Last week, we ran a few excerpts from the new book The Secret History of the War on Cancer and and solicited your questions for its author, Devra Davis. I found her answers to be extraordinarily informative, and hope you do too. According to Davis, the economics of cancer prevention (not treatment) seem to be improving hard and fast, which is plainly good news for everyone; I found her response to the question about a $1 trillion “Cancer Cure Prize” to be especially enlightening, and enlightened. Thanks to Devra for her time and wisdom, and to all of you for the questions.
Q: From a practical standpoint, what should we be doing to solve the cancer problem? It’s important to be aware of a history of lies and manipulation — and to spread that awareness — but that does not enable us to make change.
A: We should start with looking under our kitchen sinks and finding safer substitutes for the things we use every day that appear to be toxic, according to their labels. We should become informed about the goods and the bads of cancer, by finding resources such as The Green Guide that highlight what is known or suspected to increase cancer risks that we can control.
Q: What exactly are the “known for 100 years cancer-causers” that you reference?
A: For nearly a century, the following things have been understood to cause cancer: tobacco, benzene, asbestos, tars, sunlight, hormones, and radiation. You can read the book to learn more. We have met the enemy, as Pogo once quipped, and it is us. The best solution to this dilemma is for people to become informed and motivated to make simple changes in their lives that will enhance how long and how well they live.
Q: I have heard that the link between secondhand smoke and lung cancer is statistically insignificant. In fact, I’ve been told the link between drinking milk and breast cancer is more statistically significant. If this is true, why do we only ever hear that one of these (secondhand smoke) increases a person’s chances of getting cancer?
A: Secondhand smoke contains a number of proven cancer-causing agents. Human evidence on its hazards may be somewhat inconsistent, but this does not mean there is no evidence of its dangers. Rather, these inconsistencies reflect the inherent limits of the discipline. It took more than fifty years for the world’s scientists to reach an agreement on the dangers of smoking, and there are still serious scientific disagreements about the scale and scope of the problem. Those disagreements are inherent in science, and should not be misconstrued to mean there is no problem. Whether or not milk increases some illnesses, including breast cancer, is something that should be more carefully studied. It would not surprise many of my colleagues to learn that milk is not an essential food for humans after babyhood, and that it can be a source of health problems for some.
Q: From your writings, it appears that the consistent trend is that those with money are manipulating or delaying cancer research findings that would help those without money. In a capitalist society, how do we correct this?
A: There are few incentives to reduce the demand for cancer treatment by attacking cancer upstream to prevent it, and many incentives to profit from increased demand for expensive treatments/diagnoses by awaiting its arrival downstream.
We need to create new incentives in the private and public sector to prevent cancer-causing agents and exposures, and eliminate incentives for costly, ineffective, and sometimes dangerous drugs. At this point, as a May, 2007 Times editorial noted, “[t]he explosion in the use of three anti-anemia drugs to treat cancer and kidney patients illustrates much that is wrong in the American pharmaceutical marketplace.” These drugs can be life-saving in cases of severe anemia, but are being inappropriately used for many kidney dialysis and cancer patients today. Touted as giving cancer patients more energy, the drugs actually can lead to earlier deaths in many instances.
The Times piece went on to say that, “[t]hanks to big payoffs to doctors, and reckless promotional ads permitted by lax regulators, the drugs have reached blockbuster status.” In fact, the FDA has reported that these drugs may do more harm than good in many instances. The Capitol Steps, a political-satire singing troop, have even spoofed the proliferation of TV ads promoting drugs to treat increasingly bizarre diseases, like Restless Leg Syndrome.
The economic incentives are all wrong here, as Alex Berenson and Andrew Pollack noted in a May 9, 2007 Times article. The broad advertising and use of injected medicines — Aranesp and Epogen, from Amgen; and Procrit, from Johnson & Johnson, to name two – to boost the energy of cancer patients by reducing their exhausting anemias have been fueled by perfectly legal payouts or rebates in the hundreds of millions of dollars. Medicare directly reimburses doctors for buying the drugs, and then doctors also get bonuses or rebates reflecting how much of the drug they have bought.
The Times editorial also noted that, “[o]ne group of six cancer doctors in the Pacific Northwest earned a profit of about $1.8 million last year thanks to rebates from Amgen, while a large chain of dialysis centers gets an estimated 25 percent of its revenue, and a higher percentage of its profits, from the anemia drugs.” It’s possible that concerns from a recent FDA Advisory panel about these drugs will cause oncologists to rethink their use. But a more efficient way to stop this costly and inefficient practice would be to ban drug rebates. Federal laws have finally stopped drug companies from paying doctors to prescribe pills. I agree with the Times editorial board’s assertion that these prohibitions “should be extended to injected and intravenous medicines.”
Q: Is it really a surprise that large corporations have been shaping how products are perceived by and distributed to the public? Can private companies ever be part of the solution?
A: The conflicts of interest and compromise of healthcare involved in corporate sponsorship of medicine have been thoroughly parsed, documented, and indicted by Marcia Angell and many other luminaries. More money is spent advertising and creating “demand” for pharmaceuticals than is spent researching them, in many major firms. There may well be a need for the government to create outright bans on direct advertisement to consumers, and subsidies to medical education and practice.
Still, when it comes to combating cancer, I am not opposed to corporations sponsoring some activities, provided that it is done with appropriate guards against bias. Major companies are responding, in some cases on a voluntary basis, to environmental concerns about climate change, global warming, and other concerns about pollution. In fact, with respect to reducing greenhouse gases, major global firms and many large cities throughout the world have begun to act, even though the benefits cannot be seen in the short-term. The market is responding to environmental needs. The tremendous growth of green industry in building, repairs, computers, paints, and even fashion – where green is the new black – remains phenomenal, despite the recent market turmoil.
Health insurance systems are also adopting preventive policies that put more money in the pockets of those who adopt healthier personal behaviors. These include offering premium reductions to those who lose weight, stop smoking, use health clubs, and take courses in healthier home practices. This trend needs to be expanded to companies directly. Corporations that create financial incentives for pollution prevention policies in their workplaces should get reduced health insurance premiums for their employees.
Q: Recently, non-governmental organizations seeking a cure for cancer seem to have had some success in the form of large cash prizes. Is it time we had a massive (~ $1 Trillion) “Cancer Cure Prize”?
A: I’m not sure we would recognize the prize-worthy idea if we saw it, because the solution is unlikely to come from a single idea, but from the combined effects of many different resources devoted to reducing the toll of cancer. For example, my own healthcare system at the University of Pittsburgh is greening the entire system to get rid of suspect cancer-causing agents through practices as disparate as improved purchasing policies, advanced recycling and waste reduction, and improved transportation and housing.
The green building revolution makes clear the power of the purse to create markets. In Texas, at the University of Pittsburgh, and throughout the Kaiser Permanente system in California, those in charge of buying building materials and keeping buildings running have become the next generation of environmental champions. They are doing this because they save money by avoiding cleanups and repairs, while also keeping their staff healthier and more productive. As a result, such places are looking hard for environmentally safer purchases. Where they don’t find them easily, they are helping invent them. An entire new industry is making building materials from natural products and recycled materials. Old blue jeans can be shredded into fluffy cotton insulation. Used paper can be compressed to create work surfaces held together with natural plant resins. Floors can be made out of cork or natural rubber, or other fast-growing plants and trees that can be harvested and replanted. Walls can be painted in naturally-based paints that don’t leave painters or workers with red eyes, parched throats or asthma attacks. Hospital gowns can be made from recycled paper.
Q: What incentives are needed to develop more holistic and natural treatments for cancer?
A: People are voting with their pocketbooks. Expenses for integrative or alternative medicine are now billions of dollars a year. The National Center for Alternative Medicine at the NIH is funding research on some of these treatments, as is the National Cancer Institute itself. There are serious methodological issues about how best to study the combined uses of acupuncture, yoga, meditation, music, and herbal and nutritional therapies, in patients with advanced disease or in healthy people determined to stay healthy. The gold standard of clinical trials can’t work in this circumstance. Some of my colleagues, like Mitchell Gaynor, Judy Balk, Woody Merrell, Freddie Kronenberg, David Eisenberg, Mark Hyman, and Andy Weill, are devising new approaches to this important issue.
Q: The medical industry seems to make most of its profits from illness and almost nothing from wellness. Doesn’t this situation provide the wrong incentive for prevention? What would you think of a single-payer system that compensated health professionals based on the wellness of their patients?
A: This is an excellent idea that has been used by a number of countries with national health systems, including Britain, Cuba, and others.
Q: Do you see our ongoing exposure to benzene in gasoline as an issue? Is there more that we should be paying attention to regarding this particular subject?
A: Yes. I am especially concerned about children pumping gasoline, and those who live or go to school near gas stations, underground storage areas, and processing plants, where such emissions can be considerable. As with all of these hazards, the exposures and risks are far greater in the rapidly developing world, which also lacks the infrastructure to measure, monitor or mediate such conditions.
Q: The story of tobacco research sounds a lot like what is happening today with the oil industry and global warming. Do you agree?
A: The exploitation of scientific uncertainty is a growing problem. America is waking up to the fact that, on issues like global warming and environmental health, the media manufactures confusion by finding extreme views and counterpoints to highlight. As the awarding the of the Nobel Peace Prize to Al Gore and the Intergovernmental Panel on Climate Change (IPCC) show, most of the world understands that science, while uncertain, knows enough to reach some conclusions about major threats. I was a lead author of the IPCC, and participated in the process of reaching consensus with more than two thousand scientists over several years, so I know that scientific consensus evolves slowly, and is not immune to political and economic pressures.
Q: I see charities of all kinds rallying under the banner of fighting cancer, yet their results aren’t very impressive. Are these charities actually effective? If we care to donate to one, do you have any suggestions?
A: Tremendous success has been achieved in finding and treating some cancers, driven by groups like the American Cancer Society, the Komen Foundation, and the Breast Cancer Research Foundation. But these only deal with the end of the pipe. There are a number of groups working to prevent cancer, including the Environmental Working Group, the Healthy Child, Breast Cancer Action, Breast Cancer Fund, and our own center for environmental oncology.
Q: Aren’t you profiting from cancer the same way that businesses do by selling a book? Also, as someone who is so concerned with health, why are you allowing Wal-Mart to sell your book?
A: If you believe in capitalism and the marketplace, then books get sold where people go to buy them. As you may imagine, I have no control over where the book is sold. Any individual who has qualms about where the book is being sold should feel free to buy it elsewhere.
In addition, I am not profiting from the sales of this book, because if there are any profits, they will go to support the Devra Lee Davis Charitable Foundation, which is devoted to supporting research and public policy to prevent cancer.
Q: At least 30 years ago, I was reading about how the funders of medical research were making so much money that there would probably never be cures for most cancers, because a cure would mean the end of funding. Is this accurate?
A: There is money to be made in prevention. I am confident that businesses will figure this out. For instance, supplementation of food with omega-3-fatty acids will protect against heart disease and reduce the risk of cancer. The use of some broccoli extracts appears highly effective against some forms of cancer. There is no reason why other such approaches cannot be tried on a broad scale that would result in tremendous profits for those who create the best ways of delivering these products. This may involve genetically manufacturing agents that have enhanced amounts of good fats and other nutritionally desirable content.
Q: Do you have an opinion on the recent reports that an additive to plastic baby bottles and other bottles may be associated with a higher cancer risk?
A: The risks of Bisphenol A (BPA) to our children should not be dismissed, and are probably greatest before birth and immediately afterwards. As with most environmental issues, there is money to be made from doing things right and doing the right thing. BPA is a plasticizer that can leach from plastic baby bottles, especially when heated. The risk is greater for young infants, especially boys who are born prematurely. Mothers with higher levels of this compound in their blood during pregnancy produce baby boys that are less masculinized, according to important new work by Professor Shanna Swan of Rochester University. As there are safer alternatives to using this compound, these alternatives should be made broadly available.
Q: Are artificial sweeteners (namely aspartame) today’s tobacco?
A: Aspartame is unlikely to become as clearly tied with cancer as tobacco, nor is its risk likely to be as high. The concerns about aspartame relate to two matters – it was not well-tested, and it has become ubiquitous in people of all ages. The testing of its ability to cause cancer was not adequately conducted before it was approved by the FDA, within five months of Reagan’s inauguration. Prior to that time, every single scientific panel to review the data on aspartame’s safety rejected approval of it.
Recent data from a respected scientific institution in Italy reports that animals that have low doses of aspartame, comparable to what can be consumed in a diet today, have increased rates of tumors when they reach an age equivalent to the human age of sixty. With aspartame, as with many modern technologies, we are carrying out uncontrolled experiments on our children, the full results of which will only become apparent in forty years or so. Animal studies have found that every agent that we know causes cancer in humans also causes cancer in animals, when adequately tested. We would be profoundly mistaken to ignore these latest studies from animals. The human studies that have exonerated aspartame have involved looking at older people, and have never asked about the damaging effects on children of using the product throughout their lifetimes.
Q: A comprehensive study on the link between diet and cancer was just released by the American Institute for Cancer Research. Do you have any comment on it?
A: The tie of obesity with cancer is unsurprising, as is the realization that diets high in animal fats, alcohol, and red meat confer a high risk of cancer. Fat has been called a natural hazardous waste site, because it accumulates fat-loving synthetic organic chemicals, which move up the food chain. The larger and older the fish or mammal, the higher the amount of toxic chemicals it can accumulate. Generally, it makes sense to live high in the watershed – above zones into which pollutants can drain – and eat low on the food chain, where toxic chemicals are less likely to accumulate.
Q: Without disputing any of the claims in your book, I’m curious whether you have any comment on Clifton Leaf‘s Fortune article, “Why We’re Losing the War on Cancer“?
A: Leaf’s article does an excellent job of documenting the scale and scope of the efforts to find and treat cancer, and the complexities of the disease. It does not address the bulk of my book, which shows the need to attend to the known and suspected causes of cancer. No matter how efficient we may become at attacking the disease, we must address the upstream issue of preventing it from arising in the first place. Worldwide, there are about 17 million cancer causes. Most of these occur in countries lacking chemotherapy, radiation, and access to regular care. Prevention remains, as my center slogan holds, the best cure for cancer.
Q: Your describing lawyering tactics as “brilliant” and “highly paid” seems to reveal a bias. Judges are overall very independent, and, with extremely few exceptions, not susceptible to monetary inducements. Their rules are published and can be evaluated, criticized, appealed, and overturned by legislation.
A: I agree that generalizations are inherently problematic with issues as complex as lawyering on toxic hazards. Indeed, there are profound epistemological differences in the way evidence is used in law and science that create serious problems in their efforts to work together. The lack of evidence on individual specificity for cancer in science is often distorted into proof that no such direct link exists. I argue, as do many other legal scholars, that we need a clearer appreciation that where you stand on many of these issues depends on where you sit, and who has bought the chairs.