
Why Preventing Cancer Is Not the Priority in Drug Development - kungfudoi
http://www.nytimes.com/2015/12/29/upshot/why-preventing-cancer-is-not-the-priority-in-drug-development.html
======
Gatsky
This isn't a great representation of the issue. Everyone loves to hate the
drug companies.

First of all, the basic science is lacking. The vast majority of animal models
in no way resemble the normal process by which humans develop cancer. The
models are designed to grow aggressive cancers extremely fast so you can test
drugs rapidly, publish your paper and get the next grant. Even more than that,
what actually takes place in the years before a cancer becomes clinically
relevant is quite speculative. So a long term commitment to funding prevention
research is needed from governments and funding bodies, because pharma can't
fund this kind of basic science.

The other problem is that to do a good prevention trial, you need to identify
people at risk. We aren't really that good at doing this (eg we screen ALL
women above the age of 50 for breast cancer, we screen EVERYONE above the age
of 50 for bowel cancer). There is some debate about whether screening in this
manner is actually as worth wile as it has been made out to be, because it
leads to over diagnosis without a survival benefit. So you have to be careful
not to design an intervention that only prevents cancer in those who weren't
going to be affected by it anyway. This is why you can't use surrogate end
points - at the end of the day, for prevention, mortality is what matters. Are
we going to give hundreds of millions of women drug X and make them suffer
niggling side effects for 20 years because it reduces the rate of diagnosis of
breast cancer? Definitely not - overall mortality is what matters (and quality
of life).

It's not even a given that you can actually identify people at risk - some
researchers think cancer is just bad luck (ie it is not predictable at all, or
the predicting factors are unknowable). Even if this is wrong however, cancer
risk probably involves weak effects from hundreds or even thousands of
factors. We are very far from working all of this out.

A drug is probably not what we want. Actually a drug is really not what we
want. They are too expensive and too much effort to distribute and monitor.
Drugs also always produce health inequalities within and between nations. A
holistic approach to improving our health and well being would be preferable,
at least incorporating nutrition, exercise and psychology. Unfortunately the
nutritional, exercise and psychological sciences are not hitting home runs in
that regard, which is not surprising because they miss out on the billions we
spend fighting an incredibly wasteful war on cancer.

~~~
isomorphic
I could run eight miles a day with full pack, eat only protein and vegetables,
have the mental outlook of the Buddha--and yet still get cancer because BP
poured nearly two million gallons of Corexit into the Gulf of Mexico, creating
unexpected toxins in the fish I ate. If the drug companies were to provide a
pill to mitigate my hypothetical cancer, I would take it.

As you wrote, cancer risk probably involves effects from many factors.
However, I'm not sure how redirecting "billions" to, e.g., "psychological
'sciences'" serves to reduce the incidence of cancers that are essentially
environmental in origin. Healthy lifestyle only goes so far; I suspect the
vast bulk of cancers are due to environmental factors or are intrinsic to the
human aging process.

~~~
tomhoward
_I could run eight miles a day with full pack, eat only protein and
vegetables, have the mental outlook of the Buddha--and yet still get cancer
because..._

Maybe, or maybe not. When you actually have cause to investigate this stuff
deeply, as I have, it's surprising to discover how little is known about these
kinds of things.

If you could take 100 people of similar age and health and had them all "run
eight miles a day with full pack, eat only protein and vegetables, have the
mental outlook of the Buddha", and 50 developed cancer and 50 didn't, little
is known about why any given person would stay healthy and another would get
sick.

 _As you wrote, cancer risk probably involves effects from many factors.
However, I 'm not sure how redirecting "billions" to, e.g., "psychological
'sciences'" serves to reduce the incidence of cancers that are essentially
environmental in origin._

Having researched this topic in great depth, I'm now persuaded by the medical
researchers like Bruce Lipton and Rudi Tanzi who assert, with solid scientific
evidence, that psychology - particularly subconscious emotions - are a major
factor in determining whether a person will develop or recover from serious
illnesses like cancer, diabetes, Alzheimer's, MS, ALS, etc.

Of course these ideas don't get much acceptance or affirmation from the
majority of mainstream medical researchers, because, hey, everyone already
knows that psychology and physiological health are totally independent, right?

It turns out we don't actually need to be _redirecting "billions" to, e.g.,
"psychological 'sciences'"_.

It would suffice to let go of some of the unexamined assumptions and
prejudices that prevail in the current research landscape, and pay some
attention to the more open-minded researchers who are already investigating
these things and coming up with promising findings.

~~~
sireat
I would love to see some links to that scientific evidence especially about
the developing an illness from negative outlook.

It seems almost an accepted wisdom that mental outlook would play some part in
recovery process. Think positive and you will recover/improve somewhat
faster(this has been in popular press many times in last 20-30 years).

However, I have a hard time finding evidence that negative outlook makes you
get a serious illness.

This is something that I see in magazines of dubious nature("The seven all-
natural cures to dementia that your doctor is hiding from you!")

Are there publications with peer-review behind that?

~~~
tomhoward
Here's a couple of links:

[http://www.wakehealth.edu/News-
Releases/2013/Emotional_Stres...](http://www.wakehealth.edu/News-
Releases/2013/Emotional_Stress_Reduces_Effectiveness_of_Prostate_Cancer_Therapies_in_Animal_Model.htm)

[http://www.ncbi.nlm.nih.gov/m/pubmed/18190880/](http://www.ncbi.nlm.nih.gov/m/pubmed/18190880/)

The process of stress leading to disease is fairly well-established and
uncontroversial:

1) Any stress puts the body into fight or flight mode

2) When the body is in fight/flight, energy/nutrients are devoted to short-
term survival, not long-term needs like immunity, cell-repair, digestion

3) After long enough in this state (chronic fight/flight) infections take
over, cells break down, tumors form, etc.

------
apsec112
A drug to _treat_ cancer only has to be taken by people diagnosed with that
cancer, for as long as they're diagnosed with it. A drug to _prevent_ cancer
has to be taken by everyone at risk for the cancer (which might be the entire
population), for as long as they're at risk (likely decades). Hence, a
treatment drug can be expensive and can have some nasty side-effects, while a
prevention drug would have to be cheap with minimal side-effects. That's a
much tougher constraint to work under.

~~~
danieltillett
Yep. This is basically the same problem we have with Alzheimer's - the people
you need to treat are healthy people. The FDA just won’t let you test anything
with any danger in healthy people. Since all new treatments inherently have
risk it is basically impossible to give a new drug or treatment to healthy
people.

Even giving something like metafomin [1] where we have decades of knowledge is
in practice impossible to give to healthy people. No new treatment stands a
chance.

1\.
[https://en.wikipedia.org/wiki/Metformin](https://en.wikipedia.org/wiki/Metformin)

------
memracom
Just remember, Cancer isn't a disease.

It is hundreds of different disease related to mutations in the function of
cell division. Cells that don't need to divide, start dividing but the
daughter cells are not the same as the parent.

In order to treat Cancer with a drug, you need to identify which of the
hundreds of subtypes it is and give the right drug. Either that, or give
people cocktails of lots of drugs and hope that you can identify the right one
before the other ones kill the patient.

At this point there do not appear to be any magic bullets that will cure
cancer, just lots of work and research to chip away at the problem, one
subtype or one patient at a time.

And cancer appears to be inherent in what we are, animals. It seems unlikely
that we will be able to change what we are sufficiently to avoid cancer. No
vaccines are likely.

On the other hand, all the investment in Cancer research is paying off and is
chipping away at this family of diseases. There are lots of reasons, not just
new drugs, but some new drugs are part of the solution.

Maybe the human race is at a point where we have solved all the easy problems
and now have a hard slog to chip away at the rest of them, bit by bit.

------
themartorana
_" There’s more money to be made investing in drugs that will extend cancer
patients’ lives by a few months than in drugs that would prevent cancer in the
first place.

That’s one of the findings from the work of Heidi Williams, an M.I.T.
economics professor and recent MacArthur Foundation “genius” grant winner, who
studied the problem along with Eric Budish, a University of Chicago economics
professor, and Ben Roin, assistant professor of technological innovation,
entrepreneurship and strategic management at M.I.T."_

I'm damn near 40, and the phrase "there's no money in a cure" has been around
as long as I can remember. Heck, Chris Rock did a whole bit about it. [0]

Is this just putting good science behind that phrase? Is there anything new
here?

[0] [http://anonhq.com/chris-rock-on-big-pharma-no-money-in-
the-c...](http://anonhq.com/chris-rock-on-big-pharma-no-money-in-the-cure-the-
moneys-in-the-medicine/)

~~~
adevine
If there's no money in a cure, how are the new hepatitis-c cures being sold
for tens of thousands of dollars?

~~~
HarryHirsch
Because the only other cure is a liver transplant, and the market will pay
anything up to that price.

------
bayesianhorse
Well, preventing Cancer has been a priority for evolution since the first
multicellular organisms arose. It's just not that easy.

Developing a drug is an economically difficult thing: Spend billions for the
chance to win billions. The only alternatives to big pharma in developing
these drugs are big government and big charity (Gates' Foundation et al).

~~~
crusso
_Well, preventing Cancer has been a priority for evolution since the first
multicellular organisms arose_

It's only a "priority for evolution" to prevent cancer before the better years
for breeding have passed - and evolution has done a fairly good job with that.
After breeding and a little time for rearing young in the higher life forms,
evolution has no real use for us.

~~~
bayesianhorse
Multicellular organisms have to control the replication and renewal of their
cells constantly. In a simplified view, cancer is a loss of that control.

------
pessimizer
Dean Baker's comment:

 _If Patent Monopolies Bias Cancer Research, Why Not Have Publicly Funded
Trials?_

[http://cepr.net/blogs/beat-the-press/if-patent-monopolies-
bi...](http://cepr.net/blogs/beat-the-press/if-patent-monopolies-bias-cancer-
research-why-not-have-publicly-funded-trials)

------
paul_milovanov
If there is in fact such a problem with incentives, what entity do you think
might have the power to create proper incentives, and what are the odds of it
happening?

Or perhaps let's shelf this discussion at least until we figure out how to
incentivize sustainable development of new antibiotics.

In fact, one extremely effective way to reduce cancer-related mortality would
be to keep ignoring the problem with antibiotics. We may not exactly like the
way that plays out though.

~~~
netcan
I think that's a question we would benefit greatly from answering, if we
could.could markets are a powerful and useful thing. But, the longer we play
this game the more gaps emerge where human and economic incentives do not meet
eye to eye.

If it were just a question of funding it would be solvable.

~~~
paul_milovanov
Sorry, I was kidding about "what entity". The same entity that traditionally
steps in to solve the needs that otherwise are not met due to tragedy of the
commons -- government.

Patents, copyright protections (yes, they're screwed up now, but better than
without), infrastructure like roads or postal mail historically.

Just that US legislative process is spinning its wheels at the moment and for
the foreseeable future.

------
reasonattlm
The same, often perverse, incentives operate on the potential treatment of
aging. Lots of work on tinkering with end states, meaning age-related disease
in advanced stages, and next to nothing on prevention, meaning periodic repair
of the molecular damage that causes aging.

~~~
netheril96
Really? I would think the rich are very much incentivized to fund any research
that may slow down their aging (as are the poor, but they don't have enough
money). When you have achieved most of the goals in your life, the remaining
goal you have is perhaps to elongate that success for however longer you can.
For example, several Chinese emperors, starting from the first one, were
_obsessed_ with living forever, giving tons of resources and power to
"alchemists" who claimed to be able to produce medicine to keep the emperor
young.

------
JauntTrooper
Preventative tools exist today that would significantly reduce the incidence
rate of cancer.

Much of them require lifestyle modifications and regulation, unfortunately,
which is admittedly very difficult to do. Still, I suspect investment in these
areas would likely have a higher return on investment than R&D into broad
preventative drugs.

(1) Smoking Cessation: Reducing tobacco use has a =huge= positive effect on
cancer reduction - an order of magnitude higher than anything else we can do.

1 in ever 5 deaths of males over the age of 30 is due to to tobacco-induced
illnesses, and a third of those are cancer [0]. Globally, 31% of men and 6% of
women smoke daily. 17% of Americans are daily smokers. Over 1 billion people
are projected to die due to tobacco-related illnesses in the 21st century.

(2) Obesity: A recent epidemiological study found that 4% of cancer in men and
7% in women was due to obesity. It was as high as 40% for some cancers such as
endometrial and esophageal adenocarcinoma [1].

(3) Alcohol/Red & Processed Meat: Consumption of alcoholic beverages is a
known human carcinogen. A recent study estimated that 3.5% of all cancer
deaths can be attributed to alcohol [2]. A separate study found that 3% of all
cancers, including 21% of bowel cancers, was attributed to red & processed
meats [3].

(4) Environmental & Occupational Hazards: The WHO estimates 19% of all cancers
globally are attributable to environmental factors [4]. This includes air
pollution, which likely causes 3% to 14% of all lung cancers, as well as
exposure to chemicals in the workplace such as asbestos.

[0]
[http://www.ncbi.nlm.nih.gov/books/NBK54023/](http://www.ncbi.nlm.nih.gov/books/NBK54023/)

[1] [http://www.cancer.gov/about-cancer/causes-
prevention/risk/ob...](http://www.cancer.gov/about-cancer/causes-
prevention/risk/obesity/obesity-fact-sheet#q3)

[2] [http://www.cancer.gov/about-cancer/causes-
prevention/risk/al...](http://www.cancer.gov/about-cancer/causes-
prevention/risk/alcohol/alcohol-fact-sheet#q2)

[3]
[http://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines/...](http://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines/news/2015-10-27-processed-
meat-causes-cancer-warns-who-report/)

[4]
[http://www.who.int/mediacentre/factsheets/fs350/en/](http://www.who.int/mediacentre/factsheets/fs350/en/)

------
randompost
tldr; money

------
pinaceae
explain HPV vaccination then. and the banning of abestos. and all anti-smoking
legislation. and all other EPA regulation banning carcinogens. etc etc etc.

------
blhack
This logic is just dumbfounding. How do the people saying stuff like this
explain the existence of things like vaccines?

~~~
coldtea
What about vaccines? Those are quite easy to make, and are made using existing
disease-causing viruses. We know the mechanism, it applies to the whole
population, and it's relatively simple and cheap to produce.

The logistics are not the same with cancer preventing drugs at all.

~~~
dogma1138
Considering that there are no wide spread generic cancer prevention drugs how
would you know?

~~~
coldtea
We already know that cancer is not caused by a virus (at least in the general
case), so it can't be fixed in the same way as vaccines.

And we've already been looking for cancer drugs for more than half a century
to know that the logistics compared to vaccines are different. Let's put it
this way: if they knew of a method to make cancer prevention drugs as easy and
effective as vaccines, they'd have made them.

~~~
dogma1138
Nonsense there are multiple types of vaccines toxiod vaccines for example
vaccinate you against toxic compounds such as snake bites. There is quite a
bit of research into regressive therapeutic and preventative vaccines against
cancer currently. A vaccine is a process which teaches your immune system to
combat a certain condition whether it's caused by a bacteria, parasite, a
virus or a toxin it doesn't matter. If you can teach your own immune system to
combat cancer by either teaching it to attack certain markers, or by disabling
the "stealth" mechanisms which many types of cancer use to fly under it's
radar you've effectively created a vaccine.

Also vaccination is one of the most logistically complicated processes in
medicine they are extremely short lived require very precise refrigeration and
proper administration is considerably more critical than most cancer
treatments, 80-90% of the cost of vaccination programs in developed and
developing countries alike go into logistics. For cancer treatments even the
experimental highly specialized ones it's completely the opposite, and run of
the mill treatments like chemotherapy are easily administered by medical
technicians under almost any circumstances.

~~~
coldtea
> _If you can teach your own immune system to combat cancer by either teaching
> it to attack certain markers, or by disabling the "stealth" mechanisms which
> many types of cancer use to fly under it's radar you've effectively created
> a vaccine._

All of that is known, and they've been trying that for half a century with not
much success (besides the occasional report for a "cancer vaccine"). What
makes you think they don't know the logistics involved already?

> _Also vaccination is one of the most logistically complicated processes in
> medicine they are extremely short lived require very precise refrigeration
> and proper administration is considerably more critical than most cancer
> treatments, 80-90% of the cost of vaccination programs in developed and
> developing countries alike go into logistics._

Not really relevant. Being short lived and requiring "precise refrigeration
and proper administration", is not the same kind of problem as the research
for cancer vaccines.

The former is actually a solved problem, and something that even all third
world countries are able to do just fine anyway...

~~~
dogma1138
>All of that is known, and they've been trying that for half a century with
not much success (besides the occasional report for a "cancer vaccine"). What
makes you think they don't know the logistics involved already?

No it hasn't tumor antigens are a fairly recent discovery, the epigenetics of
cancer as well as it's relationship with the immune system are also quite new
fields. MUC1 was only discovered in the mid 80's it's expression initially
linked to cancer in the mid 90's since the mid to late 2000's where we
actually started trialing this out and started developing immunologic
therapeutic processes. If we are talking about cancer specific therapeutic
vaccines then there are already several on the market some of which are
classified as orphan drugs and can be sponsored most of them are currently
only life prolonging treatments for cancers with no other treatment course.

And again it's not like overall vaccination is a closed book there are only a
handful of diseases we can effectively vaccinate against and those are ones
which are immune system is pretty damn good in dealing with the begin with.

I really don't understand your argument anymore because at this point you are
arguing about the logistics of vaccinating against chickenpox vs developing
new cancer treatments which is asinine. New research is done everyday doesn't
matter if it's into vaccines for new viral diseases or cancer the logistics of
the research are the same. And if you are talking about delivery logistic than
cancer would win every blood day of the week.

