A bittersweet pill to swallow

Clifton Leaf goes a long way in explaining why cancer is still prevalent despite the hundreds of billions of dollars spent to eradicate it.

Breast cancer survivors 521 (photo credit: REUTERS)
Breast cancer survivors 521
(photo credit: REUTERS)
A Gallup poll taken in December 1949, Clifton Leaf tells us, revealed that 77 percent of Americans did not believe that a human being would land on the moon by the end of the 20th century. At the same time, 88% of respondents did think that a cure for cancer would be discovered by the year 2000. They were wrong, of course, on both counts.
In The Truth in Small Doses, Leaf, a former executive editor at Fortune and The Wall Street Journal’s SmartMoney magazine, points out that although the United States has spent hundreds of billions of dollars to eradicate cancer, 1.6 million Americans will be diagnosed with the disease and 600,000 individuals will die from it in 2013. Leaf claims that there is a “profound disconnect” between the rhetoric of “progress” and “breakthroughs,” in evidence almost every night on television news programs, and the depressing reality.
He tries to provide readers with “a clear perspective on where we are and where we need to go” through assessments of mortality statistics, treatment and prevention, public funding for research, pharmaceutical companies, and drug trials.
The Truth in Small Doses is informative, engaging and passionate; it is provocative, if not always persuasive.
Leaf makes a compelling case that more time and resources should be devoted to preventing cancer and to detecting, stopping, slowing or reversing it in its early pre-invasive stages.
Colonoscopies, he notes, have done more to reduce mortality from cancers of the colon and rectum than “any drugs or other therapy ever devised.” And early detection of breast cancer, through mammography, ultrasound imaging and other techniques, accounts for half of the decline in the age-adjusted death rate for breast cancer.
Nonetheless, Leaf reveals, according to the National Cancer Institute’s own 2010 assessment, only 7% of its budget was devoted to “prevention and control.”
Leaf blasts the National Cancer Institute, research universities and government-mandated drug trial protocols for a bureaucratic arteriosclerosis that makes “doing science” far more difficult than it was a generation ago. Researchers, he indicates, must spend greater and greater amounts of time on the grant application process, even though a smaller percentage of proposals are funded. The same people, from the same institutions, pursuing the same narrow topics, get resources – while younger, “outside the box” scientists do not. A significant proportion of grant money goes to administrative and overhead costs of the host university.
Drug trials at every stage, Leaf writes, face delays “born of a rational caution,” which extend into inertia and indecision, “often bringing the entire process to a standstill.” According to one study, 79% of cancer drugs entering Phase II of the trials do not succeed; of those that make it, 65% do not get through Phase III. Twenty-first century regulatory standards, according to Leaf, make it virtually impossible to test chemo-preventive drugs. We should not be surprised, then, that “big pharma’ now stays out of “the discovery business,” preferring instead to increase the number of diseases for which an already approved drug can be used and to “in-license” compounds after another company has brought them through several phases of drug testing.
Although it has much to recommend it, Leaf’s analysis leaves questions unanswered. The sclerotic drug-testing and research regime he describes, for example, does not appear to have retarded progress in the fight against heart disease. The decline in the percentage of scientists who get awards from federal agencies is the result of an increase in applications and flat budgets.
The “low” success rate of drug trials may not be a problem. And the rate at which research universities recover indirect costs from government agencies has gone down in the last few decades and may not cover all expenses.
Some of Leaf’s suggestions for liberating scientists seeking to eradicate cancer are intriguing. The critical shortage of tissue specimens in the US, he points out, could be addressed by adopting the bio-banking networks now in place in Iceland, Finland, the UK, Estonia and Japan.
Other suggestions, however, seem impractical or mutually contradictory.
Bypassing the current grant system by giving money directly to universities, who could then distribute the money, begs the question of which institutions to support (and with how much money) – and does not address Leaf’s objection that the same universities get funded year after year. His recommendation that government agencies “fund people, not projects” instead of demanding that investigators formulate discrete hypotheses and propose experiments to test them, probably conflicts with his hope for more grants for young scientists. And his plea that we “let scientists follow questions wherever they might lead, to let them learn as they go,” is, at once, obvious, resistant to implementation, and at odds with his support for a “systems engineering” approach that coordinates tasks “into a single complex effort.”
In the end, though, Leaf’s book does what a fine book should do. It delivers truths, in doses large and small. And it proposes big ideas about big subjects.
The writer is the Thomas and Dorothy Litwin Professor of American Studies at Cornell University.