
Cancer medicine generates enormous revenues but marginal benefits for patients? - jwblackwell
https://blogs.scientificamerican.com/cross-check/the-cancer-industry-hype-vs-reality/
======
mrosett
This article is a case study in “if you say something controversial enough,
people will pay attention regardless of the quality of your argument.”

There’s a lot of hype in the cancer industry and there are still many diseases
that can’t be treated effectively. But the bizarre claim that we aren’t any
better at treating it than we were 50 years ago is just wrong.

The timing is particularly ironic, coming after a decade of particularly rapid
progress. The survival advantage conferred by immunotherapy is very
meaningful, and it’s being used in diseases that were previously intractable.
The author waves away the benefits of immunotherapy while focusing on the cost
and side effects. Undoubtedly, it is expensive, and speaking from experience,
the side effects aren’t fun. But the cost will come down, and the side effects
are generally more manageable than chemotherapy.

If I really steelman the article, I can see a couple decent points and maybe
even agree with them. I might believe that aggressive screening is
counterproductive, for instance. But for an article complaining about “hype”,
this piece is a remarkable sequence of exaggerations, fallacies, cherry-picked
data, and hand-waving.

~~~
landtuna
Except for one throwaway sentence about life extension averaged across 72
drugs, the huge point the author is missing is that the mortality rate is not
what matters. The drugs aren't curing cancer - they're extending the lives of
those with cancer, even though those same people eventually die of cancer.
That won't show up in the mortality rates that aren't improving, but it's a
very important positive effect of the drugs, particularly if that extended
period of life can be at an acceptable quality. The industry actually measures
its success by "quality adjusted life years," not by mortality, and I think
that's the correct measure.

~~~
VHRanger
Would you not agree that spending hundreds of thousands for a few additional
months of fairly low standard of living (even if higher than before) is
wasteful on the larger scale?

~~~
s1artibartfast
That depends. As long as new drugs provide incremental impact, the benefit
should be cumulative over time. Maybe not the area of healthcare spend with
the highest ROI, but not a waste in isolation

------
johnpowell
I get a 20 minute drip of Pembrolizumab every three weeks. I had it done two
days ago. 28K per infusion.

The cancer has spread since I have been taking it. But I don't know if the
cancer is spreading slower with taking it or not.

I'm 1.5 million deep in medical bills from the last year. I no longer open my
mail or answer my phone. I am just waiting for the day I go in for treatment
and they turn me away.

~~~
xiphias2
I'm so sorry for you, US healthcare research is amazing and US healthcare
availability is really bad at the same time.

My girlfriend in Hungary got all her cancer treatment for free, even if it's a
quite poor country compared to the US.

~~~
daniel-cussen
You're confusing things.

Healthcare sometimes has a perverse supply curve, meaning the more expensive
it is, the lower the quality. This is true of many drugs: there are generics
whose side effects are well understood and have stood the test of time.
They're so good that they are still being demanded and prescribed despite
newer alternatives with incredible marketing and doctor incentives, glamorous
salespersons, all-expense paid conventions in paradisiacal locales, and
prestigious studies that show it's for sure at least 1% more effective which
makes it a game changer. And even then it's for insurance to cover.

Really cheap healthcare is really hard to get because other reasonable
economic factors still play a role. People want more of it because it's cheap
and it still costs real money to provide so there's only so much budget for
it. But if you manage to get it you will be way ahead. The big factor is that
cheap healthcare weeds out practitioners who value your money more than your
humanity. Maybe you'll also weed out a great doctor who charges a lot because
he's so good, though.

------
Damorian
As someone who works in healthcare, I don't disagree with the entire sentiment
here, with the exception of screening. In my opinion, it would be simpler and
more cost effective to monitor cancerous and precancerous indicators rather
than immediately go for surgery/treatment. Most people probably freak out if
you tell them they have a golf ball sized growth on their kidney though.

~~~
loceng
And then to take it one step further: focusing on prevention and being
proactive, which may require more research funding, however that no one can or
is widespread promoting a solid set of known practices to reduce cancer is a
problem.

~~~
smt88
> _however that no one can or is widespread promoting a solid set of known
> practices to reduce cancer is a problem_

My friend at American Cancer Society would take issue with that statement. He
flies all over the world educating public health officials about how to fight
tobacco use.

Tobacco by itself is a _huge_ cause of preventable cancers.

The next big one is sun exposure, so ACS also promotes proper sunscreen use
(and avoidance of tanning beds).

The ones caused by genes and random mutations are also a large percentage, but
you can't teach people how to avoid those.

People should get radon tests in their home as well. Most lung cancer is
either due to tobacco or radon.

After that, there isn't much advice specific to cancer: eat moderately and
exercise.

~~~
nonbel
There is a skin cancer pandemic since health authorities started warning
people to avoid the sun. It is found mostly in people who avoid/block the sun
and not eg people who work outside everyday.

[https://www.ncbi.nlm.nih.gov/pubmed/20231499](https://www.ncbi.nlm.nih.gov/pubmed/20231499)

[https://www.ncbi.nlm.nih.gov/pubmed/20541680](https://www.ncbi.nlm.nih.gov/pubmed/20541680)

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1694089/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1694089/)

Also, tobacco smoke seems to be an exceptionally weak carcinogen. It is near
impossible to get it to cause cancer in animals (while eg, radioactive dust
easily does so). Think about it, people expose themselves almost 24 hrs per
day for decades and still less than 25% get lung cancer.

[https://www.ncbi.nlm.nih.gov/pubmed/15765916](https://www.ncbi.nlm.nih.gov/pubmed/15765916)

[https://www.ncbi.nlm.nih.gov/pubmed/29370344](https://www.ncbi.nlm.nih.gov/pubmed/29370344)

~~~
mbreese
I'd be hesitant to call tobacco smoke a weak carcinogen, especially when there
are mutational signatures known to be associated with exposure to it.

But by and large, it is a numbers / probability game. You could be exposed to
a carcinogen routinely for your entire life and not have any problems. Or, you
could be exposed once, and have it hit is just the wrong place. I'd say a 25%
incidence rate is pretty high, and not something that I'd personally like to
risk. Lung cancer rates are still high, with smoking being the primary risk
factor. So, are you seriously going to argue that smoking is not something to
avoid?

Skin cancer is another... the known primary risk factor is sun exposure
(again, with a known mutational signature associated with UV light). Many
people who avoid the sun likely already know that either a) they have a family
history of skin cancer or b) they have sensitive skin that burns easily.
Either of which is a good reason to avoid sun exposure.

Given the above and other comments in this thread, I'm struggling to figure
out what your point here is. You keep attaching a lot of Pubmed links, but
frankly, in this case at least, they aren't all that compelling and don't even
begin to approach a scientific consensus. You're just cherry picking random
articles.

~~~
nonbel
You think there is no consensus that skin cancer rates are skyrocketing?

------
dannykwells
This article is absolute 100% bullshit.

-Metastatic melanoma: used to be lethal, now 50% cure rate.[1]

-Non small cell lung cancer: same, now around 25% [2, 4]

-Breast cancer used to have a terrible prognisis, now 75% survive. [3]

-Not to mention the myriad of blood cancers with new, strong, cell therapy treatment options with 40-50% durable cure rate.

I don't know this person, but seriously, whoever he is, fuck you dude.
Millions of us work day and night trying to improve care, and 99% of us arent
getting rich.

[1]
[https://www.nejm.org/doi/full/10.1056/NEJMoa1709684](https://www.nejm.org/doi/full/10.1056/NEJMoa1709684)

[2]
[https://www.nejm.org/doi/full/10.1056/NEJMoa1801946](https://www.nejm.org/doi/full/10.1056/NEJMoa1801946)

[3] [https://www.breastcancer.org/research-
news/20100930](https://www.breastcancer.org/research-news/20100930)

4\. [https://investors.merck.com/news/press-release-
details/2019/...](https://investors.merck.com/news/press-release-
details/2019/Five-Year-Survival-Data-for-Mercks-KEYTRUDA-pembrolizumab-in-
Advanced-Non-Small-Cell-Lung-Cancer-NSCLC-from-First-KEYNOTE-Trial-
at-2019-ASCO-Annual-Meeting/default.aspx)

~~~
longtimegoogler
He also wrote an article called the "Death of the Proof" that was widely
rejected by mathematicians and was also mostly hog wash.

He seems like a guy who likes to make edgy but wrong statements.

[https://blogs.scientificamerican.com/cross-check/the-
horgan-...](https://blogs.scientificamerican.com/cross-check/the-horgan-
surface-and-the-death-of-proof/)

~~~
knzhou
This is far from the first time, so let me state this more explicitly: John
Horgan is a provocateur with no knowledge of any field, whose only claim to
fame is that he is so breathtakingly and publicly wrong that he gets people
with real expertise to engage with him. Then he disingenuously frames the
result as a real intellectual controversy with him at its center.

He is one of the top reasons I don’t take anything from Scientific American
seriously anymore, and a great example of how the incentive structures in
science popularization ruin it. I find that I can tell how savvy an online
community is by how much it likes his work.

~~~
oefrha
> Mathematicians named a mathematical object after me. It’s called the Horgan
> surface, or, alternatively, Horgan non-surface. The term was intended as an
> insult, but I’m honored anyway.

Neatly summarizes this guy’s motivation for writing provocative bullshit. To
him, infamous == famous.

------
inviromentalist
Ive seen medical attempt to sell me extra services within their hospital
network with my kid. 2000$ to fix Tongue Tie with surgery. Laser procedure is
600$ and done at a dentist.

The ($200-300k/yr) physician said there was data surgery is better. So I
looked it up, no data, and surgeons started using laser because it heals
better. Upon confronting she said- if you ask a physician they will recommend
a physician. (So factionalism?)

Why is this nonscience acceptable in medical?

On a different note, hospitals somehow get patients for non hospital
needs.(disclaimer my wife owns her own practice and competes) For instance if
you go to a hospital for physical therapy, you will likely have 1 Dr for at
least 2 patients. You get 37 minutes of treatment because they can legally
bill for 1 hour. At my wife's clinic, she treats 1 on 1, and sometimes
sessions go over 1 hour.

There are no advantages of a hospital for this care.

I'm not sure if overregulation or lack of patient information is to blame. I'm
horrified at the thought of being sick and dealing with our medical cartels.

~~~
SuoDuanDao
This would be in the US I presume? Proponents of single payer focus a lot on
the issues with insurance taking profits, but I think the real problem with
capitalist medicine is that the skills needed for selling medical procedures
and helping patients heal are not really compatible. Doctors being forced to
sell their own services creates a perverse incentive towards the most
expensive procedures, which unfortunately are often also the most risky.

~~~
Hnrobert42
That person is likely not in the US. We put the $ before the digits.

------
stewbrew
Well, this is one side of the discussion. While I agree to some extent, the
author should also answer the question whether he honestly thinks he would
have been better off 90 years ago if some cancer got detected with him in,
say, 2 weeks from now (such things usually happen really fast).

You can of course take the stance that 90 years ago that cancer would have
been misdiagnosed and left untreated and that 90 years ago he would have
probably died of something else before that cancer would have got lethal. I
personally rather prefer having the cancer cut out as soon as possible.

Also some arguments are not honest. It's right that e.g. most dead men have
some form of undiagnosed prostate cancer, which they didn't notice. But
screening programs usually are not designed for e.g. 90 years old people for
who it probably doesn't make that much of a difference whether an early stage
cancer gets diagnosed. Screening programs usually are for younger people who
will most likely get old enough to benefit from an early diagnosis.

~~~
hannob
> Screening programs usually are for younger people who will most likely get
> old enough to benefit from an early diagnosis.

You say "likely". But the problem is you don't have evidence. Noone has shown
that these screening programs do have these benefits [1]. If they have I don't
think anyone would argue with that.

The tricky issue is: Actually showing the benefits of these screening programs
is hard. It requires large-scale studies with longterm followup. It's
expensive. But it nevertheless should be done.

[1]
[https://www.bmj.com/content/352/bmj.h6080](https://www.bmj.com/content/352/bmj.h6080)

~~~
Retric
People have done studies like you propose, but long term studies always lag
improvements in treatment. You can’t see 20 year mortality statistics for
2020’s cancer treatment options until 2040.

 _CDC supports screening for breast, cervical, colorectal (colon), and lung
cancers_

 _Screening for ovarian, pancreatic, prostate, testicular, and thyroid cancers
has not been shown to reduce deaths from those cancers. The USPSTF found
insufficient evidence to assess the balance of benefits and harms of screening
for bladder cancer and oral cancer in adults without symptoms, and of visual
skin examination by a doctor to screen for skin cancerexternal icon in
adults._
[https://www.cdc.gov/cancer/dcpc/prevention/screening.htm](https://www.cdc.gov/cancer/dcpc/prevention/screening.htm)

PS: Showing differences in overall mortality based on differences in treatment
for an uncommon disease requires truly massive study’s. Failing to show a
correlation is expected with noisy data and insufficient sample sizes.

~~~
stewbrew
The problem also is that diagnosis doesn't stop progressing. Today's opponents
to cancer screening often argue with data from the 1990s. On the other hand
proponents often refer to data of underpowered, badly designed trials.

Also, there exists no real guideline as to what would be "sufficient
evidence". How much better would the survival of screening participants would
have to be? In exchange, how much pain may be inflicted on people who get
false-positive results. This discussion is extremely difficult. And once you
are in the situation that you or somebody close to you get's diagnosed with
cancer, it becomes really difficult to deal with arguments like: "On average
the whole population does not benefit from you having diagnosed your cancer
early so that after some small surgery, you'll continue living as if nothing
had happened."

------
mft_
I was really hoping for a strong conclusion to this article - a powerful
answer to the obvious question of 'so what now?'. After all, the author has
just spent a lot of words tearing down the (generally well-meaning) attempts
of scientists (and others) to prolong the lives of people who are diagnosed
with cancer.

But all we get at the end is _" Conservative cancer medicine, as I envision
it, would engage in less testing, treatment, fear-mongering, military-style
rhetoric and hype. It would recognize the limits of medicine, and it would
honor the Hippocratic oath: First, do no harm."_.

Fuckin' really? No details, no data, no actual suggestion (or idea?) of how to
actually implement this? No analysis of how (or even whether) this will help
people?

And of course, let's ignore the fundamental hypocrisy here: having just spent
an article discussing how shit doctors (apparently) are at doing the best
thing for their patients, he apparently wants doctors to be the ones in
control of this new, 'do less' approach? Fucking clueless clickbait blog
nonsense - the Scientific American should be ashamed that this made it through
their editorial process as is.

-

Also, let's examine these two sections:

 _" But one study found that 72 new anticancer drugs approved by the FDA
between 2004 and 2014 prolonged survival for an average of 2.1 months. A 2017
report concluded that “most cancer drug approvals have not been shown to, or
do not, improve clinically relevant end points,” including survival and
quality of life.

Medical conservatives happily adopt new therapies “when the benefit is clear
and the evidence strong and unbiased,” the authors emphasize, but many alleged
advances “offer, at best, marginal benefits.”"_

Who, exactly, is going to serve as the judge and jury for what constitutes a
sufficient improvement in clinically relevant endpoints? Should that role be
given to "medical conservatives" \- i.e. people who the author thinks are more
trustworthy than people who disagree with him?

(PS I fully understand the application of cost:benefit analyses to new drugs -
and maybe this is a direction that the US needs to go. But note that the
author's conclusion section didn't even touch on this as an option.)

~~~
keanzu
_The authors worried that “the FDA may be approving many costly, toxic drugs
that do not improve overall survival.”_

I don't think they purport to serve as or appoint anyone to serve as judge and
jury for "sufficient" improvement. The concern is the approval of drugs which
provide no improvement.

~~~
mft_
That's not how I read it, although to be fair, it's not written clearly. This
is the full quote from the article:

 _But one study found that 72 new anticancer drugs approved by the FDA between
2004 and 2014 prolonged survival for an average of 2.1 months. A 2017 report
concluded that “most cancer drug approvals have not been shown to, or do not,
improve clinically relevant end points,” including survival and quality of
life. The authors worried that “the FDA may be approving many costly, toxic
drugs that do not improve overall survival.”_

Therefore, the implication is that drugs which prolonged survival by an
average of 2.1 months (which was the FDA's track record for approvals between
'04 and '14) are not sufficiently "clinically relevant" to justify approval
(presumably the 2017 report quoted from includes these drugs).

Therefore the question remains: if small but incremental improvements (av
2.1m) aren't sufficient to warrant approval, what level of improvement _would_
be sufficient? And who are the right people to draw this rather important line
in the sand?

~~~
keanzu
Perhaps the difference of our reading can be down to a difference in our
interpretation of "average". It is unhelpful and imprecise allowing a variety
of interpretations. I have interpreted it to be an average with a high
variance - perhaps as much as 3 months. Thus some of the drugs decrease
survival on average.

It seems that maybe you are considering a smaller variance with all the drugs
tightly clustered around the 2.1 month average where the central question
becomes - what's the cutoff and who decides?

As to who decides where the line should be drawn in the US it is the patient
and in the UK it is the government (NHS). Ideally the patient should give
informed consent for a treatment regime, that means realistic assessments of
likely outcomes sans hype.

~~~
DanBC
> As to who decides where the line should be drawn in the US it is the patient
> and in the UK it is the government (NHS).

No, this is wrong. UK patients have the same access to private healthcare as
Americans.

~~~
keanzu
Terminally ill boy denied 'potentially life-saving' treatment by NHS 'would be
given it in any US hospital'

[https://www.telegraph.co.uk/news/2017/04/03/terminally-
boy-d...](https://www.telegraph.co.uk/news/2017/04/03/terminally-boy-denied-
potentially-life-saving-treatment-nhs/)

The NHS decides what's necessary care and what's not, then they're supported
by the courts. The illusion of "same access as the US" was shattered by
Charlie Gard when reality collided with our ideals.

~~~
DanBC
In the UK: The doctors come up with a plan. The parents disagree. The doctors
need to go to court to get a ruling.

In the US: The doctors come up with a plan. The parents disagree. It is the
parents who need to go to the courts to get a ruling.

Charlie Gard's case has absolutely nothing to do with cost. In the UK children
are humans and humans have rights, and those rights are protected by the
courts. Parents do not get to own children as possessions. The courts will
focus on the child's best interests, because of the Paramountcy Principle
which flows from Article 3(3) of the EU Treaty and Article 24 of the Charter
of Fundamental Rights of the European Union, which flows from the UNCRC
article 3(1). Charlie Gard's case is about someone who cannot make a choice
for themself, and the courts focussing on that person's best interests, not on
the interests of that person's relatives.

Charlie Gard had RRM2B MDS. This has fewer than 50 cases worldwide. There is
no cure. There is no treatment. The discussion is whether to allow him to die
with pain relief, or allow medical experimentation that has no hope of success
but which will cause pain. Unsurprisingly the courts decided it was in his
best interests to be allowed to die with pain relief.

[http://blogs.bmj.com/medical-ethics/2017/07/07/never-let-
an-...](http://blogs.bmj.com/medical-ethics/2017/07/07/never-let-an-ill-child-
go-to-waste/)

You may wish to read the judgments, because almost everything written by the
US press was wrong.

[https://www.judiciary.uk/judgments/great-ormond-street-
hospi...](https://www.judiciary.uk/judgments/great-ormond-street-hospital-v-
yates-and-gard/)

[https://www.judiciary.uk/judgments/great-ormond-street-
hospi...](https://www.judiciary.uk/judgments/great-ormond-street-hospital-v-
yates-and-gard-24-july-2017/)

------
jcims
Patient schnoz blasting right on undressed port catheter? Tsk tsk.

~~~
edwhitesell
I'm not in the medical field, but I never wore a mask when my port was
accessed (the nurses did). Sure, less exposure is better, but could you
explain further?

~~~
jcims
I'm not in the medical field either, but based on my experience patients are
either asked to wear a mask or turn their head away while the port is being
accessed until it's removed or there is a dressing in place.

Step 7 : [https://www.specialove.org/wp-
content/uploads/joomla/58f-PRO...](https://www.specialove.org/wp-
content/uploads/joomla/58f-PRO_CVAD_Accessing_and_Deaccessing_Ports.pdf)

------
Hnrobert42
I am disappointed in Scientific American for publishing such shoddy work.
Anyone can cherry-pick one piece of evidence per point to make themselves seem
well supported. That doesn’t mean they are.

------
alexfromapex
It’s the narcissistic executives that lead a decent amount of the cancer
medicine companies focusing on their next round of golf or nice car. I thought
medicine would be different but it’s almost the exact same.

------
jaked89
Cancer is not a disease, but a state of overall body deterioration. You can't
fix it; only the body can fix itself.

Stop attacking it with carbs and plant oils, and give it the fuel it needs:
unprocessed animal protein and fat.

~~~
mamp
It is a disease and survival has dramatically increased because of amazing
progress in treatments. Just look at the recent drop in cancer mortality in
the US.

It is incorrect and irresponsible to blame people who get cancer for eating
badly etc. Sometimes things go wrong at a cellular level and cancer happens.

~~~
jaked89
There's no real drop, but number manipulation. They just label you as "healed"
if the tumor doesn't return after a some short period of time, which gets
shorter by the year.

Actually mortality rates are at all times high, globally.

~~~
jghn
Are you referring to the shift away from using overall survival to progression
free survival? If so I agree that this rubbed me the wrong way as well.

However if one looks there has been tremendous progress in some cancers. As an
example CML went from a swift death sentence to something approaching a
chronic condition.

------
ag56
> if 2,000 women have mammograms over a period of 10 years, one woman’s life
> will be saved by a positive diagnosis. Meanwhile 10 healthy women will be
> treated unnecessarily, and more than 200 “will experience important
> psychological distress ...

I have never understood this argument.

I’d rather be incorrectly told I had terminal cancer 100 times over, than not
be told and... die. You know what’s worse than psychological distress? Dying.
You knowing what’s worse than an unnecessary surgery? Dying.

This is so obvious, I struggle to understand how this “overdiagnosis” argument
even got started.

~~~
zzzcpan
The problem is nobody is telling you the truth or providing a way to make an
informed decision. And not just because they want to take your money, but also
because they themselves simply don't know how to make such decisions. They
pretty much just try various things on real people to see if they work or that
can confirm the hunches they have for further interventions, ignoring
consequences of doing any of it.

Like in your particular example, every unnecessary surgery actually increases
your chances of dying during surgery or sometimes after it, not to mention the
chances of crippling you forever, but you don't know what those chances
exactly are and worse, you are assuming there isn't such risk, while it's
crazy high. So high, that 100 times false positive rate absolutely makes it a
no brainer to never undergo such diagnosis, it pretty much guarantees to make
things worse for or kill a lot of people.

And yet nobody will give you the numbers to make a rational decision.

~~~
nonbel
I met someone who went for a checkup and they convinced him to get a screening
colonoscopy. It was clear but a few months later he started having problems
and went back. Then they told him he had colon cancer caused by damage to the
tissue during the colonoscopy.

------
loceng
Watching Eric Weinstein's The Portal episode #18 yesterday -
[https://www.youtube.com/watch?v=QxnkGymKuuI](https://www.youtube.com/watch?v=QxnkGymKuuI)
\- where he presents the DISC (Distributed Idea Suppression Complex), made me
frame this in a different way: what questions does the cancer treatment
industry avoid? Why aren't all cancer companies, organizations, also
researching or putting funding towards prevention? The answer is obvious to
me, however why as society don't we require a sort of tax to counter (and
fund) what the industry isn't aligned to do profits wise?

