You have stage III colon cancer. Bummer.
There is a chemotherapy regimen that has been proven in multiple clinical trials to be relatively effective for your type and stage of cancer. Good news! Like most chemotherapy, which is essentially designed to just kill a whole bunch of cells (it is also called “cytotoxic” after all—death to cells), it has some fairly serious side effects.
So here is the question: would you like to take this toxic regimen for three months, or for six months?
This is not a trick question. Do you want longer treatment and potentially more time for it to, you know, work, but obviously more toxicity? Or shorter treatment but less toxicity? A lot of really clever researchers have tried to answer this question; it’s still not completely clear what the answer is. That’s not a scandal in and of itself: this sort of issue is really hard to parse out sometimes. The cost-benefit analysis for a lot of drugs, and in particular those that treat cancer, is super complicated. You want to maximize benefit while minimizing harm, and, well, that’s a tough thing to do.
What makes it tougher, though, is that there’s no fucking money in giving people fewer drugs.
In 2017, I was in Madrid, covering the European Society of Medical Oncology’s annual meeting. I wrote some articles about cancer research. But one session of the conference stuck with me: they were debating the optimal length of therapy for stage III colorectal cancer, based on results of a couple of recent clinical trials.
Those trials compared three and six months of treatment, and well, it was complicated. For some patients, a certain chemotherapy regimen given for three months was “non-inferior” to six months, meaning it performed equivalently to the longer, more standard length of therapy. For certain other patients, and a certain other regimen, that non-inferiority could not be definitively established; six months would remain the standard for them.
So far this was relatively normal cancer meeting fare; but a few experts who spoke to the massive crowd said something I found particularly notable. I’m paraphrasing at this point, but essentially, they all said some version of this: “No one is going to fund a definitive study on this, so I think this is the best data we’re going to get.”
Woof! Let’s translate: “Drug companies are interested only in giving more of their extremely profitable drugs to people, not less. As a result, we cannot definitively study how to reduce side effects while still offering the most effective possible treatment.”
More specifically, the best way to answer the question would be to design a prospective, randomized trial where some people were given the longer regimen and some the shorter. This would need to be a very large trial to tease out what might be fairly small differences between the treatments. Large trials cost a lot of money.
When large trials are needed to test if some new drug might be better than existing drugs, Pfizer or Merck or whoever plops down huge chunks of money without batting an eye. If the trial works—and by the time they reach the point of funding large, expensive, phase 3 clinical trials, they’re at least relatively confident that it will work—then they have a new and enormous source of income. Given that some newer cancer drugs can cost hundreds of thousands of dollars per patient, it is an easy decision.
But when large trials are needed to examine how to give people less therapy, we, the general cancer-having public, are often shit out of luck.
Here are three things:
Purdue Pharmaceuticals filed for bankruptcy the other day, part of an effort to manage the 2000-plus lawsuits that have been filed against it for fueling the opioid crisis. There is now abundant evidence that the Sacklers and others at the company actively worked to increase subscribing of clearly addictive and dangerous drugs in order to make a few more bucks before laundering their demonic image through I dunno a wing at the Guggenheim or whatever.
According to a new Reuters report, Merck purposely misled the public about its popular hair loss drug Propecia, disguising its potential to cause sexual dysfunction and other problems in men. “[D]ocuments show that Merck knew roughly 20 years ago that sales of the drug would suffer if the public became aware of Propecia’s possible long-term effects on men’s sexual health.”
Under the Trump administration, the U.S. Food and Drug Administration’s enforcement actions—the agency’s tools to protect the public from dangerous drugs, medical devices, and foods—have dropped by one third compared to the previous administration. “Industry may well take the message from this that the cop is not on the beat as often,” said a former FDA official-turned non-profit/science watchdog type.
This has been three things.
There are really good doctors and researchers out there who would prefer their patients could take less toxic medicine but get the same result. Your doctor, the one you’ve been seeing after your stage III colon cancer diagnosis, is probably one of them! They work with what they’ve got.
In 2018, some of these really good researchers tried to definitively answer the question of three-versus-six months of chemotherapy for people with your particular brand of malignancy. They examined existing data from six trials, involving more than 12,000 patients; this can be an effective tool, but it is not that ideal option, the prospective, randomized, big-ass trial. Here’s how their study concluded:
Among patients with stage III colon cancer receiving adjuvant therapy with FOLFOX or CAPOX [these are the acronyms for the two chemotherapy regimens, containing multiple drugs each], noninferiority of 3 months of therapy, as compared with 6 months, was not confirmed in the overall population. However, in patients treated with CAPOX, 3 months of therapy was as effective as 6 months, particularly in the lower-risk subgroup. (Funded by the National Cancer Institute and others.)
You’ll be forgiven for being confused. Much like before, it seems that some people can receive a shorter duration of therapy safely and effectively; others can’t. Cancer is complicated! With every new bit of research, it can feel like it gets more complicated; it isn’t one disease, but several hundred, driven sometimes by genes and sometimes by environment and usually be some combination of the two, with a whole host of possible treatments that may or may not work based on those varying factors. These sorts of bit-of-column-A, bit-of-column-B conclusions aren’t uncommon. But look at that last bit:
(Funded by the National Cancer Institute and others.)
Curious what the “others” are? Here you go, in all its acronymical glory:
CALGB/SWOG 80702 was supported by grants (U10CA180821, U10CA180835, U10CA180882, and U10CA180888) from the National Cancer Institute; IDEA France by Institut National du Cancer and a grant (PHRC2009) from Programme Hospitalier de Recherche Clinique en Cancérologie; SCOT by a grant (EME 09/800/34) from the National Institute for Health Research, Efficacy and Mechanism Evaluation, the National Institute for Health Research, Health Technology Assessment, and a grant (C1348/A15960) from Cancer Research United Kingdom; ACHIEVE by the Japanese Foundation for Multidisciplinary Cancer Treatment; TOSCA by a grant (FARM 5RWTWZ) from L’Agenzia Italiana del Farmaco; and HORG by the HORG Foundation.
Don’t bother scanning through that for Genentech, Sanofi, or any of the other makers of the drugs involved. They’re not in there. Just public institutions like the National Cancer Institute.
Here is one more thing:
The Trump administration’s most recent budget request included a cut of $900 million from the National Cancer Institute’s bottom line, representing nearly 15 percent of its total.
This has been one more thing.
random bits
The Global Climate Strike is coming up. Just FYI.
Scientists found what is essentially the biggest possible neutron star. It is more than twice as massive as the sun, but only 15 miles in diameter. Imagine taking someone of normal human height and mashing their full mass (well, twice their full mass, but close enough) down into a tiny person approximately one thousandth of an inch tall—more or less the width of a human hair.
Look everyone has made the same joke/comment/it’s not funny, but it is AMAZING that like three people die from vaping and everyone’s like OH SHIT BAN THEM while the CDC is still not even allowed to study gun violence.
Hey look, that little heart button is begging to be pressed. Don’t be rude.
notes from [gestures around]
Here are some photos of bugs I took here in Indonesia:
Also in the evenings there are lizards just sort of everywhere, and it’s great. They’re mostly geckos, and you can see them on the walls of your place, on the back-lit sign of a grocery store, wherever. No particular point here, other than that lizards are cool.
Find me: