Capitalism and Cancer

In our recent conversation, Dr. Natalya Dinat made a strong case that health systems cannot serve their purpose when they exist wholly within the bounds of a capitalist economy. She contrasted the case of COVID-19 - for which we have effective treatment within a year - with that of malaria, for which we have no great treatment despite decades of research. The COVID case was clearly a scramble to make profits - whoever made the best COVID vaccine within a certain time frame was going to make a lot of money. In the case of malaria, an effective treatment is unlikely to make anyone rich.

Prior to this conversation I had primarily thought of capitalism contributing to health crises through encouraging us to consume greater and greater quantities of highly addictive food-like substances, like doughnuts. A while ago I wrote about how capitalist systems encouraged the introduction of cotton seed oil - an essentially free by-product of US cotton production - and its adverse effects on the health of the population.

But Dr. Dinat's observations raise an interesting question: Does the profit motive determine our research agenda? And, in the case of cancer, might the quest for endless profits be getting in the way of a possible cure?

In a recent interview, Dr. Rob Gatenby explained his evolutionary approach to cancer treatment. The interview itself is worth listening to in its entirety, especially for those with some research training. For those who don't have that training, consider this the simplified version.

The first thing to understand is that physicians are bound by something called the "standard of care". This essentially means that your physician must offer you the same treatments that everyone else is being offered. If your physician doesn't do this, she may open herself up to the risk of a lawsuit, especially in the United States where medical malpractice lawsuits are very common.

In the case of cancer therapies, the "standard of care" is to give the maximum allowable dose of a specific therapy - let's stick to chemotherapy for the moment. Chemotherapy is essentially an extremely toxic combination of drugs that kills a lot of healthy cells as well as killing the cancer cells. So you give the patient as much poison as their body can handle, knowing that the cancer cells are more likely to succumb to the poison. In some cases and for some cancers, this works very well.

But in the majority of cases something awful happens. Some cancer cells become resistant to the treatment altogether. Because these resistant cells were so few, they weren't even visible at the end of the traditional treatments. So the patient may go home thinking that they're cured (or at least that the cancer is in remission) because those few cancer cells that remain are simply too few to be seen by traditional diagnostic equipment. Too often the patient will be back in the hospital within a year or two as those resistant cancer cells multiply. Worse, the therapies that worked previously won't work at all, because now you have a tumour that is completely resistant to conventional chemotherapy. If you've ever lost a friend or a loved one to cancer, this pattern may seem all too familiar to you.

So what's the alternative? Dr. Gatenby suggests that we treat cancer as we would any invasive species. In a given moth population, for example, there will be heterogeneity when it comes to responding to a specific toxin - it will kill some moths, others will have some kind of genetic protection. So even if 90% of moths are killed by a given pesticide, you won't be able to get rid of all of them. Those resistant 10% who aren't killed will multiply and will select for resistance to the toxin until in a few years you have as many moths as you started with. Worse yet, you'll have a completely ineffective pesticide. This is analogous with the case of chemotherapy and the resistant cancer cells.

But in moth populations there is a solution. First of all, don't kill all of the moths that are sensitive to the pesticide. It turns out that resistance to the pesticide requires a certain amount of energy, which means that those moths that are sensitive to the pesticide (meaning that they're vulnerable) will out-compete their pesticide resistant relatives in the absence of the pesticide. Using mathematical models you can actually calculate how much and how often to spray in order to increase the number of sensitive moths. If you can get to 100% sensitivity, then you can go in with a strong pesticide and completely eradicate the population. You can also achieve some of these same results by using different pesticides or a combination of pesticides on a population that is already near extinction.

That's fine for moths, but does it work in cancers? Dr. Gatenby has done some initial research that indicates that it absolutely does work in cancers. Surprisingly, his research team found that the non-resistant cancer cells were seven times stronger than the resistant cells (they were expecting 2-3 times stronger), a number that would indicate that it's extremely probable that one could devise an "extinction strategy" to get rid of the cancer completely. Even more surprisingly, some of the test subjects - all of whom were diagnosed with stage four metastatic colon cancer, a condition that pretty much guarantees a lifespan of no more than 18 months - are still alive and using the therapy some five years after the study began. That's a remarkable result for a new cancer therapy - nearly all of the drugs that have been approved in the past few years were approved on data that showed that they extended lifespan by a matter of weeks or at most months.

At the end of the conversation, Dr. Gatenby explains that despite these successes, he's having a lot of trouble finding oncologists to work with. Part of the roadblock is the question of "standard of care", but there's something even deeper. 

For the past 40 years or more, cancer research has been looking for the next breakthrough, the next wonder drug that will somehow cure all cancers. Every year billions of dollars go into this form of cancer research. The money in turn creates pressure on regulators to approve new drugs that at most have a very limited benefit and, at worst, may induce side effects that could shorten life rather than extend it. Those new drugs are very expensive - spending $10,000 a month on chemotherapy alone is not uncommon for cancer patients in the USA.

What Dr. Gatenby is proposing is an innovation that might change all that. We don't need new drugs, according to his methodology, we just need to change the way we administer them so that we can eradicate the cancer using evolutionary dynamics between resistant and sensitive cancer cells. The drugs he uses in his trials are off-patent meaning that no drug company is going to get rich by adopting this approach.

And because no one is likely to get rich from this, no one is interested in funding it. What doesn't get funded has no chance of seeing the light of day. One study, even one promising study, generates nowhere near enough data to get this therapy approved for general use. Unless similar studies are funded and undertaken, we're stuck with the status quo, as dismal as the status quo has been. 

This story is bad enough, but what makes it potentially much worse are the implications. If this therapy - which on the face of it sounds so promising - is struggling to find research backing what does that mean for research in general? How many people are currently suffering or have passed away because of a skewed research agenda? For how long will we accept a system that prioritises profit over human life in a very literal sense?

On the plus side, all of the resources needed to explore Dr. Gatenby's hypothesis already exist. Billions of dollars already go into cancer research, the drugs have been developed long ago, and improvements in imaging and diagnostic equipment mean that one could apply his mathematical models with a precision that would have been impossible a few years ago. All that's missing is the political will.