Saturday, 30 March 2013

Let’s Find Another Metaphor for “The War on Cancer”

Written by  Dr. Tahseen AlSaleem
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I was born and raised in a small town at the banks of the river Tigris in Southern Iraq. Though belonging to a tiny religious group (Mandaeans). I was protected by a close circle of family, relatives and friends. Thus, I grew aggressive, idealistic, and somewhat naive. When I finished my training and fellowship in pathology in Philadelphia, I rushed back home and was appointed at the University of Baghdad Medical School. There, I established a Department of Pathology and Tumor Registry and started an advanced training program in pathology. Later the cancer registry covered the whole country and as Secretary General of the Iraq Cancer Society, I took active part in cancer education and prevention.

At the end of the 70's however, the things started to change to the worse very quickly and the educational and medical establishment started to be dismantled systematically. Then, the wars ignited, internally and with neighbors, leaving behind horrible scenes of pain, suffering, death and destruction.

So, at the end of the first Gulf war, my children, my wife, and I decided that we would come back to the United States, leaving behind all of our belonging, including our house, cars and my own laboratory.

Through the support of all the people we had met and with the hard work of my children, the whole family is now considered as a shining example of the American Dream.

In spite of all these successes, still my heart sinks whenever I hear the word "war" in whatever context; I guess it is the "post-traumatic stress disorder". So, I have mixed feelings when I hear in newscasts and read in newspapers, about the great successes in the "war on cancer.

And, indeed, it is a great success. The absolute rate of cancer cancer mortality in the United States has fallen during the two consecutive years of 2005 and 2006. This happened in the face of an aging population and following eight consecutive years of relative decline. Progress was noted in control of the most common cancers- lung (in men), breast, colon and prostate.

Also in the news, of course, is the war in Iraq, extremely personally painful and traumatic to me. I saw cars exploding, buildings burning, and men, women and children dead and wounded, being dragged in the streets by whatever and whoever can carry them to the nearest hospital. I can't help but think: If this war produces death and destruction, why should we have a "war on cancer" to be able to save lives?

The majority of cancers are caused by environmental factors and lifestyle. In Iraq, for example, the upper aerodigestive and lung cancers are related to smoking and poor oral hygiene. Urinary bladder cancer is associated with schistomiasis and smoking. Kaposi's sarcoma, common in Africa, hepatocellular carcinomas in the Far East and carcinomas of the cervix are all related to viral infections.

Epstein Barr virus (EBV) is a common cause of cancer in Iraq and in other developing countries and as is related to Burkitt lymphoma, nasopharyangeal carcinoma, and Hodgkin lymphoma. These oncogenic viruses are not only common internationally due to malnutrition and repeated infections, but are also common in AIDS patients. Fortunately, the recent development of immunization may control carcinomas of the cervix and of the liver in the future, but there are no vaccines for EBV or HIV yet.

Bacterial invaders are also responsible for the production of cancer all over the world, including H. pylori closely associated with gastric carcinomas and lymphomas.

In many developing countries, there has been an increase in the incidence colorectal cancer, related to westernized dietary habits. So, if we can control all of these viral and bacterial "invaders" and help modify people's lifestyles by education, we may not need a large "war on cancer" at all.

Cancer cells are not real foreign "invaders". They are cells of our own and use our own genes except in a way a little bit smarter. Cancer cells have learned to survive in hostile environments and mastered the secret of eternity. But, haven't humans themselves been looking for the secret of eternity for thousands of years, since the days of Gilgamesh?

Once cancer invades surrounding structures and metastasizes, a cure is elusive. We will literally have to wage a "war" in an attempt to get rid of the cancer cells. We use all available nuclear, chemical and even biological weapons. But the cancer stem cells' identity and whereabouts are not well known to us yet.

Until research reveals the stem cell mysteries, early diagnosis remains very important and the best weapon is the very ancient one- that is to say, (the sword!) surgically removing the cancerous tissue and the surrounding "innocent" cells.

During this "war" against established cancer, there is a large and painful "collateral" damage. In addition to the well known early and late complications of therapy, there is very little known about the quality of life or survivors. Only recently, the quality of life became incorporated in Phase III cancer treatment trials. Most of the available data so far speak little about the quality of life of cancer patients.

Cancer establishment and spread may not be only related to cancer cells themselves, but may also apparently have many "collaborators" from non-cancerous cells- for example, stroma, neovasculature and regulatory T cells. It is only recently that through cooperation of the scientific community and industry that attention has been directed towards these factors with remarkably successful results.

Cancer cells frequently shut off antiproliferative genes by hypermetalation. Agents are now available to hypomethylate these genes and tame the cancer cells preventing them from proliferation rather than killing them. I believe that cancer cells are dangerous to us because we do not understand them. Careful study of these remarkable cells may reveal many secrets of our own biological machine.

Once we understand cancer cells, we may not need to wage a "war" on them at all. In the meantime, I hope that somebody will invent a metaphor other than "war on cancer," one that reflects the remarkable scientific progress in cancer research during the last 35 years.

* FoxChase Cancer Center, Philadelphia, PA

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