The Problem with “How Tos”

While scrolling through MSN’s online page, I stumbled on the catchy headline: “7 Tips to Decrease Cancer Risk and Prevent Recurrence.”  The article says “cancer survivors can help cancer-proof their bodies by managing their weight in the healthiest way possible. The same way of eating that will help you lose weight in a healthy manner is the same way of eating that will help you improve your immune function and promote anti-cancer activity in your body.”  Sounds simple.  

Of the seven useful tips, my favorites include eating a plant-based diet; exercising (i.e. parking away from a store, walking down longer store aisles, etc.); sleeping better (but only when it's dark and not before feeling tired???); and integrating mindfulness (e.g. less stress).  So, if I’m reading correctly, all the lazy, close-parking, short-aisle walking, daytime napping, ADHD types have a higher risk of cancer. 

Before I dive into what may come off as a snarky commentary on what is ultimately, helpful advice, let me say that the correlations between obesity and cancer are convincing, as are the studies promoting anti-oxidants and leafy greens as strong cancer fighting agents.  By eating a balanced diet and exercising, one can improve immune function which can help stave off cancer.  Mom and Craig were strong advocates of eating well, and following nutritional guidelines to maximize their chances for overcoming cancer.  That being said, following simple tips is easier said than done, and in the end, may not change the outcome. 

The problem with “How Tos” is that they imply that if people would simply eat more blueberries, park farther away from the grocery store, avoid alcohol, or be more patient, they too could avoid cancer.  But what happens when a healthy diet isn’t enough?  What after ingesting anti-oxidants and flax seed oil, walking ten flights of stairs, and slowing life down, we still “catch” cancer?  After all, Craig was extremely healthy.  He worked out religiously, avoided butter and trans-fats, ate veggies and whole proteins, and he still “caught” cancer.  For Mom, no amount of blueberry shakes and long walks down Skyline prevented her tumor from recurring.  And if the "Seven Tips" were true and healthy living was the golden cup, how do we explain Keith Richards, Nick Nolte, and the other seven-tip rebels?  What gives? 

The challenge with “How Tos” is not that they are misleading in their advice; it’s simply that cancer is far more complicated than what seven tips can adequately capture.  For decades, cancer has stumped some of the best scientists across the globe.  The first chemo agent was developed in the 1940s.  In 1971, Richard Nixon declared a war on cancer with the National Cancer Act.  Since then, countless federal task forces, foundations, non-governmental organizations, private businesses and academia have teamed to find a cure.  Billions of dollars later, the war against cancer continues, with “Stand Up To Cancer” being the latest initiative to join the cause.  To be sure, we’ve made great strides in cancer treatment and research.  From 1975 to 2005, death rates from breast cancer and colorectal cancer fell from 31 to 24 and 28 to 17 per 100,000 people, respectively.   This is largely due to better screening and advancements in chemotherapy treatments.  Exciting new treatments like angiogenesis inhibitors (e.g. Avastin), epidermal growth factor receptor (EGFR) inhibitors (e.g. Tarceva) and others have also emerged on the market, making some cancers easier to treat.    

Yet, despite advances in cancer treatment, progress has been wildly uneven. According to Newsweek’s “We Fought Cancer…And Cancer Won,” the death rates for other cancers, including lung, pancreatic, liver, and melanoma, have increased.  Cancer is on track to kill over 500,000 people this year.  The difficulty in finding a cure has not been from a lack of trying.  Cancer cells create multiple pathways for growth.  While innovations targeting one pathway may help slow cancer, it’s typically only a matter of time until cancer cells discover alternative pathways to proliferation.  As the article explains:

"Most cells use the VEGF pathway [that Avastin blocks], but there are at least 12 other pathways, and Avastin doesn't block any of them. With VEGF out of commission, malignant cells turn to these alternatives...[With] Tarceva, given to lung-cancer patients, which turns off a molecule called EGFR that fuels the proliferation of some lung and other cancer cells...Even if a tiny fraction of malignant cells in the tumor or at metastatic sites use a proliferation pathway other than EGFR, they proliferate unchecked; most patients are dead within three years." 

Though we have made great strides in understanding and treating some cancers, and improving the quality of life for cancer patients, other cancer remain stuck.  We’ve only begun to scratch the surface of the biological and molecular complexity of the 100 types of cancers identified so far.  Where science remains stuck, patients have few options and death is almost a certainty.  The article suggests that to overcome cancer, oncologists must target all the various cancers that comprise cancer, or the dozens of different pathways that cells use to proliferate and spread.  Determining how a particular patient's tumor works and treating the growth, replication, and angiogenesis pathways with multiple drugs may lead to better outcomes.

But transferring breakthroughs in scientific research into breakthroughs in therapies is another step altogether.  In the cross-sections of funding, interest, and risk are cancer studies – some are provocative and may lead to major breakthroughs, others are slogging away at tricky problems, building on past research to improve current treatments and standards of care.  All have the possibility of making a difference and advancing what we know about cancer(s).  The problem is the time it takes transferring scientific studies from the thought to the laboratory to the pharmacy.  FDA approval is long and costly.  The article states that whereas 20 percent of compounds for other diseases acquire FDA approval, for cancer, only 8 percent are of compounds are approved.  The possibility of wealth generated from patent rights provides disincentives for market competition.  There is less incentive to invest research time and money in largely unprofitable areas or in obscure cancers with little chance for fame and glory.  Insurance companies generally accept only approved treatments, so if science lags behind, so too does the health coverage. 

With that said, breakthroughs in one area tend to affect cancer treatments as a whole.  And with every study, we move closer to understanding cancer’s complexity and how to better treat the varieties of mutations.  The last thirty five years fighting cancer has proven that more research is needed to not only develop cures, but to discover preventative techniques that ultimately decrease the likelihood of cancer.  To the extent that an anti-oxidant rich diet, daily exercise, and a stress-free life help stave off inflammatory or other processes that may contribute to cell mutations, tips such as MSN’s Seven How Tos are useful. 

But what Newsweek’s piece “We Fought Cancer…And Cancer Won” reminds us is that, for some, cancer is a crapshoot.  Our culture likes to emphasize the success stories, the Lance Armstrong’s of the world who battle back testicular cancer only to win seven Tour de Frances, and the advances in technology that may someday lead to a cure.  These stories must be told.  But equally as important are the thousands of stories where there are no cures, where technology lags behind, and where despite everything, cancer wins.  Craig’s kidney cancer emerged from the depths of nowhere.  While in hindsight, he could have had more blueberries while growing up, my gut tells me that he probably would have developed cancer anyway.  As for Mom, scientists have only now discovered cell mutations and pathways that may contribute to the cancer's growth.  Something tells me, her diet was only a part of the puzzle.  We’re just beginning to understand why cancers develop, and how they grow.  I suspect that, in time, we will have a new way of viewing cancer, and perhaps a new term altogether – one that accounts for each cancer's complexity.    

I realize that the tone may sound defeatist.  To the contrary.  I am advocate for taking proactive steps to decrease cancer risk.  But, there’s a careful balance between emphasizing the tools that are available to promote a healthy immune system and implicitly blaming the victim for not doing enough.  When will our “yes we can” culture be okay with acknowledging that sometimes “no we can’t…at least not yet.”  Not all cancers are the same and not all are winnable.  Cancer is a combination of environment, diet, biology and genes, or in other words, bad luck.  We’ve made a lot of progress with a handful of cancers, but there are still cancers that remain terribly hard to treat.  One can do everything possible to avoid it, but often, there’s little one can do.  That's where we are, but with hope, more advances are on the horizon.     -- J