Azra Raza. Photo: Columbia University
- Cancer, Azra Raza explains, is vicious and self-obsessed: it learns to grow faster, and become stronger, smarter and more dangerous.
- The failure rate of potential cancer-treating drugs brought into clinical trials using preclinical drug testing platforms is as high as 95%.
- In ‘The First Cell’, Azra Raza offers early detection as a way to shift gears and take a shot at significantly improving patient outcomes.
Despite advances in medical science, cancer remains a deadly disease. Some 18.1 million cancer cases were diagnosed globally in 2018; half of these people died. The American Cancer Society has estimated that the world’s cancer burden will soar to 21.7 million new cases and 13 million deaths by 2030.
US-based Azra Raza, a respected oncologist of Pakistani origin, has been treating cancer patients for around two decades. Her grouse, articulated in her book, The First Cell, is that most new drugs add mere months to one’s life, that too at great physical, financial and emotional cost. In her telling, the reason the war on cancer has reached an impasse is because doctors are essentially trying to protect the last cell, instead of checking the disease at birth. This has to change, and now, Raza writes with an evangelist’s passion.
Raza is a specialist in a bone marrow preleukemic condition called myelodysplastic syndrome (MDS), and acute myeloid leukemia (AML), which develops in a third of MDS patients. The treatment landscape for AML has not evolved much in the last half century, nor in fact has it vis-à-vis most common types of cancers. With minor variations, the slash-poison-burn approach to treating cancer remains the staple: surgery, chemotherapy and radiation. No one, she says, is winning the war on cancer. Claims to the contrary are mostly hype.
Why is the situation so dismal? Cancer, Raza explains, is vicious and self-obsessed. It learns to grow faster and become stronger, smarter and more dangerous with each successive division. Even the more common cancers have proved to be more complex. Regrettably, the pharmaceutical industry has been obsessed with developing treatment strategies for so complex a disease by trying to duplicate its complexity in tissue culture cell lines or animal models, with unmitigated disaster. This is a scandal.
The failure rate of drugs brought into clinical trials using such preclinical drug testing platforms is, believe it or not, as high as 95%. The 5% of drugs that are eventually approved might as well have failed, since they only prolong the survival of patients by a few months or so at best. One of Raza’s more shocking revelations is that since 2005, 70% of approved drugs have gone on to show zero improvement in survival rates, while up to 70% have actually harmed patients.
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Against this background, Raza argues that the time has come to stop chasing after the last cancer cell and focus on eliminating the first. It would be better still to prevent the appearance of the first cancer cell by identifying its earliest footprints. That is, according to Raza, prevention is the only compassionate and universally applicable cure for cancer, and the prevention she advocates is by identifying and eradicating transformed cancerous cells at their inception, before they organize into a bona fide malignant, incurable disease.
Azra Raza
HarperCollins India, 2019
Is this all utopian? No, Raza writes. It is achievable in a reasonable time. Bert Vogelstein at Johns Hopkins University is quoted as saying that 50 years from now, cancer deaths could be down by 75% just through prevention, early detection and development of newer strategies.
Cancer has among the lowest rate of positive outcomes among many disease indications. It takes around a decade to bring a new cancer drug into the market at an obnoxious cost, typically at least many hundred million dollars. But these rarely translate into any significant benefit for patients (although they are often profitable). Despite the US alone spending over $500 billion on cancer since 1971, according to one estimate, the medical world is still uncertain about its roots.
Raza argues that since chemotherapy can’t kill every cancer cell, the surviving cells regrow. “This is the reason why even the most successful targeted therapies fail.” But for the pharmaceuticals industry, developing newer medicines as opposed to radically changing gears offers a market of potentially infinite monetary gain. This is also why each new drug is presented as a long-awaited breakthrough. By the time a pharma company begins clinical trials with human participants, the stakes are already too high, and the company is struggling to find the tiniest statistical benefits over other products in the market.
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Raza offers early detection as a way to transcend this rat race of sorts, shift gears and take a shot at significantly improving patient outcomes. Her own story has shaped her thinking on the subject, because she lost her husband to cancer.
Most advances in cancer treatment have been incremental. And Raza warns: “If we continue in the same direction, spending precious resources to improve the same models, it will take us another few hundred years to arrive at a meaningful solution for cancer.”
The First Cell also says screening has helped save the lives of colorectal cancer patients. The challenge is to improve detection rates of pre-cancers through minimally invasive tests, before they become cancer. Through such methods, “we can save the lives of 120 million, one-third of the population slated to get cancer in their lifetime.”
To be sure, Raza is not against all cancer research; her concerns are aimed largely at early detection. Her book is an alarm of sorts that seems to say ‘we presently lack the conceptual archetypes to solve such a wicked problem’. “The future is in preventing cancer by identifying the earlier markers of the first cancel cell rather than chasing after the last. I have been saying this since 1984, and I will continue to say it until someone listens.”
The First Cell is an honest and deeply moving work from a committed and caring clinician, peppered with literary references. It is a book that all oncologists, cancer patients and those caring for them ought to read. If and when cancer is conquered, Raza will have played an important role in that battle, that much seems sure.
M.R. Narayan Swamy is a veteran journalist.