Hippocrates and the multi-locked door. Or: ‘I offered it up to the Stars and The Night Sky’.

In 1971 Richard Nixon declared “War on Cancer” with the signing of the National Cancer Act. Now significant progress has been made in the following 46 years but today, as you read this, more  and more people seem to be being diagnosed with cancer. The Independent cited a 75 per cent estimated increase in cancer cases between 2008 and 2030.

Umm….That’s big. Are we winning the war? Many think not.

Therapies so far have involved a mainly singular approach to treatment. Surgery, chemotherapy, radiotherapy. Or maybe, chemotherapy, surgery, chemotherapy, radiotherapy etc. The line up may change, but the actors are the same and in the majority of cases they come on once the last has left the stage, in singular procession. An oncologist in this documentary https://www.survivingterminalcancer.com (long but worth the watch) suggests that our failure in winning this “War” is two-pronged. 1; this singular approach is failing us, and 2; the balance of power (or progress) is weighed-down with money. Simply put, big-pharma isn’t so interested in supporting research into already present medicines trialled in new adjuvant combinations, or even natural components. You can’t patent them, and you can’t make money off of them. The business approach wins out, which most would expect….but balance that against the fact that you’re dealing in people’s ‘live or die’ scenario, not just margin. Ethically, morally, is this the correct balance? It seems the capitalist model here has outmoded any humanist model.

One humanist voice of medicine is surely the Hippocratic oath. It is also a founding principle of medicine and a cornerstone of medical practice. Despite what many think, it’s not something doctors are still bound to swear to – though some medical schools maintain a ceremony where graduating doctors swear an updated version in recognition of its guiding importance. The updated version runs as follows:

I swear to fulfil, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of over-treatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.

I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

The modern version, which puts the patient in primary focus (as does the original version), allows that for the benefit of the sick, all measures required should be applied in patient treatment (avoiding over treatment etc). However oncologists today aren’t given the means to enact this aspect of their code when our economic system aims for profit over patient-benefit. Our oncologists enter medicine, an incredibly tricky coal-face medicine, in order to help patients. What they are given to work with is a system based on economic competition and cost vs revenue. A system that is financially more interested in looking to the cures of tomorrow rather than finding new ways of approaching what we already have in the chemist department. The balance is swayed overwhelmingly towards the pound/dollar and while we’re all being led my margin, profit and loss (let’s face it, pharma have the keys to the drugs cupboard) I wonder if we’re somehow missing the wood for the trees and overlooking new combinations. Regulations  also bar the oncologist from trying anything too jazzy with combination treatments… so what we have now, is some patients experimenting on themselves. Hardly ideal.  [Seriously – that video I signposted above.. I know it’s a long watch. I mean, it’s a 1.5 hr documentary but it’s seriously engaging and thought-provoking. It’s like any good Attenborough (but more about drugs/regulation/pharma and less about animal copulation)].

In these 46 years since Nixon’s declaration, an incredible amount of drugs have been developed in the “war” (incidentally this phrasing (“war”) is where I think a lot of the problematic cancer ‘battle’ language comes from). Some drugs have seen success, others not, but like a Dr in the above video suggests… what if the so-far locked door of a cancer cure isn’t just a one lock, one key scenario. What if it is this multi-lock mechanism with lots of keys that need turning? What if we need to carpet-bomb the door with a whole host of things and blow it up like Arnie? Are we truly exploring that possibility with trials, or focusing instead on the new singular ‘wonder-drug’? An approach that perhaps denies speed of progress. Yes, it’s scientifically rigid, but yes, phase 3 trialling is slow.

Trials certainly are expensive and if companies would only stand to make small margin (if any) after costs associated with an adjuvant ‘throw the kitchen sink at it’ approach, there’s no incentive to switch-up the programme. There’s no incentive to try a new or varied collection of drugs in tandem with radiotherapy and surgical technique in a myriad of ways. Yes, this is basically throwing everything at the wall… but when so many are dying – I wonder if there’s much more to lose. This approach is not a risk worth taking monetarily for big-pharma, where scientifically a trial of X in combo with Y in combo with Z in combo with Xsquared etc would provide a multitude of outcomes for all the different combinations. Outcomes are expensive, and for this type of trialling, the costs would be astronomical. Pharma won’t touch it with a barge-pole.

A silly comparison, but what made me start to think about this was a piece of music by a band called The Dirty Three, called ‘I offered it up to the stars and the night sky”. https://youtu.be/5zC2JdhomPI. It’s beautiful. It starts with a single violin and from there on builds and builds with other layers added until there’s this fully whole track, born out of (I think) improvisation. Listening to this on a train ride back to the sticks, I thought of how few things are done in the singular. We don’t have one singular emotion to express, we don’t listen to music generally that’s one-track in solo. We don’t just have one type of cell and we don’t have one track minds (unless you’re Trump and right now he’s firmly stuck on a misogyny loop). We live in the space of the multiple. I wonder if a systematic singular line by line approach to trailing medicines is hampering us, because it just can’t keep up. Our bodies as very individual expressions of genes might exist behind a multi-locked door.

So I suppose drug companies will continue to build and trial expensive treatments line by line (which is still a large cost as a process) in the name of hitting pay-day if the drugs attain a certain level of success. At the same time perhaps big pharma will continue to blind-side the myriad of ways that already present medicines, therapies, and perhaps natural components could work together.

I wonder if we’re chucking away 46 years of drug development and knowledge in the rush for a future payday that might never come.

Notes for the reader:
1) I am an arts student. I know sweet FA about medical science so if I’ve got something wrong here, tell me. I’d love to know that things aren’t as bad as I think they are. Educate moi!
2) I hope I’ve got you into The Dirty Three. 
3) I am eating a carrot cake and while I could apologise for the overuse of the comma or bad grammar, currently my concentration is set on the cake. I’ll do it later. 

2 Comments

  1. My cancer surgeon told me that one of the reasons that more people are being diagnosed with cancer is because of better testing. For example, more and more people are getting diagnosed with colon cancer because many, many more people are getting colonoscopies. It’s not the total picture, but it is a part of it. Diagnostic tools have come a long way in four decades.

    Like

    1. A very sage point….one also that I hadn’t considered. Would that mean that perhaps premature deaths with unknown cause rates go down as a statistic? Good food for thought thee, thank you.

      Liked by 1 person

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