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Question: When is chemotherapy the wrong choice?

Clifford Hudis: 
Well, that’s a hard question to answer because that gets to a real nitty-gritty issue:  Why do we use chemotherapy?  How does it work?  And so there are very specific clinical situations I can describe that would answer your question but they wouldn’t be applicable to most people. They wouldn’t even relate to what most people are going through. An easy example is chemotherapy is not the right choice when somebody does not have an invasive breast cancer. There are some breast cancers that while present have no ability to spread to other parts of the body. The second thing which is-- becomes a little more of a slippery slope is there are some patients with very
low-risk breast cancer where chemotherapy is not the right choice and there are patients who have metastatic breast cancer-- that’s the kind of breast cancer that’s not curable-- where chemotherapy may be the right choice later but maybe not initially. So it’s hard to be more specific than that.


Question: Is breast cancer linked to environmental destruction?

Clifford Hudis:  Well, that’s a very complex issue because specifically there are certainly links. Ozone depletion with increased UV light exposure causes melanoma and less scary skin cancers like basal cells and squamous cells. Toxins in high concentration certainly cause some specific cancers like bladder cancer, lung cancer and so forth. The more general question people are asking is whether their overall environment that they transit through over the course of decades does that cause cancers that are common like breast or colon?  And that’s a pretty tough thing to answer. Very carefully done studies for example of the low-level pesticide exposures that you might get living in a rural community have not-- and I want to emphasize that-- have not shown the expected association with breast cancers yet that’s a popular assumption out there. The other thing that I just will interject and at the risk of being a little bit controversial I want to point this out--  Not talking about industrial accidents or egregious abuse of the environment, but some of the low-level toxins in the environment are there for reasons that in the net sum may be worth it. For example, a very healthy food supply protected by pesticides may raise some risks but this week it’s a topical issue because there’s concerns about the quantity of food produced on earth, and the truth is that we need some kind of management of those crops to feed 6, 7, 9 billion people expected over the next decades. And so we’re balancing kinds of risks and yes, we could have for example a purely organic food supply but what would we trade off to get that?  Would we trade off starvation in poor countries?  Would we trade off occasional poisonings of healthy people because there were bacterial over- there was bacterial overgrowth in those foods and so forth?  And I know venturing a little beyond my narrow area of expertise but I think you have to think somewhat globally about all of this. So an ideal world you’d have perfectly safe pesticides that never caused a problem and that’s what we should work towards but the attribution of causality from the environment to breast cancer in particular remains a very, very difficult issue.

Question: Does mercury in fish cause cancer?

Clifford Hudis: Mercury in fish has been associated with other very specific neurotoxic effects but not specifically breast cancer. I’ll give you a very concrete story. Now again I’m venturing outside my area of expertise but there’s a kind of controversy regarding cell phone use and brain cancer that’s been highlighted by recent events in the news. What’s interesting about it is that the issue was raised, it was refuted by every study that’s looked at it so far, and there’s kind of a second wave of skepticism saying, “Well, how do we know that over the decades to come we won’t discover that it does?”  So then we do basic science and the truth is that at the basic science level right now it’s been very hard to even demonstrate a mechanism by which cell phones would cause brain tumors, and yet the concern lives on and it’s addressed in a very expensive fashion in some cases. So we have to admit that we bring biases to it. In the example I just gave, there is a bias that cell phones must cause some kind of bad outcome, cancers, and we’re willing to explore it ad infinitum as it were, and maybe it does but we don’t have evidence that it does.


Question: Are pharmaceutical companies doing enough?

Clifford Hudis:  Very, very complex question. Pharmaceutical companies are doing what they can do primarily to raise shareholder value. That is of course always embedded in an idea that they’re trying to make the world better but they try to make the world better in part because it improves their profitability. Right? 

In an ideal world more of this work would be done by unbiased investigators funded publicly so that there would be no need to let’s say increase shareholder value, but that’s not the world we live in. In the world we have right now, a modest amount of work is done on the public side and a lot is done on the private side. I would like more to be done but it’s expensive and people make choices based on economics as opposed to health.

Question:Is the government doing enough?

Clifford Hudis:  Well, at the risk of sounding self-serving and recognizing that there’s no government on earth that devotes as much money to cancer research as the U.S., I have to point out that the rate of growth in that funding has been essentially zero for many, many years now. In inflationary terms, the purchasing power of the U.S. federal budget for cancer research has gone down. The estimates I’ve heard are about 20% over the last eight to ten years and so we have to ask ourselves as a society, “Is this reduced investment in cancer research specifically and health care research in general actually the way we want to direct our focus?”  If collectively our society says, “Yes. We don’t want to do public sector research,” then I guess we’re doing the right thing. I personally would hope we would come to a different conclusion. I think the public funding of science overall, health overall, and cancer specifically all is important. About a third of Americans are going to die of cancer. The proportion of money we spend on that relative to other less life-threatening concerns is somewhat disheartening at times.



 

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