The Yankees Out There            April
22, 2013

By Leonard Zwelling

            This
is an important article for anyone interested in the cancer problem faced by
the people of the United States.

http://www.nytimes.com/2013/04/22/health/patients-genes-seen-as-future

            The
cancer problem is really simple to state. There’s too much of it and it is
killing people. The solution is far harder. We have been at it formally for
over 40 years now and for the most part, lifestyle changes have had far larger
effects on cancer incidence and death rates than anything emerging from a
research laboratory.

            Thus,
one could define the state of affairs of the cancer problem as in the stage of
extreme “don’t know”.

            You
could. But most academic cancer centers do not believe that that level of
honesty is conducive to happy boards and voluminous fundraising. So they try
something else, probably best called “the cure is just around the corner”
strategy. If you throw enough money at the problem, we can make it go away.
Thus, this article.

            The
article describes the weapons of mass sequencing being utilized by competing
academic centers in New York City. There is now expensive construction for the
purpose of housing the expensive newly recruited to prove or disprove two basic
theories of the cancer problem.

            Theory
One: We get cancer because something in our genetic makeup puts us in a more
susceptible category. This is the higher risk at birth scenario. This has been
proven to be true for among other diseases breast cancer associated with brca1
and brca2 genotypes. There are other excellent examples. It remains to be seen
if most cancer in adults arises due to genetic proclivities, but it is
certainly possible.

            Theory
Two: We get cancer due to the accumulation of various mutations in one or a few
cells. These mutations drive carcinogenesis. The associated research position
here is to microdissect human cancers through the sequencing of the cancers’
DNA looking for these mutations. This will be followed by the use designer
drugs that target the mutations or the aberrant proteins they produce, and thus
personalize cancer treatment to each cancer patient’s particular cancer. Again,
there have been noteworthy examples confirming this hypothesis in some cases,
but again, probably not in most cancers where the human clinical malignancy is
heterogeneous in every way conceivable including genetically and unlikely to
have one specific genomic signature that identifies a vulnerability to one or
several drugs.

            Where
does that leave you if you are a master of the universe running a large cancer
center with limited resources due to budget pressures, decreased patient
revenues and a shrinking NIH budget? Furthermore, you are in a high fixed cost
business in which people and the physical plant make up most of your costs and
your revenue stream is a variable one based on both volume and unit revenue per
unit of work, which is dropping. Do you follow the big boys from New York or do
you choose a different path?

            To
date, we at MD Anderson seem to be willing to compete with the teams in New
York, Boston, San Francisco and San Diego to build infrastructure and hire
talent along the lines of the institutions described in the NY Times article.
This is despite the fact that historically, research like this has not been our
long suit, but rather exemplary and cutting edge clinical care has been, even
when that care may have been invented elsewhere.

            It
looks like we are swinging for the fences along with the big boys on the coasts
and doing so alone despite the presence across the parking lot of people with
real expertise along these lines at Baylor College of Medicine. We could
cooperate with them and probably have the muscle of the boys on the Atlantic
and Pacific.

            But
I am reminded of Brad Pitt’s line from the film Moneyball based on Michael
Lewis’ best seller about how the Oakland A’s used a new model to build a
winning baseball team.

            In
a meeting with his team’s talent brain trust, Pitt as A’s General Manager Billy
Bean says; “If we think like the Yankees in here, we lose to the Yankees out
there”.

            Talk
among yourselves.