THE MOSS REPORTS Newsletter (11/07/04)

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THE MOSS REPORTS Newsletter (11/07/04)

 

 

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Ralph W. Moss, Ph.D. Weekly CancerDecisions.com

Newsletter #157 11/07/04

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THE MOSS REPORTS

 

 

It has been said that a statistician is a person who believes that

figures don't lie, but who, if pressed, admits that some of them won't

stand up, either.

 

This week and next week as well I review an important statement by

Andrew von Eschenbach, MD, the director of the National Cancer Institute,

in which he outlines his " challenge vision " for the future of cancer

research, and makes the astonishing assertion that cancer will be

essentially conquered by 2015.

 

Clearly, Dr. von Eschenbach is persuaded that the war on cancer has so

far been modestly successful. However, as I document in this week's

newsletter, the statistics on which he bases this opinion do not stand up

to scrutiny.

 

For thirty years I have been studying the field of cancer therapy and

chronicling the war on cancer. The fruit of my long career in this

field is The Moss Reports, a comprehensive library of guides to both the

conventional and alternative treatment of over 230 different kinds of

cancer. For cancer patients there can be few more useful guides and

decision-making tools than a Moss Report.

 

To order a Moss Report please visit our website,

www.cancerdecisions.com, or call Diane at 1-800-980-1234 (814-238-3367

from outside the US).

 

We look forward to helping you.

 

 

 

IN GOD WE TRUST, ALL OTHERS SHOW DATA:

A REPLY TO THE NCI DIRECTOR'S " CHALLENGE VISION "

 

 

In a recent article, Andrew C. von Eschenbach, MD, the director of the

National Cancer Institute (NCI), elaborated on his " challenge vision "

for the National Cancer Program of the United States (Eschenbach 2004).

Since the NCI recently put forward a proposed budget of more than $6.2

billion dollars for the financial year 2005, Dr. von Eschenbach's

article can also be read as a justification for this mammoth request.

 

Despite widespread concern that the 33-year-old war on cancer has not

resulted in significant improvements in treating the dread disease, Dr.

von Eschenbach continues to define the problem in essentially military

terms. Like many a military commander, he assures us that victory is

within our grasp, and that winning is just a matter of mustering enough

resources and manpower. But he is obliged to admit that " the hoped-for

`cure' for this complex set of diseases has proven far more elusive

than anticipated. " He even makes reference to a cover story in Fortune

magazine that concluded that we are in fact losing that war.

 

For my previous article on why we are losing the war on cancer click or

go:

http://www.cancerdecisions.com/040404.html

 

Yet Dr. von Eschenbach continues to believe that his organization is

making rapid progress. He even puts forward the astonishing claim that it

is possible for NCI, by pursuing its current research initiatives, to

achieve " the elimination of the suffering and death due to cancer by

2015. "

 

I had to read this statement over several times to make sure that my

eyes were not deceiving me. Cancer annually kills 6.2 million people

around the globe, and causes intense suffering to many millions more. The

World Health Organization (WHO) predicts that by the year 2020 cancer

rates will further increase by 50 percent to 15 million new cases per

year (WHO 2004). In the US alone, cancer afflicts nearly 1.4 million and

kills 563,700 annually. To eliminate that degree of suffering in just

11 years would be the greatest medical achievement in world history.

 

This is not the first time that we have heard breathtakingly

over-optimistic projections about the imminent defeat of cancer. The

Nixon White

House promised a cure for cancer in time for the American bicentennial

in 1976. That anniversary produced a spectacular OpSail display in New

York Harbor, but, alas, no cure for cancer.

 

Over the last several decades we have gotten used to periodic

predictions of the coming demise of cancer. " Decades of breakthroughs

have

raised hopes again and again for people with cancer, " wrote Fortune

editor

Clifton Leaf in his article on losing the war on cancer, " but have

failed to deliver on expectations " (Leaf 2004). Interferon,

interleukin-2,

Endostatin, high-dose chemotherapy for breast cancer—most the claims

have turned out to be highly exaggerated. For the last ten years we have

been hearing about the wonders of `targeted' therapies and how they too

are going to revolutionize oncology. But despite Dr. von Eschenbach's

enthusiastic endorsement, the actual track record of these treatments

has been disappointing. The orthodox medical community is by no means

alone in making extravagant claims of this sort. On the alternative

side,

there have been books with titles such as " World Without Cancer, " " The

Death of Cancer, " and " The Cure for All Cancers. " All of them have

proven to be equally illusory. A cynic would say we've heard it all

before. I myself favor the unofficial motto of the NIH: " In God We

Trust. All

Others Show Data. "

 

Extraordinary claims demand rigorous documentation. For Dr. von

Eschenbach to come forward with such a provocative assertion one would

expect

him to present an iron-clad case. Yet some of his arguments are

astonishingly weak.

 

For example, the philosophical foundation of Dr. von Eschenbach's case

is that the impending conquest of cancer is an extension of the

extraordinary progress that has been made in the last 100 years. " At

the turn

of the twentieth century, " he writes, " the likelihood of an individual

surviving cancer was zero. Today, two out of three people diagnosed

with cancer will be alive 5 years after diagnosis. "

 

This statement is misleading on two counts. First, it is far from true

that a century ago one's chance of surviving cancer was zero. Effective

cancer treatment relies still, just as it has for the past hundred

years, on one basic principle: the removal or ablation of the entire

tumor

wherever possible. Perhaps the best known example of an effective form

of treatment that has been around for over a hundred years is the

Halsted radical mastectomy for breast cancer. This treatment was

pioneered

by William Halsted, MD, a famous Johns Hopkins surgeon, who published

his classic paper on the subject in 1894. Halsted's paper was based on

his experience with the surgical treatment of 50 cases, dating back to

1889. The recurrence rate among Halsted's patients was not 100 percent,

as von Eschenbach tacitly suggests with his claim of `zero survival.'

In fact, the recurrence rate recorded by Halsted was a mere 6 percent!

That's right. More than 100 years ago, 47 out of 50 (94 percent) of

breast cancer patients treated at a major university hospital survived

their cancer, even though many of these patients were already in the grip

of locally advanced disease at the time of diagnosis. In fact, the

" Halsted radical " remained the standard treatment for 75 years and only

fell out of favor in the 1970s, when it was realized that less radical

procedures were equally effective. (It is still sometimes used today.)

 

But a more pivotal issue is Dr. von Eschenbach's reliance on the

statistical construct of improved five-year survival as an accurate

yardstick

of progress in cancer therapeutics. Change in five-year survival is

actually an unreliable way of judging progress in the treatment of

cancer, since it is susceptible to a statistical artifact called

`lead-time

bias'. The misleading nature of the five-year survival yardstick was

exposed more than 35 years ago in a landmark article in the Journal of

the

National Cancer Institute (Hutchison 1968). It has been estimated that

about half of the perceived benefit of treatment is actually due to

lead-time bias (Shwartz 1980).

 

Lead-time bias is essentially the interval between the time that a

cancer is detected using modern diagnostic techniques and the point at

which it would have been clinically detected by doctors in the past. This

statistical artifact came to the scientific community's attention when

mammography (diagnostic x-rays for breast cancer) became common. As a

result of mammography, breast cancer was being detected earlier, and more

frequently, resulting in statistics that suggested that breast cancer

patients were living longer. This was at first enthusiastically chalked

up to the benefits of aggressive treatment, but upon closer examination

the presumed life-extension turned out to be illusory. In reality,

women were simply being diagnosed sooner than they would have been before

the advent of mammography. They were not actually living longer; they

merely received an earlier diagnosis.

 

Yet, although universally acknowledged by medical statisticians,

lead-time bias was - and continues to be - conveniently ignored and

overlooked in study after study. It has led to the entrenched

misconception that

we really are winning the war on cancer because more people are living

five years after their initial diagnosis. Lead-time bias, as I wrote in

Questioning Chemotherapy, " accounts for much of the illusory

`improvements' seen over the last few decades in treating breast and

other kinds

of cancer. Patients are actually dying with the same regularity. But

the statistics look a whole lot better " (Moss 1995).

 

" Even if therapy is ineffectual, " wrote Yale University statistics

professor Alvan R. Feinstein, PhD, " the period of survival will be

increased " because of the " added time that is provided by the early,

pre-symptomatic detection of the disease. " These remarks of Prof.

Feinstein's

were published in the New England Journal of Medicine, the most widely

cited medical publication in the US (Feinstein 1985). Yet, as I pointed

out in Questioning Chemotherapy, these startling conclusions " are almost

never taken into consideration by those who make public pronouncements

concerning the alleged benefits of modern treatment " (Moss 1995).

 

Early diagnosis, in addition to creating the illusion of longer

survival, has also resulted in a surge in the number of people being

labeled

cancer patients. Although it has undeniably saved many lives, screening

has also resulted in the detection of very early stage cancers whose

malignancy is questionable, such as ductal carcinoma in situ (DCIS) of

the breast or very early, still-encapsulated prostate cancers, many of

which would never have progressed to frank, clinically invasive cancer

before the person died of other causes. Since these patients generally

survive five years and more even without treatment, it is no wonder that

the number of " survivors, " especially of breast and prostate cancer,

has increased in recent decades. In fact, today, breast cancer survivors

make up 22 percent of the total and prostate cancer survivors make up

another 17 percent (NCI 2004).

 

Several years ago, Canadian oncologist Prof. Ian Tannock gently mocked

the US tendency to multiply the number of prostate cancer cases through

the over-zealous use of the Prostate Specific Antigen (PSA) test as a

screening device. He referred to this, satirically, as the " eradication

of a disease: how we cured asymptomatic prostate cancer. "

 

Dr. Tannock stressed that through aggressive treatment, the quality of

life for a great many men could be seriously impaired, firstly by the

knowledge that they had " cancer, " and then by the morbidity caused by

radical treatment (Tannock 2002). PSA-based prostate cancer screening has

now been called into question and is no longer generally regarded as

either sensitive or specific enough on its own for the accurate detection

of prostate cancer.

 

My point is that this overly aggressive screening of the US population

has greatly increased the number of people who have been shifted into

the `cancer patient' category. These newly minted cancer patients are

then treated for a " disease " that in all likelihood would never have

troubled them, much less killed them.

 

The combined impact of lead-time bias and over-zealous screening is

profound. It has enabled politicians to claim triumphantly that there

are

now 9.8 million cancer survivors in the US—as if that alone were a sign

of great progress in treating a fatal disease.

 

This sort of statistical sleight-of-hand is the unsound foundation on

which the concept of five-year survival is built.

 

Besides, curing early-stage cancer is relatively straightforward:

surgery alone is often all that is needed. But curing disseminated

cancer is

a much more difficult challenge. It would be instructive if Dr. von

Eschenbach would talk about the five-year survival statistics for

patients with metastatic disease. That would give us a better measure

of just

how successful conventional (or `targeted') treatments are in treating

the hundreds of thousands of people for whom surgery, radiation and

chemotherapy have failed to stop the progress of the disease. I would

have

liked to see von Eschenbach acknowledge and discuss the fact that for

the statistically major kinds of advanced cancer there has been no

significant improvement in survival between the 1970s and today (Leaf

2004).

These are precisely the tough issues that will have to be tackled if

NCI is going to eliminate the massive suffering and death caused by

cancer— by 2015, or any year thereafter.

 

 

Manageable and Chronic

 

 

Dr. von Eschenbach also asserts that NCI is redefining cancer from the

rapidly progressive disease of today to what he calls a " manageable,

chronic " disease. I welcome the shift towards regarding cancer as a

controllable disease, but the NCI is by no means the first to embrace

that

goal. In 1972, in an era when conventional medicine decreed that cancer

had to be quickly treated in radical fashion, a layperson named Betty

Lee Morales founded the CAM-oriented Cancer Control Society. The key

concept was to seek out less toxic treatments that could be utilized over

the long haul to keep cancer at bay. That in fact was the central

concept of holistic or " metabolic " therapy. The CCS still exists and

promotes this core philosophy. In the late 1990s, urologist William

Fair III,

MD, then of Memorial Sloan-Kettering, introduced this concept into many

conventional medical circles, before his own death from cancer in 2002.

Of course it is gratifying to hear this CAM philosophy espoused by the

director of the NCI, but it would have been even more gratifying if he

had expressed some belated appreciation of the unsung heroes of

complementary medicine for their three decades of effort to reshape

the goals

and practice of oncology.

 

TO BE CONCLUDED, WITH REFERENCES, NEXT WEEK.

 

 

--Ralph W. Moss, PhD

 

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IMPORTANT DISCLAIMER

 

The news and other items in this newsletter are intended for

informational purposes only. Nothing in this newsletter is intended to

be a

substitute for professional medical advice.

 

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