A vision for the future

Predicting the next revolution in cancer care is admittedly an uncertain undertaking but cumulative evidence of a system gone astray and nascent trends for correction are unmistakable. Until recently, researchers and their sponsors focused their efforts, and clinicians and their patients centered their hope more on the eradication of advanced cancer than on its prevention or detection in surgically curable early stages. This arose from the belief that cancer represents a seldom preventable, deadly tissue growth that is difficult to diagnose in early stages, is distinct from the host and, as such, must be eradicated. However, while surgery is adept at eradicating early-stage cancer, the types of cancer drugs fostered by the notion of non-self are inefficacious in altering patients’ outcome, and the notion itself was proven obsolete by recent advances in cancer genetics. Additionally, it is increasingly clear that translational application of cancer genetics data is the foundation for the emerging pharmacogenomics of the future that will replace the trial-and-error approach of the past. Thus, the time has come to develop a new approach to cancer control based not on eradication at any cost but on comprehensive, stepwise, and evidence-based measures. They include prevention, early diagnosis, and, when these fail, on controlling the aberrant molecular genetic pathways underlying the development, growth, and dissemination of cancer (the caveat “when these fail” underscores the difficulties of controlling complex genetic abnormalities often associated with advanced cancer). Adoption of such broad-based cancer control measures requires a fundamental paradigm shift 1 of such a magnitude and reach that its adoption and implementation is likely to be resisted by supporters of the old, cell-kill paradigm. Indeed, as Max Planck the physicist who postulated the quantum theory observed, “An important scientific innovation rarely makes its way by gradually winning over and convertingits opponents … Instead, opponents gradually die out and the new generation adopts the idea from the beginning”. It might be argued that old hypotheses about the nature of cancer and theories about its treatment seemed cogent when first proposed and were proven wrong only in retrospect, and that the new paradigm might also lead us adrift. However, the inability of the old paradigm to explain most of the recent scientific tenets regarding the nature of cancer and its inadequacy as a foundation for spawning efficacious treatments can be neither redeemed, redressed, nor improved by any future discoveries potentially on its path. In contrast, the new paradigm is anchored on new scientific information regarding the nature, development, and progression of cancer and is supported by clinical studies that provide proof of concept of each of its component parts. Indeed, the crucial role played by prevention and screening on declining of cancer incidence rates recorded since 1992 was underscored in NCI’s 2001 Cancer Progress Report 2. It acknowledged, “Behind the numbers are declines in certain behaviors that cause cancer, especially cigarette smoking by adults. More people are getting screened for breast, cervical, and colorectal cancers”. Likewise, the success of Imatinib mesylate, a drug developed to harness the molecular defect that causes chronic myelocytic leukemia rather than to kill the leukemic cells, and its success in the clinical arena provide proof of concept in support of molecularly targeted agents of the future. Thus, because it is sound in conception, based on scientific and clinical evidence, and of plausible implementation, the proposed new paradigm is likely to succeed in controlling cancer. Nevertheless, cognizant of the enormity of the task at hand and of the difficulties lying ahead my purpose is not to impose my vision for the future but to encourage a long overdue paradigm shift that is necessary to ultimately control cancer, whether or not it follows my proposal. The fate of over one million Americans who develop cancer each year, and millions more around the World, depend on it.


Leukemia Influenza Sarcoma Paclitaxel Doxorubicin 


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© Springer Science + Business Media B.V 2008

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