This recent piece in Scientific American, adapted from John Horgan’s talk at Stevens Institute of Technology, reviews the vast scope and questionable effectiveness of the cancer research and treatment industries.
Each year, 1.7 million Americans are diagnosed with cancer, while 600,000 Americans die from the disease annually. The annual cost of cancer treatment is estimated to reach $175 billion this year. The total amount spent on cancer research since Richard Nixon declared a “war on cancer” in 1971 has surpassed at least $250 billion.
Despite these investments, there has been little progress in reducing the mortality associated with most cancers. The age-adjusted mortality rate from cancer — that is, the rate of cancer deaths in the population adjusted for the fact that older people are more likely to develop the disease — is the same that it was in 1930. While cancer mortality has decreased 30% from the early ’90s, this only occurred after decades of increasing cancer mortality; more importantly, analyses have suggested both this decrease and the prior increase can be almost entirely attributed to changes in smoking rates over time.
Cancer-related clinical trials have the highest failure rate of any therapeutic area, and various hypotheses to explain the causes of cancer — hormones, viruses, genetics, carcinogens, etc. — have generally failed to yield effective treatments. Drugs approved by the FDA between 2004 and 2014 extended survival by an average of only 2.1 months, and patients’ annual treatment costs exceed $100,000. Immunotherapy, despite substantial press coverage and patient interest, can benefit fewer than 10% of patients and costs more than $1,000,000. More than 40% of those receiving a cancer diagnosis in the United States will lose their life savings within two years.
The benefits of cancer screening are similarly questionable. Research over the past decade has shown our bodies regularly develop and treat cancers without any clinical intervention. Repeated analyses of mammography, prostate-specific antigen (PSA) screening, and other forms of early cancer detection have clearly shown they do little to reduce cancer mortality. More importantly, many cancer screening procedures have a high rate of false positives and subject healthy patients to potentially harmful treatments, including surgery, chemotherapy, and radiotherapy. This has led to widespread calls to discontinue screening programs, as some claim the programs’ high costs, harmful effects, and tendency to lead to overtreatment outweigh any benefits of early detection.
The size of the cancer industry has also fostered corruption and conflicts of interest. The 1,200 cancer centers in the United States spend $173 million annually on advertising, often leveraging emotional appeals that provide patients with unrealistic expectations about the effectiveness of treatment while entirely suppressing the associated costs. Cancer specialists can be paid by drug companies to prescribe certain drugs, which incentivizes them to describe these drugs in the terminology we often see in cancer therapy: “breakthrough,” “miracle,” “game-changer,” etc. The massive commercial incentives have led to cancer research’s own reproducibility crisis, with multiple analyses finding the majority of highly cited cancer trials fail to replicate when independently tested.
In sum, the article describes a massive treatment and research infrastructure that, despite its size, public prominence, and supposed importance, has demonstrably failed to deliver meaningful benefits to patients. The author notes this has led some doctors to begin practicing “conservative medicine,” acknowledging the limited impact novel pharmacology has had on the course of disease and instead relying on fewer, simpler treatment methodologies.
Additional Reading
The Cost of Cancer: Systemic Issues
This 2016 analysis charts the rapid growth of spending on cancer treatment alongside a shift to more personalized and complex therapeutics.
This 2019 analysis estimates significant federal cancer research funding is supplemented by $6 billion per year in additional funding from nonprofits. Cancer research funding does not track disease burden well, with some of the deadliest cancers receiving relatively little funding and vice versa.
This 2016 blog post estimates the total funding since Nixon’s “war on cancer” declaration exceeds $250 billion.
The Cost of Cancer Care: Individual Issues
This 2017 analysis finds “the average price of a novel anticancer drug routinely exceeds US$100,000 per year or course of treatment” and estimates the worldwide financial burden of cancer treatment will exceed $150 billion by 2020.
This 2018 analysis found 42.4% of those 50 years or older diagnosed with cancer had depleted their entire life’s assets within two years of treatment.
This 2018 article argues the heavy marketing of cancer immunotherapy distorts the fact that very few patients can benefit from it and ignores the incredibly high costs (both financial and health-related) associated with the treatment.
This 2016 analysis reviews the dangers associated with cancer immunotherapy, which often must nearly kill the patient to kill the cancer.
This 2017 analysis found only 8% of patients can be expected to benefit from immunotherapy.
Siddhartha Mukherjee, author of The Emperor of All Maladies, writes in The New Yorker that the cost of a course of cancer immunotherapy often exceeds $1,000,000. He argues it would bankrupt the health-care system if used broadly.
Cancer Advertising and Promotion
This 2017 story by Kaiser Health News finds patients and caregivers are regularly misled by doctors and treatment facilities, which frame new therapies using terms such as “breakthrough,” “game-changer,” “miracle,” etc. These terms obscure the low probability of effectiveness for new therapies.
This 2018 analysis by TruthInAdvertising found cancer centers spent $173 million on advertising in 2014, often leveraging patient testimonials to promote a sense of hope and suppress consideration of costs, even when the probability of successfully treating a given cancer was relatively low.
This 2014 analysis similarly found most cancer center advertisements leverage emotional appeals and rarely provide realistic presentations of expected treatment effectiveness or costs.
Vinay Prasad argues financial incentives push doctors to exaggerate the likely benefits and downplay the harms and costs of the cancer treatments they recommend to patients.
Cancer Treatment Failures
This 2006 analysis finds the majority of the decrease in cancer mortality observed since the early 1990s can be attributed to decreased smoking rates.
C. Glenn Begley and Lee Ellis argue the failure rate in clinical oncology research is sufficiently high to require dramatic change in the field. They found 47 of 53 “landmark” cancer studies could not be successfully replicated.
The Reproducibility Project found only five of 14 highly cited cancer studies could be replicated.
John Horgan reviews Azra Raza’s 2019 book, The First Cell: And the Human Costs of Pursuing Cancer to the Last. Raza argues little progress has been made in the “war on cancer,” with the exception of a few, specific diagnoses (e.g., blood, bone marrow, and lymph cancers).
Issues With Cancer Screening
This 2015 article argues a focus on survival rate has inflated the clinical benefit of cancer screening. Cancer screening has merely allowed patients to live longer with a diagnosis of cancer by catching the disease earlier; mortality data indicates patients’ overall lifespans have not been extended by early detection.
This 2010 analysis found 25% breast cancers detected by mammography and 60% of prostate cancers detected via PSA are “overdiagnoses” and the conditions either were not present or would have resolved themselves without clinical intervention. This suggests any treatment of these overdiagnoses had no clinical benefit.
This 2019 article summarizes the misplaced enthusiasm for screening, arguing the past belief that widespread cancer screening will reduce mortality is not supported by the data.
This 2013 Cochrane analysis finds that for every 2,000 women screened for breast cancer using mammography, one death will be averted, 10 women will be unnecessarily treated, and another 200 women will receive false positives that are caught before treatment begins.
An additional 2013 Cochrane analysis finds prostate cancer screening has not led to a decrease in prostate cancer mortality and likely has led to significant harm due to the treatment of false positives.
The NNT finds there is no net benefit to breast cancer mammography, with the harms of overdiagnosis and overtreatment exceeding any benefits of early detection.
The NNT similarly finds the benefits of early detection of prostate cancer are negligible and do not offset the harm associated with the treatment of false-positive diagnoses.
This 2017 article notes estimates that each prostate cancer diagnosis successfully caught early by PSA screening is offset by 240 false positives.
In this 2015 analysis, John Ioannidis argues cancer screening has negligible or nonexistent benefits for all-cause mortality.
John Ioannidis goes further in this 2018 editorial, arguing evidence of the ineffectiveness of screening programs is sufficiently strong to encourage the abandonment of these programs.
Michael Baum, who helped found the U.K.’s breast cancer screening program, argues the overall harm associated with overtreatment of breast cancer outweighs any benefits that may be associated with early detection, and as such, screening programs should be abandoned.
Richard Ablin, who discovered the prostate-specific antigen (PSA), describes the test as a “profit-driven public health disaster” with substantial clinical and financial costs and limited evidence of benefit.
Comments on The Cancer Industry: Hype vs. Reality
I am not sure what this article is about. All of current medicine runs on hype, or more precisely, acceptance of poor standards, and the industry includes academic and medical researcher. The ability to generate on line publications has caused proliferation of highly profitable publishing operations which could not keep going without significant lowering of standards. And it is not just the recent open access journals who are essentially what used to be called vanity press by charging authors high fees. The most prestigious journals publish highly questionable papers and many secondary sources included one published by science broadcast the results uncritically. The absence of universally accepted neutral authority— American Heart, American Diabetes and even the NIH have strong bias — means that everything must be read with suspicion..
Cancer probably generates the least hype, at least in the sense, that most of us — professionals and patients alike — are not optimistic about the state of of cancer treatment. For uncertainty, medical nutrition is the worst — Harvard School of Public Health told us that red meat causes diabetes and BMJ called for physicians to undertake vigilante activity against red meat. That red meat consumption went down substantially during the diabetes epidemic does not seem to change anything.
Along with the expanding number of journals and flood of publications, we have proliferation of critiques of those publications but these have little effect. There is a whole industry of exposés of the literature — like the current article — some of which are on target but all of which can be ignored. The problem is a breakdown in standards and a peer-review system that is outmoded in a field where there is controversy and poor agreement of what constitutes acceptable practice.
The question of inadequate diagnostic tests is a somewhat separate issue but here, too, criticism is widespread but may have limited effect. Explaining the astounding statistical errors in mammograms is standard in teaching statistics (e.g. Gigerenzer’s Calculated Risks…) and has become a internet parlor game — Google “YouTube mammogram statistical error” and you will find dozens of examples. I have used the example in lectures myself. I usually add “no oncologist would take action based on a mammogram alone” but I am not so sure. Certainly the Susan Komen website underestimates the potential error “(https://ww5.komen.org/BreastCancer/AccuracyofMammograms.html).
One of the features of the hype and corruption is the acceptance of terms that are value judgements as if they were statements of facts. “Evidence Based Medicine” never explains, by analogy with a court of law, who decided on the admissibility of the evidence. And if we knew which diets were “healthy” we wouldn’t have the current confusion. Along these lines, I am not sure that the “conservative” approach offered as a solution in this piece holds much promise. Medicine tends to consider a conservative approach the use of established practice, whether or not it has the desired outcome, the main point of the article. A conservative approach may entail reluctance to examine new ideas. My own field, application of ketogenic diets shows great promise, notwithstanding that most researchers in the field are explicit about about how little data we really have. There is hype in support and also in opposition but the latter seems like more of a threat: one of the reasons we think ketogenic diets may be helpful for cancer is the relation of cancer to diabetes and the role of insulin and energy metabolism. The data establish ketogenic diets as the first approach in diabetes. The resistance of the medical community to the idea suggests the limits of a conservative approach.
John Horgan does an excellent good job in highlighting how the pharmaceutical industry has corrupted cancer diagnosis and treatment. It is important to recognize that over 1,600 people die each day from cancer in the US according to the recent article from the American Cancer Society (https://doi.org/10.3322/caac.21590). In China, over 8,000 people die each day from cancer. There is no way that these numbers can be sugar coated. These daily cancer death rates exceed that expected for a worst-case scenario with the current coronavirus pandemic.
I have first-hand knowledge of a pharmaceutical company (KAZIA) that continues to treat glioblastoma patients with a drug (CDC-0084) that was shown to have “Zero Response Rate” in reducing glioblastoma in preclinical studies and in a phase 1 clinical trial. This information was presented at the Boston Glioblastoma Drug Development Summit (Dec. 10-11, https://glioblastoma-drugdevelopment.com). Many other presentations at this meeting involved drugs that produce significant patient harm with little if any therapeutic benefit. Is it moral to treat cancer patients with drugs that have no therapeutic benefit and are disconnected to the known biology of the disease? Have some oncologist forgotten the passage from their PRAYER OF MAIMONIDES? “Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures.”
We recently published a paper describing in detail how the current standard of care for glioblastoma contributes to the rapid recurrence and demise of most patients (https://doi.org/10.1007/s11064-019-02795-4). All people should know this information, as the take-home message would also apply to the treatment of most metastatic cancers. Indeed, a recent study showed hyperprogressive disease in lung cancer patients treated with the PD-1/PD-L1 immunotherapy drugs that are regularly hyped in the media as successful treatments for a broad range of cancers (JAMA Oncol. doi:10.1001/jamaoncol.2018.3676). In other words, the immunotherapy killed some of the patients faster than did the standard of care or even the disease itself. Paul Alan (Microsoft c-founder) and Blake Nordstrom (Nordstrom’s department stores) both died within weeks of receiving their treatment for lymphoma (WSJ, October 16, 2018, page A2; and January 3, 2019, page B3, respectively). As immunotherapy drugs are highly expensive, I predict that treatment-associated death from these drugs will be greater for wealthy people than for poor people. On the other hand, more poor people than wealthy people will suffer the consequences of financial toxicity, a new form of cancer-associated toxicity arising from drug price gouging (McGiniss, A., eScholarship@BC). Has the new morality become drug profit over patient outcome?
It is my opinion that many of the NCCN guidelines contribute to the current cancer crisis in not recognizing that cancer is primarily a metabolic disease and not a genetic disease. The recommended NCCN guidelines put cancer patients at risk for spreading tumor cells or for causing significant harm to normal body physiology. Our recently accepted paper in the journal Frontiers in Nutrition (doi:10.3389/fnut.2020.00021) describes how breast tissue biopsies create inflammatory oncotaxis that can facilitate the spread of breast tumor cells. Biopsies are also known to spread other cancers as well (PMID:8751221; DOI: https://doi.org/10.1378/chest.118.4.936). Cancer spread through tissue biopsy is an unintended consequence of guidelines that are disconnected from the known biology of tumors. Travis Christofferson reviews evidence in his new book, Curable, showing that breast tumor recurrence is similar in patients receiving radical mastectomy vs simple mastectomy, yet many breast cancer patients continue to receive disfiguring radical mastectomies (pages 59-69). Is it possible that some oncologists do not read or possibly ignore information in peer-reviewed medical journals?
Although most oncologists practice their craft with well-meaning intentions, most are unfamiliar with the emerging evidence that cancer is primarily a metabolic disease driven by the fermentation of glucose and glutamine. Non-toxic, cost-effective therapies can be developed rapidly based on this new knowledge of cancer biology. It is my view that cancer deaths can be reduced by 50% in about 10 years once this knowledge becomes more widely recognized and acted upon.
I can therefore endorse the opinion of John Horgan and applaud CrossFit for initiating the discussion on this important topic.
Thomas N. Seyfried,
Professor.
To address the comments above, the truth is that in a lot of cases, survival rates with current standard of care therapies are not impressing anyone, despite the money and efforts that go into research. In order for medicine to move forward, there has to be a little bit of devil’s advocate play, and cancer is no exception. In regard to the comments on alternative therapies, I don’t think CF has ever once discussed anything that hasn’t been backed by research. It is true that the majority of cancers have abnormal mitochondrial structure and function, which means potential exploitation with metabolic therapies, ketosis being one of them. With that said, it has to be recognized where ketogenic therapies are appropriate and where maybe they aren’t but there has to be room for discussions like these to promote exploration for new and novel therapies, otherwise we won’t get the answers to these questions. This probably applies to screening programs and diagnoses, too.
It’s also worth mentioning that alternative medicine is different than complementary - this is pulled directly from the paper that Craig linked to:
“It is important to note that complementary and integrative medicine are not the same as AM as defined in our study (13). Whereas complementary and integrative medicine incorporate a wide range of therapies that complement conventional medicine, AM is an unproven therapy that was given in place of conventional treatment.”
It’s not fair to put metabolic therapies in the same boat as alternative therapies like those listed above (“alkaline diets, homeopathy, etc.”)
So, I would disagree that these articles are misleading. They are opening up room for discussion around metabolic-based non-toxic therapies. And this isn’t to discredit standard of care cancer therapies, but rather improve on them, and possibly use strategies that enhance their efficacy and mitigate side effects.
For example:
⁃PI3K inhibitors are shown to be more effective when you lower insulin with a ketogenic diet (https://www.cancer.gov/news-events/cancer-currents-blog/2018/pi3k-resistance-ketogenic-diet-diabetes-drug)
⁃The anti-tumour effects of radiation have been shown to improve when paired with a ketogenic diet (https://www.sciencedaily.com/releases/2012/12/121204112610.htm)
⁃Most cancer types do respond to ketogenic therapies as you can see in figure 1 of this paper (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842847/)
⁃There is a clinical trial currently looking at the combination of a ketogenic and chemo in breast cancer (https://clinicaltrials.gov/ct2/show/NCT03535701)
⁃“Increased metabolic oxidative stress in cancer cells would in turn be predicted to selectively sensitize cancer cells to conventional radiation and chemotherapies.” (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4215472/)
So, at the end of the day, it’s important to talk about these nuances and keep in mind the cancer type when considering treatment and screening, as it appears here that breast cancer and prostate cancer need improved screening procedures as this article highlights.
Another fun cancer article to discuss. Does CrossFit.com speak with any Oncologists before writing cancer-specific articles to maybe get educated opinions or information? These are articles are very misleading as Stephen P. pointed out in his comment.
All of the cancer articles posted on CF.com talk about metabolic processes, discrediting accepted science, using ketosis as a cure-all to cancer (most studies quoted on-site have applied to glioblastomas only), and also going against NCCN Guidelines for cancer therapy. Information about NCCN Guidelines can be found here if you do not know about them - https://www.nccn.org/patients/clinical/default.aspx. Please go and try to discredit NCCN Guidelines. I'll wait...
Cancer cells can be normal looking in appearance to the body (I'm over-simplifying this) and sometimes the only difference that makes them cancerous is becoming immortal. Overpopulation of a growth becomes a tumor and that can compromise someone. Targeted therapy is difficult to differentiate normal cells versus cancerous cells when they both have so many of the same features. Failure of therapy is high in late-stage, aggressive cancers. This may be one of the reasons. See further down for another reason.
Alternative therapies do not work. The article, "Use of Alternative Medicine for Cancer and Its Impact on Survival" by S Johnson et al (https://doi.org/10.1093/jnci/djx145) shows using alternative medicine as a poor choice for cancer patients in terms of survival. I have seen so many patients decline accepted treatment at Stage I to come back to see me when they have a fungating breast mass erupting out of their chest wall, lymphadenopathy in the pelvis that is so large it is causing edema in the leg(s) making it difficult to walk, or innumerable bony metastases with excruciating bone pain and pathologic fractures.
Proper screening tools and tests that are interpreted correctly and in the context of a specific patient are extremely helpful in stopping cancer early in the disease process. Most cancers do not just disappear. Late-stage cancers in the chest, abdomen, and pelvis are extremely hard to treat and cure because symptoms do not show until you have a mass the size of a softball or bigger (for example). A patient cannot see this mass sticking out of the body. It does not lead them to see a doctor until way too late. By this point, the tumor burden is extremely large and the chances of local invasion, lymphatic spread, and metastases are very high.
CrossFit.com is a treasure trove of helpful, useful, and life-changing information. But you need to temper what is published sometimes so that people are not misled.
This article may give some people the impression that early diagnosis and treatments don't work and that they should seek alternative treatments.
However, peer-reviewed research consistently supports the effectiveness of early diagnosis and treatment.
It's not fair to correlate the issues endemic of a profit-based healthcare system with the effectiveness of proper detection and treatment.
Alternative treatments, in the vast majority of cases is ineffective and don't pass muster under review, and take in significant profits on the sale of false hope (alkaline diets, homeopathy, etc). These pseudo Sciences would be a better focus of scrutiny than giving false impressions of effective scientific research.
The Cancer Industry: Hype vs. Reality
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