
When Cancer Was Conquerable - apsec112
https://reason.com/archives/2018/05/12/when-cancer-was-conquerable/
======
scott_s
> _More radically, it might be possible to repeal the 1962 Kefauver-Harris
> amendment to the Federal Food, Drug, and Cosmetic Act, a provision that
> requires drug developers to prove a medication 's efficacy (rather than just
> its safety) before it can receive FDA approval. Since this more stringent
> authorization process was enacted, the average number of new drugs
> greenlighted per year has dropped by more than half, while the death rate
> from drug toxicity stayed constant. The additional regulation has produced
> stagnation, in other words, with no upside in terms of improved safety._

If that were to happen, we can expect that the drug market would become like
the supplement market: full of pseudo-science and products that do nothing.
Right now, supplement makers are prohibited from making specific medical
claims; they can say something like "gives you energy," but they can't say
"cures cancer." The only reason they _don 't_ is because they legally _can
't_. (And even then they sometimes do, and sometimes get away with it.) If
they were suddenly allowed to, we would not get a flood of new drugs from the
current pharmaceutical companies. We would get a flood of sugar pills from the
current supplement companies.

The "since" part of the paragraph is also a bit of non-sequitur. Before and
after the 1962 provision, drug companies had to prove safety, so it's not a
surprise the death rate from drug toxicity stayed constant. Proving efficacy
is about preventing companies from exploiting the public by selling stuff that
has no hope of ever working as advertised.

The blind spot of proposals like this is that they assume good-faith actors
acting rationally. They completely ignore bad-faith actors willing to
sociopathically exploit people.

~~~
drewg123
How does this act relate to drugs targeted to specific genetic markers?

I think we're moving into an era when we need to consider that everybody is
different, and a lot of cancers are different. This isn't like curing a
bacteria, where (mostly) one-size fits all.

I wonder: is it possible to bring a drug to market that is ineffective and
sometimes fatal to most people without a genetic marker, but is safe and will
cure cancer for those with the marker?

~~~
chimeracoder
> I wonder: is it possible to bring a drug to market that is ineffective and
> sometimes fatal to most people without a genetic marker

We already do this. A large class of both antipsychotics and antidepressants
require certain genes in order to metabolize properly and have the intended
effect, instead of just giving a bunch of side effects with no benefit.

These genes are not universal and not evenly distributed; people of certain
ethnic backgrounds are dramatically less likely to have the requisite genes,
which means that most antipsychotics and antidepressants literally don't work
on them.

~~~
perl4ever
Do you have a citation for this?

------
iooi
> Cancer deaths have fallen by a total of just 5 percent since 1950.

This is suuuuper misleading, to the point where I'm thinking that the author
has an agenda.

Cancer _deaths_ is the wrong metric to use, since population is always
increasing and the proportion of people getting cancer is also changing over
time.

You want to look at the cancer death _rate_ instead, from 1991 to 2015 the
cancer death rate decreased by _26%_. It's also really important to take into
account that mortality rates are _vastly_ different across different types of
cancers and across genders -- in that same time period, the death rate for
males with lung cancer decreased by 45%! [2]

Again, this article is misleading and probably has an agenda behind it. If you
want to learn more about the history of cancer treatment, _The Emperor of All
Maladies_ is a great book.

[1] [https://www.cancer.org/latest-news/understanding-cancer-
deat...](https://www.cancer.org/latest-news/understanding-cancer-death-
rates.html) [2] [https://www.cancer.org/latest-news/facts-and-
figures-2018-ra...](https://www.cancer.org/latest-news/facts-and-
figures-2018-rate-of-deaths-from-cancer-continues-decline.html)

~~~
simulate
Scott Alexander (Slatestarcodex) had a post about this earlier this month:

[http://slatestarcodex.com/2018/08/01/cancer-progress-much-
mo...](http://slatestarcodex.com/2018/08/01/cancer-progress-much-more-than-
you-wanted-to-know/)

The gist of the post was that cancer rates since 1990 have gone down primarily
because smoking has declined, not because cancer treatment has improved.

~~~
iooi
Which isn't related to cancer death _rates_ , which is the proportion of
people who die from cancer out of the population of people that have cancer.

~~~
losvedir
It touches on that, too. It's also a hard metric to work with because we're
getting better at _detecting_ cancers, including more benign and earlier stage
ones. I believe the SSC post found that most of the improvement in cancer
mortality was more an artifact of detection than actual improvements in care.
i.e.: if you look _only_ at equivalent Stage 4 cancers, then the death rate
from there hasn't changed much over time.

------
baldfat
Lost my son at 12 years old in 2013 (Bone Cancer) and lost my sister when she
was 15 in 1996 (Brain Cancer). The fight for pediatric cancer research funding
is worse. If you have a chemo for kids (All of kids cells are growing which
makes it much more difficult to fight cancer) it has less side-effects and is
effective for adults. If you have a new adult chemo it doesn't mean nothing
for Pediatric. We went over 20+ years without one new Chemo till St.
Baldrick's funded chemo for Neroblastoma came out a few years ago.

Bone Cancer does have funding, from dog owners. Bone Cancer my son has hasn't
had a change in survival rates in 35 years. Fortuitously people have greater
hope for a cure for dogs then sick kids and are putting millions into bone
cancer research and we hope that once they finally have something we can start
the 10 year process of testing for kids.

We wouldn't have done the trial for bone cancer. Reason is that when your in a
trial you have to leave the tumor in the body so they can see the
effectiveness. Bone cancer is extremely painful and is only curable through
surgery. Why would anyone agree to leaving the painful hard tumor in your kids
body???

My son had a 15% chance of surviving 5 years when he was diagnosed with bone
cancer (It was in his whole left femur and both lungs, bone cancer for some
reason grows in your lungs so you have crazy bone cells growing in your
lungs). He made it past 4.5 years, but it grew into both legs, his neck, and
hip and had countless surgeries, radiation and chemo and it all sucked. That
the funding isn't there is a constant thought in your brain at all times. Heck
American Cancer Society (Largest on the planet) gave a penny per dollar raised
to pediatric cancer research and then cut funding to kids camps and family
resources about 7 years ago so they could focus on adult research. They
finally agreed to stop using pictures of kids sick on their fund raising
efforts. So yeah it is frustrating.

~~~
sandworm101
You touch on the twisted point about medicine for dogs: there are often lots
more treatments for them, at least as many as for humans. But this isnt
because of funding. it is because nearly ever human treatmemt was once tested
on dogs. And they arent all pets... or even sick. Sometimes the path to human
testing leads through dark places.

~~~
ericmcer
Uh no, they definitely have specific research facilities for animal treatment.
We have a for profit healthcare system, and in that system it goes: Wealthy
people > Wealthy peoples pets > poor people.

~~~
baldfat
We had the best medical experience. We had awesome doctors and awesome
hospital.

I have to say my son was adopted. He was a dirt poor kid who was neglected and
had serious mental health issues due to his enviroment. My son got his femur
replaced by one of the best pediatric orthopedic surgeons. His surgeon
actually invested the procedure where they replace your femur bone instead of
an removing the leg at the hip. We also got to stay at Children's Hospital of
Philadelphia (CHOP) and stay at the Ronald McDonald House (This is where it
actually was founded).

I figure I will share this video of him since I mentioned his Mental Health
issues. My kid was so resilient and he got better. His body didn't get healed
but his heart and mind is the biggest miracle I have ever witnessed.

[https://vimeo.com/65522201](https://vimeo.com/65522201)

------
sofon
> One proposal, developed by American economist Bartley Madden, is "free-to-
> choose medicine." Once drugs have passed Phase I trials demonstrating
> safety, doctors would be able to prescribe them... > > More radically, it
> might be possible to repeal the 1962 Kefauver-Harris amendment to the
> Federal Food, Drug, and Cosmetic Act, a provision that requires drug
> developers to prove a medication's efficacy (rather than just its safety)
> before it can receive FDA approval.

Personally I'd be in favour of letting seriously ill people try whatever they
want. However I would not be in favour of allowing companies to charge for
drugs which had not yet been proved effective.

Providing drugs for free might give companies more data to help develop (or
potentially prove safety, efficacy) but generating revenue here is too open to
abuse.

~~~
sithadmin
>Providing drugs for free might give companies more data to help develop (or
potentially prove safety, efficacy)

It's a nice thought, but you generally can't have patients and doctors opting-
in for unproven treatments and expect the resulting data to stand up to any
sort of scrutiny. To glean useful data, one would require a really, really
large-n study population and clear impacts from use of the drug that are so
pronounced they drown out nearly all other confounding factors (e.g. studies
on the health impact of cigarettes) -- and expecting an unproven, last-resort
type drug to attract a study population this large is just unrealistic.

~~~
candiodari
It's not just that experiments won't work like that, it's the consequences of
experimenting on live human beings ... that is where the real problem lies.
These companies don't want the freedom to experiment, they already have that.
The technical way to state what they want is permission to do stage 2 trials
... and not be responsible for patient outcomes. If their liver gets
reabsorbed (which is one of the more common "oops"es for drug testing), they
don't want to pay for 50 years of dialysis plus constant treatments. That's
what they're asking for.

------
dlojudice
Maybe at the time, from 40's to 70's, (1) there were low hanging fruits. It's
reasonable to think the discovery process has become harder and (2) we didn't
know much about how a fast clinical trial could go wrong [1]

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

~~~
tyu100
Yes, this was a ridiculous article. In addition, the FDA actually has fast-
track approval for drugs in areas with no good treatment and any drug showing
exceptional efficacy will make it through the approval process very quickly.

~~~
TheBeardKing
Keep in mind Reason is a libertarian site and approaches every topic with the
goal of portraying the modern government always as a roadblock with never any
benefit. Every article will be totally one-sided to not mention positive
aspects of any government program or agency.

edit: They actually did quickly mention FDA fast-track:

>There have been some moves in the right direction. Between 1992 and 2002, the
FDA launched three special programs to allow for faster approval of drugs for
certain serious diseases, including cancer. And current FDA Commissioner Scott
Gottlieb shows at least some appetite for further reform.

~~~
r_smart
I hear Reason used to be good. My experience with it over the last three years
or so is that it's mostly garbage. It's become a lot of narrative confirmation
but with little quality reasoning (drink!) or evidence. I don't go there
anymore if I can help it.

This law could be terrible, but if that's true, it should be provable without
pretending to have data (the safety ratings are the same after non-safety
legislation was passed!).

Then there was that one time they published an anti-first amendment screed on
the website.

Reason annoys the bejesus out of me.

------
babkayaga
To summarize: two proposals: 1\. Once drugs have passed Phase I trials ...
prescribe them 2\. repeal ... a provision that requires drug developers to
prove a medication's efficacy

How is this different from Right to Try act?
[https://edition.cnn.com/2018/05/30/politics/right-to-try-
don...](https://edition.cnn.com/2018/05/30/politics/right-to-try-donald-
trump/index.html)

------
psychometry
>In 1971, three decades after Gilman's discovery, the U.S. government declared
a "war on cancer." Since then, we have spent nearly $200 billion in federal
money on research to defeat the disease. But we haven't gotten much bang for
our buck: Cancer deaths have fallen by a total of just 5 percent since 1950.
(In comparison, heart disease deaths are a third of what they were then,
thanks to innovations like statins, stents, and bypass surgery.)

People live a lot longer than in 1950, which gives them more years to get
cancer. This is why you have to report age-diagnosis-specific outcomes and not
merely incidence or prevalence.

------
HarryHirsch
What is the author even talking about, saying there is no progress in cancer
therapy? Hanahan doesn't even mention immunology in the "Hallmarks of Cancer"
(that's an influential review article from 2000), and less than ten years
later it's a huge field of research, with several very powerful drugs in the
clinic.

~~~
ryanackley
He looks at it empirically

> Cancer deaths have fallen by a total of just 5 percent since 1950. (In
> comparison, heart disease deaths are a third of what they were then, thanks
> to innovations like statins, stents, and bypass surgery.)

Not sure if this takes into account x year survival rates.

~~~
cptskippy
That was my first thought. What about early detection and treatment?

There's a saying "live long enough and you'll die of cancer".

------
axus
The article could have done a post-mortem of the 20-year taxol approval. It
sounds obviously wrong, but I'd like to know how it could be done right.

Cancer can be very complex, and treatment based on assumptions can shorten
lives and kill fertility when another treatment would have been appropriate.

A webcomic author updated their blog about their experience:
[https://www.erfworld.com/blog/view/60504/rob-lindas-1st-
anni...](https://www.erfworld.com/blog/view/60504/rob-lindas-1st-anniversary)

------
anovikov
I think the whole reason why cancer deaths aren't receding as fast as we'd
like them to is exactly that heart disease deaths, and violent deaths
(anything from murder to suicide to a car accident) are receding quickly.
Therefore, people live longer, and get cancer with higher probability.

~~~
TheBeardKing
Right, it would make much more sense to talk about cancer diagnosis or
survivability by a certain age, like 50 or 60. By 70-90 most people have been
exposed to so many carcinogens the likelihood of some sort of cancer is near
guaranteed.

~~~
beat
It's not even carcinogens. Cellular decay is a thing. As we age, our genetics
start breaking down due to imperfect copying. Cancer is basically just bugs in
DNA's software.

------
paulpauper
Progress is slow because much of the long hanging fruit has been picked

Cancer is much more difficult and complicated than other types of diseases

Clinical trials bypass the FDA but very seldom result in cures or improved
survival. It's not like people with advanced cancer are being denied
experimental treatments, but the problem is for every success that gets media
attention, the vast majority of these treatments do nothing or are even
harmful

~~~
nonbel
>"Progress is slow because much of the long hanging fruit has been picked

Cancer is much more difficult and complicated than other types of diseases"

Or maybe the people researching it haven't been doing a very good job and have
generated a bunch of irreproducible (even in principle) results:
[https://news.ycombinator.com/item?id=17702380](https://news.ycombinator.com/item?id=17702380)

Trying to make sense of a topic when the literature is filled with incorrect
facts would be quite difficult and complicated.

------
tenYearsGone
It’s actually really easy force research to move faster, but to do so people
basically must throw caution to the wind, and gamble with the possibility of
extremely unpleasant outcomes, on top of also not surviving.

Being less safe is as simple as operating outside the conventional protections
that regulatory bodies use, in order to safeguard ethics.

If that’s not your priority, and you want to press your luck, feel free to
take your chances, so long as you acknowlege your adoption of the risks that
ride along with that decision.

Break the law, in favor of searching places others dare not go. It’s uncharted
territory, out where there’s no lifeguard. Maybe it seems timid to shy away
from risk in a dire situation, but honestly, push hard enough, and I’m sure
enterprising people will ignore their own safety in pursuit of impatience.

------
MisterBastahrd
Reason is an unserious publication with an ironic name. The author of this
particular article has a financial interest in pushing untested medicine on
the suffering. Cancer is a catch-all for a number of different diseases
(having a few similarities) that require different treatments. The author
chooses to ignore the average age of the population, the size of the
population, the diet of the population, and obesity within the population when
pulling out statistics. The regulatory framework surrounding medical treatment
and drug testing exists BECAUSE people were being harmed by untested medicine.

Thalidomide is just one example.

------
agumonkey
Told that to oncologist, got vaporized. It's a tough moral issue, lack of
regulation = deaths, too much regulation = deaths.

~~~
nybble41
> lack of regulation = deaths, too much regulation = deaths

lack of regulation = people make their own choices, take risks, and sometimes
suffer the consequences

too much regulation = people die because you killed them

Freedom comes with risk, even at times the risk of death. It is not your place
to decide how much risk other people are allowed to take.

~~~
agumonkey
Exactly how I feel about this, with the added bonus of white-coat syndrom. If
some doctor says 'you are dead' then why fight.

------
alexandercrohde
I'd be curious to hear why these highly experimental approaches (e.g
reprogramming immune cells) can't be done in animals with cancer to vet them.

However, I appreciate the spirit of constant vigilance against the lethargy of
bureaucracy, even if I know nothing myself firsthand on this topic.

~~~
mjewkes
>why these highly experimental approaches (e.g reprogramming immune cells)
can't be done in animals with cancer

They absolutely are, all the time. Animal testing is relatively cheap (esp.
for mice) and widespread in biotech. It's generally hard to get an IND
approval (step 1 of human testing) without successful animal tests.

Animal models, unfortunately, aren't super effective at predicting human
outcomes.

------
valuearb
“In 1971, Congress passed the National Cancer Act, which established 69
geographically dispersed, NCI-designated cancer research and treatment
centers. James Watson—one of the discoverers of the structure of DNA and at
the time a member of the National Cancer Advisory Board—objected strenuously
to the move. In fact, DeVita in his memoir remembers the Nobel winner calling
the cancer centers program "a pile of shit." Watson was fired that day.”

Watson didn’t understand congress rarely approves anything that durant supply
pork to a majority of districts.

------
tlear
It is quite incredible just how clueless we are about human biology, cancer
and related things on the fundamental level.

Like a bunch of cavemen staring sky and imagining a bear and wondering why
some light move around unlike others.

~~~
xamuel
Don't know why people are downvoting you. I did my postdoc at a biomedical
research institute at a prestigious university, and you're 100% right. The
work I was doing was related to using ontologies to label anatomical parts.
Forget "staring at the sky and imagining a bear", that would be tremendous
progress if the cavemen actually agreed on one common word, "bear"!

------
EamonnMR
My understanding is that they won't approve a cancer drug unless it's strictly
as or more effective than existing drugs, even if it's efficacy to side effect
ratio is more favorable.

------
bproven
What are the options in regular (preventive maintenance ) cancer screening?
Cancer is horrible and I feel like by the time we discover the cancer - when
it presents itself as a symptom - it can be too late. I realize in general
preventive medicine seems to be rarely practiced and medical costs are insane
(especially in the US), but is it scientifically feasible to detect most
cancers early if proper screening were done on a regular basis?

------
michaelbuckbee
The HPV Vaccine (and consequent drop in cervical cancer rates - [1]) certainly
seems like an improvement. Similarly, the near fanatical application of
sunscreen, reduction in cancer causing chemicals, etc. I would have thought
would have brought the cancer rate down as well.

1 - [https://www.sciencealert.com/the-hpv-vaccine-has-halved-
cerv...](https://www.sciencealert.com/the-hpv-vaccine-has-halved-cervical-
cancer-rates-in-the-past-10-years)

~~~
beat
HPV vaccine isn't just preventing cancer. I have a rare and potentially fatal
condition - HPV warts growing on my vocal cords. I need laser surgery on my
vocal cords a few times a year to keep talking, and ultimately to keep
breathing.

It's really rare, though... 1.6 adult cases per 100k, and about twice that
many child cases (doctors generally believe it's passed during childbirth).
Children die from it because it goes undiagnosed, with doctors treating it as
bronchitis, when the only actual treatment is specialist surgery.

At any rate, I totally applaud the rise of HPV vaccine. No one should have to
deal with this crap.

------
csours
Bottom line up front: If you have good points, make them. Don't lie to me.

Ways this article misuses statistics and history (lies):

0\. Title: When Cancer was Conquerable.

Response: Cancer has never been conquerable. Chemotherapy increased survival
rates. Also, cancer is not a single disease.

1\. "The first attempt to treat cancer in humans with chemotherapy happened
within days of doctors realizing that it reduced the size of tumors in mice."

Response: True, but misleading. Critical question: What treatment is being
replaced? When nothing else worked, you might as well try something. Going
from 0% effective treatment to 20% effective treatment is huge enough to
warrant extreme risks. Going from 50% to 55% may not warrant the same risks.

2\. "Cancer deaths have fallen by a total of just 5 percent since 1950."

Response: Everyone will die eventually, some people die of cancer; many more
people die with cancer (but not necessarily because of cancer). A better
metric would be a combination of things like added years of life due to
treatment and quality of life factors.

3\. "It is now nearly impossible to conceive of going from a eureka moment to
human testing in a few years, much less a few days."

Response: Thank goodness. First, all the easy solutions have been tried.
Second, if there is a reasonably, or even partially effective solution in
place, the new proposal MUST at least shown to be safe - something that cannot
be done in a few days.

4\. "To find cures for cancer, we need novel approaches that produce dramatic
results. The only way to get them is by lowering barriers to entry."

Response: The only way to reproduce the dramatic results of the past is to
stop treating cancer, and then replace the lack of treatment with a new
treatment. Also, there is no such thing "the only way". There is "the only
thing I thought of" or "this is the way I think will work"

5\. "Running a clinical trial now requires getting "protocols" approved."

Response: Among other things, if you just run a study and then try to find
some benefit, you will ALWAYS find some benefit.

6\. "The problem is clear: Despite tens of billions of dollars every year
spent on research, progress in combating cancer has slowed to a snail's pace."

Response:
[https://en.wikipedia.org/wiki/Potato_paradox](https://en.wikipedia.org/wiki/Potato_paradox)

7\. "Years ago, a Cato Institute study estimated the loss of life resulting
from FDA-related drug delays from 1962 to 1985 in the hundreds of thousands."

Response: Did Cato also do a study to show lives saved by FDA (and IRB, and
safety testing) drug cancellations? New drugs are not risk free.

8\. "We used to think cancer was conquerable. Today, that idea is often
laughed off as utopian. But there are countless reasons to believe that
progress has slowed because of organizational and governmental problems, not
because the disease is inherently incurable."

Response: We also used to thing we'd have anti-gravity and moon bases by this
point. There is also a much deeper understanding of the class of diseases
known as cancer.

~~~
CryptoPunk
I'm just going to respond to a few of these:

>>Response: Cancer has never been conquerable. Chemotherapy increased survival
rates.

This is a reference to the confidence early researchers had, as a result of
the rapid pace of progress. Your literal reading of it is disingenuous.

>>Response: True, but misleading. Critical question: What treatment is being
replaced? When nothing else worked, you might as well try something.

An article is limited in the number of caveats it can include. It's pretty
harsh to describe a pertinent fact: that human experimentation came much
earlier 70 years ago, which in turn resulted in some rapid advances in cancer
treatment, as "misleading", because it didn't outline every other contributing
factor to the change.

Also, there are cancers today that are 100% fatal. We don't see the rapid time
from discovery to human use for drugs used for this class of cancer.

>>Response: Among other things, if you just run a study and then try to find
some benefit, you will ALWAYS find some benefit.

This is hyperbole, and in any case, doesn't negate the point about the rising
costs of doing human studies.

So you start your comment with:

>>Ways this article misuses statistics and history (lies):

And all I see is you misreading the points made, or disagreeing with the
implications of the points made.

If you're going to accuse people of lying, you have a moral responsibility to
be more rigorous with your arguments.

~~~
csours
> This is a reference to the confidence early researchers had, as a result of
> the rapid pace of progress. Your literal reading of it is disingenuous.

You can't have it both ways. It's either a factual article or a puff piece.
(It's a puff piece by the way).

> An article is limited in the number of caveats it can include.

The author does not introduce ANY caveats which get in the way of her points.

> If you're going to accuse people of lying, you have a moral responsibility
> to be more rigorous with your arguments.

[http://wondermark.com/1k62/](http://wondermark.com/1k62/)

~~~
CryptoPunk
The article doesn't include the caveat that the slowdown in progress could be
due to the low hanging fruit being picked in the early decades? You're not
giving the article a fair or honest review.

