cells of established malignancies, the
so-called microenvironment of the whole tumor. Other groups of investigators
are closely monitoring the body’s response to cancer with attention to the
immunologic and vascular systems, including the non-blood forming elements of the
bone marrow. Every single one of these endeavors is worthy of pursuit as are
additional clinical trials, the development of better animal models and
population-based studies of cancer trends and their effects in specific groups of people. This is the cancer world of today. And it bears a striking
resemblance to the one of 43 years ago when the War on Cancer began. The
technology is surely more sophisticated. But is the thinking?
What is cancer really?
As an ex-medical oncologist, ex-molecular
pharmacologist, ex-research administrator and ex-DC health policy staffer, it
seems to me that cancer is a natural outgrowth of life. It is pretty much what
every chronic disease that kills a lot of Americans tends to be. It probably arises
from an unfortunate interaction between the environmental and the genetic. The clinical
manifestations of most cancers occur long after the age of procreation. So
while a tragedy for the individual cancer patient and his or her family, these
afflictions are of no consequence to the universe or even just the biosphere.
We are probably making a bigger and less favorable impact on the environment
with the poisons and radiation we use to treat cancer than the cancer itself
It is not likely that cancer will bend to
our will no matter how much money we pour into research or how much access we
give to every single American with cancer to the best of cancer care—where ever
So let’s divide the problem in two.
Part one is medicine. We should offer the
best of modern cancer medicine to every single patient that we can. Those
organizations that promote this care through education and patient support are
to be congratulated whether or not they award a single research grant. If even
one more patient gets access to a place like MD Anderson that can really alter
the natural history of an individual cancer patient’s disease using current
medical knowledge, I am for it.
Part two is research, particularly that
research aimed at understanding the nature of malignancy and translating those
discoveries to improve the delivery of better cancer medicine for patients.
Let’s not confuse what we know about treating people with cancer with what we
know about the etiology of an individual’s tumor. Usually, we have no idea and it doesn’t matter
anyway often why any given clinical malignancy occurs. To pour every single
resource into the pursuit of a genetic signature of individual cancers in the
hope of crafting some magic and individualized potion for every patient’s tumor
is not quite ready for prime time in most instances. Furthermore, so many of
the real breakthroughs in clinical cancer treatment have been found through serendipity
and empiricism. Planning the pursuit of a goal is great when the GPS is in
place and the satellites are aloft. That simply is not the case for cancer.
So let’s have more banquets with more
stars and more awards and more glitter but let’s not kid ourselves that the
ribbons and the walks and the appeals for cash will translate into cures. Let’s
delete that word anyway. Curing cancer is like curing life and not what we have
in mind when we enter medical school anyway and surely not after we finish
oncology training. By then, we have seen and touched the “enemy” and realize
that we are in a lot less control than we would like to think. The only logical
response to clinical cancer is humility, not hubris, for life itself is a
What if we decided to be honest with the
public and say that we really don’t know what to do next. We don’t know which of
the many research avenues being pursued is going to bear fruit. We don’t know
what we don’t know.
After all, how many Nobel Prize winners
really knew that what they did to win the prize would change the world while
they were doing it? Few, if any. Sure they hoped. But, as Dr. Kripke always
said, “hope is not a strategy.” Hope is hope and very important especially in
clinical care. In science, we need a better plan to deploy the limited
resources we have to reach specific milestones.
My favorite idea about a goal in the War on
Cancer was first advanced to me by ASCO Executive Director and CEO Allen Lichter.
When it comes to cancer: “First, nobody
dies.” That’s a good goal. Let’s start our research there.
Pursue everything that we can pay for.
But let’s be honest with the nature of the challenge. The secret to cancer is
the secret to life itself. That will not be a secret nature gives up easily.
At one level we have to make a key
decision. Is cancer a product of intelligent design so that a reductionist
attack such as that being mounted by the genomicists to pick apart explanted
tumors and divine their origin makes sense? In actuality, this is looking to interrogate
a pile of iron filings to discern what kind of car they were. (Full credit to
Dr. Dan Karp for that one).
Or, like life itself, did cancer evolve
out of genetic mutations, even random ones, being pressured by environmental
forces that somehow allowed a mistake that might kill the organism but to persist in time for reasons we simply do not yet fully understand.
If the former is true, perhaps genetic
dissection will result in new treatments. If the latter is true, we might be
better analyzing the genetic susceptibility of non-malignant genomes and trying
to understand and minimize the forces that favor malignant transformation
within our bodies and in our environments.
Intelligent design? Would an intelligent
consciousness design a camel? Or a cancer? Talk among yourselves.