1. In the March 22, 2004 issue of Fortune, an extensive expose of why there has been no progress in drug treatment of cancer in three decades, the author writes that it is not localized tumors that kill people with cancer, it is the process of metastasis, 90% of the time. Aggressive cells spreading to the bones, liver, lungs, brain or other vital areas, that are wreaking havoc.

You'd think cancer researchers would be bearing down on the intricate mechanisms of invasion and spread? However, according to a Fortune examination of NCI grants going back to 1972, less than 0.5% of study proposals focused primarily on metastasis, trying to understand its role in cancer or just the process itself. Of nearly 8,900 NCI grant proposals awarded in 2003, 92% didn't even mention the word metastasis.

So pharmaceutical companies don't concentrate on sloving the problem of metastasis (the thing that really kills people); they focus on devising drugs that shrink tumors (the thing that dosen't). There is a national problem in the way we treat the problem. A patient responds to therapy when their tumor shrinks, but apparently this has nothing to do with survival. A tumor responds, that is shrinks a little, then quickly grows and spreads. The cancer comes back with a vengeance and a cancer patient is given a death sentence by metastasis.

Sure, some critics will say that researchers are bearing down on invasion and spread, but why are most oncologists still doing the same old thing? Even oncologists will admit that the role of chemotherapy is unclear, that responses are generally transient, and virtually no cures are reported. Even today, 90% of all drug cures occur in only 10% of cancer types that are intrinsically drug-sensitive, acute childhood leukemia, testicular, and Hodgkin's disease. Oncologists will also admit that an active drug (a drug that may temporarily shrink a tumor) has no relationship to a cure.

The Fortune article is one of the most complete and revealing on the subject; a must reading for anyone who wants to understand the US healthcare's mistaken direction:

http://blog.aperio.com/articles/Fortune_Cancer.pdf

Posted at 12:52AM on Sep 3rd 2006 by Gregory D. Pawelski

2. Thanks for the given information

Posted at 9:39AM on Sep 3rd 2006 by Taras

3. "The complexity of metastasis may well have discouraged research. To metastasize, cancer cells have to acquire several dozen genetic alterations -- in contrast with the handful typically necessary to initiate a primary tumor, Massague said.
Further complicating matters, each case of metastasis -- breast cancer that spreads to a lung, for instance, or prostate cancer that spreads to bone -- is genetically and molecularly different from the rest."


http://www.goupstate.com/apps/pbcs.dll/article?AID=/20060815/ZNYT04/608150321/1051/NEWS01

We have recently seen the possible benefit from gene therapy with Rosenberg's trial on melanoma metastasis. It took him a decade to get here.

With the very recent understading of the genome, the future looks bright for potential genetically-based treatments of metastasis. The "mistaken direction" which saves important days, months, and years, for patients and their families will continue to play a vitally important role for many years to come.

Posted at 1:14PM on Sep 3rd 2006 by Michelle

4. Metastasis is an organism-wide phenomenon that may involve dozens of processes. It's hard to do replicable experiements when there are so many variables. So, instead, researchers opt for more straightforward experiments that generate plenty of reproducible results (like tumor shrinkage). This gives the illusion that researchers have done something meaningful.

Tens of thousands of scientists pushing a goal of finding the tiniest improvements in treatment rather than genuine breakthroughs, that fosters redundant problems and rewards academic achievement and publication above all else.

The needed change in the "war on cancer" will not be on the types of drugs being developed, but on the understanding of the drugs we have. The system is overloaded with drugs and underloaded with the wisdom and expertise for using them.

Posted at 5:39PM on Sep 3rd 2006 by Gregory D. Pawelski

5. From 1600 B.C. on, historians find records of attempts to treat cancer. In the naturalist Disney film, "Never Cry Wolf", the biologist sent to the Arctic to observe the behavior of wolves found that the wolves would kill off the easiest prey, which were sometimes animals suffering from leukemia.

It's everywhere and one may think from reading some authors that academic achievement and publication are the only two things that drive scientists who labor many hours and have little time to blog while they actually make menial salaries.

There are 7 million Americans living today who have been cured of cancer. Twenty years ago, surgery for breast cancer routinely removed the entire breast, lymph nodes and chest muscles in a procedure called radical mastectomy. New methods favor a "lumpectomy" or removal of merely the lump, followed by radiation and/or chemotherapy. In other words, surgeons are becoming more rational and restrained in their efforts to surgically remove the cancer.

Richard Adamson, PhD, Chief of Cancer Etiology at the National Cancer Institute, says that progress has been made against cancer as death rates from colon and rectal cancer have fallen 15-20% in the last 20 years; and other death rates have dropped, including 20% for ovarian, 30% for bladder and 40% for cervical cancer.

Bruce Ponder, one of the British contributors to the discovery of the BRCA1 and BRCA2 breast cancer genes, states: “We have come a long way in the past two decades and what we see is dauntingly complex. It’s like walking on a waterbed: resolve one problem and five or six others pop up somewhere else. It is not one disease, it’s hundreds.”

Try not to get too depressed. We are making progress. There are thousands who truly care, who fight the battle and are part of the solution.

Here's an example:
http://www.nhregister.com/site/index.cfm?newsid=16376693&BRD=1281&PAG=461&dept_id=517515&rfi=8

Posted at 9:16PM on Sep 3rd 2006 by Michelle

6. That's the sad thing. There will be more people dying of cancer before they even find the cure for it. And I know that we are not suppose to be losing hope but from the looks of it. We'll soon find ourselves hoping for nothing.

Posted at 10:24PM on Sep 3rd 2006 by tin8

7. It seems that a lot of cancer patients are coerced into forgoing surgery and head right into chemo, even when a cancer can be surgically excised. Even those that are so-called inoperable, with todays surgical precision, it is few and far between. Some researchers believe the reason for better survival for patients who could undergo complete resection without any tumor left behind is that these tumors are biologically less aggressive and would do better regardless of the type of treatment they receive, and that the removal of lymph nodes at the time of surgery may additionally contribute to a better outcome.

The line of reasoning frequently used to explain the value of surgery included five points. First, surgery is thought to remove resistant clones of tumor cells and thus decrease the likelihood of the early onset of drug resistance. Second, the removal of large masses likely to be associated with poorly vascularized areas of tumor improves the probability of delivering adequate drug doses to the remaining cancer cells. Third, the higher growth fraction in better vascularized small masses enhanced the effect of chemotherapy. Fourth, smaller masses required fewer cycles of chemotherapy and thus decreased the likelihood of drug resistance. Fifth, removal of bulky disease enhances the immune system.

It is likely that surgical skill is a more important determinant of prognosis than the aggressive nature of the cancer or its stage at diagnosis. You are more likely to get a good surgeon at an institution that has performed surgeries on many patients with successful outcomes. Some surgeons view chemotherapy as a remedy for bad surgery. Chemotherapy just isn't good enough to make up for surgical mistakes (e.g. failure to get good margins, tumor spills during surgery, etc.). The most important prognostic factor is the surgeon.

A chemo-induced gene mutation can happen when the original chemo received does not work (all the more reason to test the tumor first). The cancer comes back. When it does this, the cancer comes back more aggressively (metastasis). The mutagenic effects of chemotherapy on a genetically-unstable tumor, drives the tumor into a state of more aggressive behavior. You might kill off a whole lot of cancer, only to cause a mutation in the remaining cancer, such that the remaining cancer behaves in a more aggressive fashion. Like when chemotherapy on an ER+ cancer brings about a remission, but in the process also causes any remaining cancer to become ER-.

Posted at 1:12PM on Sep 4th 2006 by Gregory D. Pawelski

8. All chemotherapy will induce genotoxicity. That's a given. And it, of course, is NOT just treatment that can lead to resistance, but the very nature of a particular tumor itself.

Oncologists should take account of potential resistance mechanisms when treating patients: it is often feasible to design combinations with old or new drugs which exploit these apparent weaknesses to the patient's advantage. The development of drug resistance is one reason that drugs are often given in combination. It is thought that this may reduce the incidence of developing resistance to any one drug.

G.P. states "Chemotherapy just isn't good enough to make up for surgical mistakes."

Who determines what a surgical mistake is? Just because cancer returns, one blames the surgeon? Ouch.
Sounds like I might as well forego chemotherapy. But, I say no. Science is moving along rapidly in the field of cancer research despite what one may read from some.

http://www.sciencedaily.com/releases/2005/02/050224105956.htm

Don't throw out the chemotherapy baby with the "poor" surgical outcome bathwater. In fact, chemotherapy benefits those with gene mutations.

http://professional.cancerconsultants.com/news.aspx?id=29057

Posted at 5:55PM on Sep 4th 2006 by Michelle

9. Researchers have seen that whether a tumor was a breast, lung or ovarian tumor, it didn't correlate to how the cancers interacted with standard anticancer drugs. Their findings suggest that traditional cancer treatments, which have established different drug regimens for breast, lung or ovarian cancer, should be replaced with therapies that use drugs deemed to be of highest benefit. Treatment choice should be determined by how each patient's tumor reacts to anticancer drugs, regardless of the tumor's anatomical origin.

A drug's effect is independent of where the tumor came from in the body. Under current treatment selection methods virtually no chemotherapeutic drug has been successful in more than 50 percent of patients with advanced cancer. But instead of considering a drug that works only ten percent of the time a failure, it would be better to consider such a drug effective for one in ten tumors and to search for the agents among the current arsenal of chemotherapeutic drugs that will work for the rest.

Every cancer patient should have their own unique chemotherapy trial based on consultation of pathogenic profiles and drug sensitivity testing. Having a good tumor-drug match not only would improve survival rates, it would be cost-effective, and the high cost of the newer cancer therapies reinforces the necessity of choosing the right therapy the first time around.

Posted at 11:10AM on Sep 5th 2006 by Gregory D. Pawelski

10. It's simply too early to make definitve statements about individualized chemoassay testing. The companies producing the tests know this and in vivo studies have begun. Until then, the evidence is woefully lacking. I look forward to the study results. The infesrence arrow form the evidence to the claim does not exist at this time.

http://www.cigna.com/health/provider/medical/procedural/coverage_positions/medical/mm_0203_coveragepositioncriteria_in_vitro_chemosens_chemoresist_assays.pdf#search=%22individualized%20chemotherapy%20unproven%22

Posted at 11:52PM on Sep 5th 2006 by Michelle

11. One of the woeful inadequacies of the cancer research leadership is that only one specific assay technology is worth studying, rather than carrying out comparative studies of different types of assay technologies, based on different biological endpoints. What are they afraid of? Even the NCI and NCI-funded university researchers put all of their eggs in a single basket in shackling the whole concept of cell culture assays to a single technology, rather than moving from the cell proliferation endpoint to the cell death endpoint.

The NCI made a feable attempt years ago to study cell culture assays of lung cancer. Their expertise was in establishing permanent cell lines and they only tested tumors after first culturing them to amplify their cell number. The result was that their assay evaluability rate for primary lung cancers was only 11%. The second problem they had was that they were selecting subpopulations. Subsequent work showed that you get different results when you test passaged cells compared to primary, fresh tumors. The third problem was that the ability to get lung cancer to actually grow is an independent marker for virulent disease. It was actually the single greatest negative predictor for survival.

So the NCI concluded that it was too much trouble and not all that useful. If they couldn't get it to work at the NCI, then of course no one can do it. "If Mickie doesn't like it, nobody will." What a heck of a way to do science! One of the physicians that worked on these studies now knows and readily grasps the limitations and non-applicability of the NCI efforts.

Also, the NCI has a huge lab working on microarrays to look for patterns of mRNA and protein expression which are predictive of chemotherapy response. They spent two years trying to find patterns which correlated using the NCI's various established ovarian cell lines. They thought they had something, but when they started to apply them to fresh tumor specimens, none of the results in the cell lines was applicable to the fresh tumors. Everything they'd worked out in the cell lines was not worth anything and they had to start over from square one.

But thanks to the genius of the American private enterprise system, start-up companies sprouted, and successfully achieved what the NCI and NCI-funded university researchers could not do, bring cell culture assays into mainstream practice in cancer medicine. There is an enormous amount of published, peer-reviewed research documenting the accuracy of cell culture assays. Scores of studies in thousands of patients, based on both response and survival. The preponderance of currently-available evidence argues persuasively in favor of the use of the assays.

Having some foreknowledge of a given chemo agent's expected result before it is administered into the body, would benefit the individual patient. The cost of drugs is enormous! Patients are followed with serial CT scans, MRI's and even Pet Scans, just to see if a tumor is growing or shrinking. Not to mention the hospitalizations for toxicity, bone marrow tranfusions, etc. The point is, the cost of ineffective therapy is truly enormous and cell culture assay testing is particularly good at identifying ineffective therapy.

Posted at 3:18AM on Sep 6th 2006 by Gregory D. Pawelski

12. "There is an enormous amount of published, peer-reviewed research documenting the accuracy of cell culture assays. Scores of studies in thousands of patients, based on both response and survival.

In fact, "the bulk of the literature regarding extreme drug resistance assays have focused on correlation studies that correlate results from predictive in vitro assays with observed outcomes of chemotherapy. However, in these studies, the patients do not receive assay-guided chemotherapy regimens. As discussed in a 2000 TEC Assessment, correlational studies are inadequate for several reasons. FIRST, such studies often aggregate patients with different tumor types, disease characteristics, chemotherapy options, and probabilities of response. This process is problematic since the accuracy of each assay used to predict in vivo response probably varies across different malignancies and patient characteristics. SECOND, the method by which assay results are translated into treatment decisions is not standardized. Without knowing the rules for converting assay findings into treatment choices, it is impossible to determine the effects of assay-guided treatment on health outcomes. THIRD, it is important to consider not only response, but also survival and adverse effects. The overall value of assay-guided therapy depends on the net balance of ALL health outcomes observed after treatment for all patients subjected to testing, regardless of the assay results or the accuracy of its predication for response. A literature search found no prospective studies focusing on the use of the EDR.

For example, Staib and colleagues studied the use of the DISC chemosensitivity index Ci assay to select effective chemotherapy for 226 patients with previously untreated acute myeloid leukemia. (21). Of the 162 evaluable patients, there were 11 (69%) complete response rates, 34 (21%) blast reduction, no response in 17 (10%), relapse after complete response in 53 (48%), and deaths in 89 (55%). When compared to a non-randomized comparison group, none of the documented outcomes were statistically significantly different. This is an example of a typical study that does not address the limitations noted in the above discussion. In fact, no studies have been identified that provided direct evidence comparing outcomes for patients treated either by assay-guided therapy or contemporaneous empiric therapy.

http://www.regence.com/trgmedpol/lab/lab06.html

Again, one cannot make a claim of benefit without the data to supoort said benefit. For example, I can tell you that the carrot holds a particular health benefit. I can then state that the my test accurately predicts the amount of beta carotene in the carrot, the carotenoid deemed to be beneficial. Can I then state that the carrots identified by my technique as having the most beta-carotene benefit an individual more than those carrots with less beta-carotene? No. Not until I've done the research on the individuals.

Luckily, those companies who have developed the assay tests understand the need to show benefit before tooting their own horns.

And, those rigorously performed tests have just begun. I look forward to the results. Until then, despite the excitement, I'll reserve my opinion.

Posted at 8:13AM on Sep 6th 2006 by Michelle

13. When most academic oncologists refer to cell culture assays, they are virtually always referring to and thinking about "the human tumor stem cell assay" or "clonogenic assay," Yet this technology hasn't been used by any private sector laboratory for more than 15 years.

Most so-called "tech assessments" omit any mention or reference at all to the non-clonogenic or "cell death (apoptotic) assays" which have been most extensively studied and reported on in recent years. These assays are the ones in use at a number of private laboratories, as well as reported in major studies by European and Japanese investigators and by the National Cancer Institute.

There was a summary paper from a National Cancer Institute study published at the American Society of Clinical Oncologist Annual Conference in 1998, that looked at 13 different studies in "in vitro" drug sensitivity testing for patients with cancer. Many different cancers were represented in these studies. The chemotherapy response rates went up from 3% to 66% (using standard chemotherapy drugs and procedures) and from 21% to 81% (using in vitro testing for the most responsive drug) and patient survival increased from 4.5 months to 11.2 months (using standard procedures) and from 6.2 months to 38.5 months (using in vitro testing).

Established cell lines have been proven to have no predictive value at all with respect to clinical activity. The NCI spent $15 million dollars on a single cell suspension fresh tumor assay with cell proliferation, rather than cell death as an endpoint. When is didn't work, they folded their hand and specifically discouraged future applications of cell culture testing. They never supported any drug development work based on primary cultures of three dimensional cell clusters with cell death endpoints, which do very nicely recapitulate known disease specific activity endpoints. However, history tends to repeat itself. Good luck on your so-called "rigorously performed tests."

Posted at 11:40AM on Sep 6th 2006 by Gregory D. Pawelski

14. A search of PUBMED shows very few studies over the past 5 years on cell culture assay benefit. Maybe the field is heating up again. Perhaps the companies, with their newfound incomes from some health insurance companies, can do the rigorous research not yet done. They know it's required. They don't need "luck" unless they just want to post testimonials as research.

They need evidence.

Until then, we have some studies to look back on. As just one example:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10738268&dopt=Abstract

Posted at 11:56AM on Sep 6th 2006 by Michelle

15. You just proved my points in your limited review about EDR and the tech assessements. Thanks!

Posted at 4:28PM on Sep 6th 2006 by Gregory D. Pawelski

16. I make no inference to chemoresistance assay benefit as being nothing more than quack science by directing one to this site.

And neither dies the author:
http://quackwatch.org/01QuackeryRelatedTopics/Tests/eva.html

The time for prospective trials has arrived. Until then, I'll reserve my opinion.

Posted at 7:28PM on Sep 6th 2006 by Michelle

17. It is extraordinary difficult to prove the efficacy of chemotherapy in general and of specific drug regimens in particular in studies of empiric-directed chemotherapy (which little has been achieved in the area of empiric methods of drug selection). Only with extremely large studies has it been possible to document that chemotherapy of any type produces survival advantages in many clinical situations.

According to the National Cancer Institute’s March 31, 2006 official cancer information website on "state of the art" chemotherapy for recurrent or metastatic breast cancer, it is unclear whether single-agent chemotherapy or combination chemotherapy is preferable for first-line treatment. At this time, no data support the superiority of any particular regimen. So, it would appear that published reports of clinical trials provide precious little in the way of guidance.

In the total absence of guidance from published reports of clinical trials then, what basis are treatment regimens selected instead? What basis are drugs chosen today for use in the many clinical settings in which a single best empiric regimen has not been well-defined? ASCO says that this should be further based on a patient's health status and patient treatment preferences. So what is being done?

Recently published in the journal Health Affairs is a joint Harvard/Michigan study. The authors documented a clear association between reimbursement to the oncologists for the chemotherapy of breast, lung, and colorectal cancer and the regimens which the oncologists selected for the patients. In other words, oncologists tended to base their treatment decisions on which regimen provided the greatest financial remuneration to the oncologist.

A March 8, 2006 New York Times article described the study. One of the more interesting aspects of the story was a comment from an executive with ASCO, who disputed the study's findings, saying that cancer doctors select treatments only on the basis of clinical evidence.

Yet a "Patterns of Care" reported a survey of breast cancer oncologists based in academic medical centers and community based, private practice medical oncologists. The former oncologists do not derive personal profit from the administration of infusion chemotherapy, the latter oncologists do derive personal profit from infusion chemotherapy, while deriving no profit from prescribing oral-dosed chemotherapy.

The results of the survey could not have been more clear-cut. For first line chemotherapy of metastatic breast cancer, 84-88% of the academic center-based oncologists (who are motivated to keep off-protocol patients out of their chemotherapy infusion rooms to reserve these rooms for on-protocol patients) prescribed an oral-dose drug (capecitabine), while only 13% prescribed infusion drugs, and none of them prescribed the expensive, highly remunerative drug docetaxel.

In contrast, among the commuity-based oncologists, only 18% prescribed the non-remunerative oral-dose drug (capecitabine), while 75% prescribed remunerative infusion drugs, and about 40% prescribed the expensive, highly remunerative drug docetaxel.

The existence of this profit motive in drug selection has been one of the major factors working against the individualization of cancer chemotherapy. In the absence of a cell culture assays, oncologists will continue to base their drug selections on reimbursement more than on any other single factor. Absent assay testing, they are free to choose the most remunerative therapy. They have your "quack" by the beak.

Posted at 9:47PM on Sep 6th 2006 by Gregory D. Pawelski

18. A far less cynical take is indicated below. I'm beginning to see that the real disgust with the current cancer therapy worldview comes back to a focus on money. But, is that cynical worldview completely accurate? Is the patient nothing more than a valuable commodity?

March 8, 2006
Pay Method Said to Sway Drug Choices of Oncologists
By REED ABELSON

Correction Appended


The way cancer doctors are paid may influence the choice of drugs they use in chemotherapy, a study published yesterday has concluded.

Payment methods do not seem to affect whether doctors favor chemotherapy over other treatments, the study's authors said. But once they decide to use chemotherapy, the current payment system appears to prompt some doctors to use more expensive drugs, the study found.

"Providers who were more generously reimbursed," the authors wrote, "prescribed more costly chemotherapy regimens to metastatic breast, colorectal and lung cancer patients." The study, by researchers from the University of Michigan and Harvard University, is published in the current issue of the academic journal Health Affairs.

Unlike other physicians, a cancer doctor can profit from the sale of chemotherapy drugs in a practice known as the chemotherapy concession. These doctors are paid for the cost of the chemotherapy drugs given intravenously in their offices — even though they frequently purchase the drugs at lower prices than the amounts they are paid in insurance reimbursements.

One government study said that cancer doctors, or oncologists, were receiving discounts as high as 86 percent on some chemotherapy drugs. The doctors then pocketed the difference.

While critics say this creates a potential conflict of interest among oncologists advising patients on treatment, the doctors have said the profit is needed to pay the high cost of running their practices. They also have said the revenue allows patients to be treated in their offices rather than in a hospital, which is more expensive and less convenient to patients. But some insurers, including Medicare, the federal insurance program for the elderly, have tried to change the way they pay doctors to reduce their profit from the sale of chemotherapy drugs.

An executive with the American Society of Clinical Oncology, Dr. Joseph S. Bailes, disputed the study's findings, saying that cancer doctors select treatments only on the basis of clinical evidence. "All of us are looking at clinical trials," he said.

Recent changes in the Medicare reimbursement system, aimed at paying doctors more for the services they provide and less for the drugs, help address some of the concerns, he said. Medicare also began a program this year in which oncologists are paid simply to tell Medicare about the treatments they are choosing. "What we're trying to do is to increasingly pay for quality, not just services," said Dr. Peter B. Bach, a senior official with Medicare.

The researchers looked at how much Medicare paid for different chemotherapy drugs and how 9,357 cancer patients over 65 years old in late stages of the disease were treated from 1995 to 1998. The researchers focused on the treatment of metastatic cancer, or cancer that has spread in the body, because they said doctors had the most discretion in treating patients in advanced stages of the disease and in prescribing chemotherapy treatments.

Because there is little evidence that one chemotherapy drug works better than another, "the physicians have more control over the agents chosen," one of the authors, Joseph P. Newhouse, a professor of health policy and management at Harvard, said in an interview.

Dr. Bailes disagreed. He said there was clear clinical evidence about which drugs should be used even in advanced stages of the disease and that doctors recommended the most appropriate treatments.

Doctors, despite their insistence that their treatment decisions are based solely on what is best for the patient, are affected by payment policies and other financial influences, including gifts from drug companies, said another of the study's authors, Dr. Craig C. Earle, an associate professor of medicine at Harvard and an oncologist at the Dana-Farber Cancer Institute in Boston. "When people look for correlations, it really does affect what we do," he said.



Correction: March 13, 2006

An article in Business Day on Wednesday about a study in the journal Health Affairs assessing the impact of payment methods on doctors' choices of cancer drugs misstated the scope of the findings. Although some of the discussion in the article referred to the continuing practice of payment to cancer doctors for the drugs used by patients, the Health Affairs study dealt only with Medicare reimbursement for such drugs from 1995 to 1998, not current payment methods.

Posted at 6:54AM on Sep 7th 2006 by Michelle

19. For all those who think oncologists are in it for their next yacht payment:

http://waysandmeans.house.gov/hearings.asp?formmode=printfriendly&id=5247

Posted at 11:06PM on Sep 7th 2006 by Michelle

20. While the Michigan/Harvard study showed results before the new Medicare reform, the Patterns of Care study showed results that the Medicare reforms are still not working. It is still an impossible conflict of interest. Once a decision to give chemotherapy is taken, oncologists receiving more-generous Medicare reimbursements used more-costly treatment regimens.

I didn't need two studies to tell me the reality that once a decision to give chemotherapy is taken, the medical oncologists at our so-called community cancer center had the financial incentive to prescribe a $15,000 Taxol + Carboplatin combination regimen to my wife, instead of a $1,500 alkylating agent (Leukeran) she had before. It is commonplace to give the same treatment to a recurrence (after six months) as was given for the original tumor.

Patients who develop recurrent ovarian cancer more than six months after first-line chemotherapy (in my wife's case, 24 years) can experience another remission following treatment with the identical first-line chemotherapy that was previously used (in her case, an alkylating agent).

Even one of the vice presidents of Bristol-Myers Squibb remarked to me that single-agent Carboplatin, which has the same mechanism that affects tumor cells like Leukeran (both alkylating agents) would have been much better for her.

But our so-called community cancer center oncologists do not think about what they are doing. They do what they are told, by populations studies and oncology associations that protect the ability of medical oncologists to choose drugs largely on the basis on profit margin.

It's not that all oncologists are bad people. It's just that it is still an impossible conflict of interest. Some oncologists prescribe chemotherapy drugs with equal efficacies and toxicities. I would imagine that some are influenced by the whole state of affairs, possibly without even entirely admitting it. There are so many ways for humans to rationalize their behavior. The solution is to change the system.

Posted at 6:29PM on Sep 8th 2006 by Gregory D. Pawelski