Listening to a voice of reason on cancer

WHAT a relief it was to hear a voice of sanity and realism about cancer and the plethora of new drug treatments being produced and promoted by drug firms, at vast expense to those paying for them.

Dr Richard Sullivan, Professor of Cancer and Global Health at King’s College, London, who was in New Zealand for a conference on cancer, was interviewed by Kim Hill on her RNZ Saturday morning programme on February 2, and was scathing about some of the recently developed, hugely expensive, cancertreating drugs being promoted — sometimes by dubious means, such as funding apparently unbiased ‘‘experts’’ and ostensibly patientcentred pressure groups (they’ve learnt from Big Tobacco) — by pharmaceutical companies.

Some of these ‘‘miracle cures’’, he said, ‘‘don’t do what it says on the tin’’, pointing out that the use of surrogate endpoints in research has confused matters. For instance, observed shrinkage in tumour size with treatment (a commonly used indirect research endpoint) doesn’t automatically mean that length or quality of life has been improved — sometimes they’re made worse.

He also noted that the astronomical prices charged for these drugs are frequently unjustified, and represent very high returns for the maker on their research and development costs. The cost of R&D is a constantly proffered ‘‘justification’’ for the high prices charged (though often the basic research has been done by governmentfunded entities, such as universities), but it pales compared to the marketing expenditure of Big Pharma companies.

The Washington Post reported in 2015 that in 2013, 10 big pharmaceutical companies together spent

$US60.8 billion ($NZ89.4 million) on R&D, but $US98.3 billion on marketing. Johnson & Johnson spent

$US8.2 billion on R&D, but

$US17.2 billion on marketing. Only one spent more (just) on R&D

($US9.3 billion) than marketing

($US9 billion).

It’s worth noting, too, that research can be designed to maximise the benefit to a company’s bottom line, at the expense of patients. Roche researched a year’s treatment with Herceptin, but didn’t report on the efficacy and relative incidence of side effects of shorter treatment regimes.

Prof Sullivan also noted how politics encourages high prices. The astronomical prices paid in ‘‘the land of the free’’ (to charge what one likes) for many drugs have become regarded as normal, and sometime British Prime Minister David Cameron’s politically driven ‘‘exceptional cancer drug fund’’ for England and Wales, unconstrained by the National Institute for Health and Care Excellence’s evidencebased process, created a freeforall for new drugs, and at times shortened patient lives. Thank goodness New Zealand has Pharmac.

He reminded listeners that drugs are only responsible for 8%10% of cancer control (the main tools are surgery and radiotherapy) and that early detection is vital.

In that context, it was helpful to hear evidencebased advice from Prof Sullivan about prostate screening. He pointed out that prostate cancer is almost ubiquitous in older men (80% of those aged 80 will have some form of it), but most of those picked up by populationbased prostate specific antigen (PSA) screening are what he called ‘‘pussycats’’, which their hosts will die with, not of. Many of the

‘‘tigers’’ (rapidly progressive cancers) will already have spread by the time of detection.

He was adamant that ‘‘No country should be doing [populationbased]

PSA screening’’, because, overall, the harm done to men (through invasive investigation, and treatment) by populationbased screening of those without symptoms, or a family history of prostate cancer, exceeds its benefits.

The public is regularly told of men whose cancers have been found and treated. It’s perhaps understandable that some whose cancer was found by PSA screening have an unreasoned passion for screening, despite the evidence.

One article seen recently by Civis, though, told of a cancer detected by investigation of blood in the urine, and concluded with an exhortation for all men over 50 to have regular screening by PSA and digital examination.

That’s not only a nonsequitur, but actively harmful advice. Such enthusiasts should remember the doctors’ traditional mantra ‘‘First, do no harm’’.