Opinions Like Kittens: Philosopical Thoughts on Cancer Treatment

Like most cancer patients, I’ve found that treatment has definitely been a learning process. While most of these learning experiences have been on a personal level, I think this whole experience has also made me take a lot of issues in health care ethics (and philosophy more generally) more seriously than I had before (which is somewhat ironic, because I used to teach health care ethics). In any case, here’s ten things I think I think about philosophy, science, health care ethics, and cancer. I promise this will be my only “traditional” blog post, in which I make unsupported arguments about substantive matters of fact supported by nothing but my own intuition (no sources here, because I’m just too lazy :)). Many of you probably know more about these things than I do, but I just thought I’d give my two cents (and, as a semi-professional philosopher, I’m pretty OK with being told that I’m wrong):

1. The treatment of TC was a success story in the history of medicine, and this has implications for philosophy of science. In 1975, metastatic testicular cancer had a 5-year survival rate of around 10%; these days, it’s closer to 90%. The pioneering work was all done by Dr. Einhorn at Indiana University, who has continued to be the world’s leading expert on testicular cancer (he treated Lance Armstrong, and is still the head of the testes cancer group at IU). Plus, he responded to a question I e-mailed him within two hours! A little more on that question later, though. Even since the early 80s (when the current treatment regimen was more or less fixed) things have really improved—e.g., the combination of steroids and antinausea drugs (e.g., Zofran) have decreased the average frequency of vomiting from 12/day to 0/day. In most cases, BEP patients actually gain weight, though that hasn’t been the experience in my case. So, the success of BEP chemotheraphy is evidence of favor of what I might call “who cares about the mechanism?” view of scientific methodology—we do science by throwing random chemicals in vats (or grow bacteria, etc.), throw the resulting mixtures at malignant tumors, and hope like hell something works.
2. The attempt to extend the “principles” behind the treatment of TC to the treatment of other solid tumors was not a success story in the history of medicine, and this has lessons for philosophy of science, too. The 1980s were filled with thousands of trials of various combinations of chemotoxic drugs for every imaginable type of solid tumor (breast, lung, colon). At best, these trials led to treatments that were moderately more successful than what had been the case; at worst, the trials subjected patients to fairly terrible side effects for little or no benefit. It turns out that TC is simply a bad analogue for most other cancers, for the same reason that it’s so reason that it’s (relatively) easy to treat – cells from the testicles are pretty easy to kill when compared to just about every type of cell. Radiation kills them; so do the three drugs used in BEP (bleomycin, etoposide, cisplatin). Independently, each method is capable of killing a large proportion of TC cells, though not enough to prevent a quick relapse. Together, though, they kill enough to sustain a cure in a majority of cases. If nothing else, I think TC is a good reminder that cancer isn’t a monolithic entity, and that research done on individual treatments on individual cancers may have little or no applicability to the treatment of other cancers. So, maybe the treatment of TC (which didn’t require much focus on the underlying mechanisms of the cancer) is more of anomaly than a paradigm-shifting case.
3. There is a big disconnect between actual cancer research and the public perception of cancer research, particularly concerning the relationship between cancer and particular food choices. After spending much of the last month of Google Scholar, PubMed, and NCI website, it looks to me like we have some evidence that various foods—fruit juices, refined sugars, red meats, green tea, soy products, coffee, chocolate,  etc.—do something to the evolution and growth of specific types of cancer cells during specific stages of growth, but it looks we don’t have any great evidence concerning what they do, to which types of cancer cells, or about how these things might interact with things like chemotherapy. For example, it seems plausible that antioxidants might prevent the sort of cell damage that leads to the development of cancerous cells; however, it also seems plausible that these things might serve to protect cells from cytotoxic chemotherapy and/or accelerate the growth of malignant tumors (even in the absence of chemotherapy). In general, it looks to me like all of this research is pretty equivocal, and that there’s actually very little to be said beside “eat a balanced diet” or something similarly innocuous. In general, I think it’s unfortunate that so many talk shows and cancer books make it seem like there is some magical bullet cancer cure figure-out-able out through common sense and ordinary observation, and that research oncologists are somehow overlooking these potential treatments. I think there’s a lesson for philosophy of science buried here somewhere. Way too often, introductory courses in philosophy tend to focus on theories that obviously aren’t scientific (like astrology), rather than on theories that overreach their scientific underpinnings (cancer diets, the autism vaccine hullaballoo, and so on).
4.  We do know at least two magical bullets when it comes to cancer prevention: don’t smoke and exercise at least 150/minutes weekly. Also, political libertarians are wrong. The studies concerning both smoking and exercise are pretty unequivocal, and the effect size is massive. Again, I’m not sure what the general lesson is here, but I think that policy-making entities need to start thinking of physical inactivity in the same way they started thinking about smoking during the 1980s—as a massive public health problem that needs to be primarily addressed at a policy level, and not at a personal level. (I feel like I’m reciting the intro to about a dozen Human Kinetics books here…). These sorts of issues always seem to me like case studies in why undiluted political libertarianism (of the Ron Paul variety) makes no sense, at least from a results-matter point of view. After all, if libertarians had gotten their way on smoking (and the government hadn’t “interfered” through various taxes and punitive measure against smoking), people in the U.S. would, on average, have lost something 2-3 years of life expectancy (and probably considerably more in terms of disability-free-life-years). Smoking and physical inactivity are good examples of the sorts of behaviors that (1) we have very good evidence are massively harmful and (2) we have equally good evidence that lots of people will continue to engage in these behaviors if left to their own devices.
5.  I think cancer and chemotherapy provide a good model of evolution via natural selection. Sixty years of clinical trials have shown that relapsed cancers show a much higher resistance to the cytotoxic drugs with which they were initially treated. The explanation for this is that these cells are the direct descendants of a very select group of the initial cancer cells—i.e., the cells that had mutations allowing them to survive first-round chemotherapy. Cancer cells, in general, show very high genetic variability, and they also mutate and reproduce very quickly. In this sense, they provide a succinct model for the evolutionary process, including parts of the story that are often overlooked. So, for example, I think cancer cells nicely illustrate Darwin’s point about the success of invasive species. If organisms (or cells, in this case) were designed to flourish in their chosen environments (as Darwin’s creationist opponents held), we shouldn’t see them being beaten out by invasive species that weren’t designed for these environments. But in cancer (as in many other places in nature), this is precisely what happens—cells from another part of the body end up being much, much more successful than the cells that were “supposed” to live there. This isn’t good for the person with cancer (or for the containing ecosystem, in the case of invasive species), of course, but that’s something worth emphasizing, too—evolution isn’t “directed” toward any specific end, even if it sometimes useful to talk about it as if it were.
6.  There is something worrisome about the whole “general practitioner as gatekeeper to people who actually know what they are talking about” model of health care. This is one thing U.S.-style HMOs and European-style centralized systems share, and my medical history has left me with mixed feelings about it (though I’ve no idea what the alternative would be). I could go into a ton of horror stories from my past regarding bad recommendations I’ve received from MDs about cardiac arrhythmias, insomnia, lower-extremity tendonapathies, and so on. My most recent complaint is that my (general-purpose, though very friendly) oncologist seems to be only vaguely aware of the specifics of the BEP protocol—he consistently misdescribes the timings of various doses, forgets to prescribe secondary drugs unless I repeatedly ask, and so on. More seriously, he recently delayed treatment for 11 days (and suggested delaying 14 days) on account of low neutrophils, which I am now convinced is a significant misunderstanding of the BEP protocol (I e-mailed Dr. Einhorn to ask about this, and he confirmed my suspicion). I understand that, as a matter of practicality and cost, specialists cannot direct the treatment of every individual patient. However, I do think there is a role for a significantly increased use of computer systems that would guide general practitioners on what the current, evidence-based treatment recommendations are for various conditions. I also think that GPs should be required to consult with relevant subject-matter experts within their research group, in any case where they are dealing with conditions with which they are unfamiliar. I know that some of these things probably *are* requirements, but I never seem to see used effectively in action. In any case, given the technological resources available to us, I think that relying even a moderate amount on MDs’ quickly outdated medical-school education is a poor way of determining proper treatment for uncommon conditions. The fact that cures rates for solid tumors are significantly higher at research centers than at smaller, regional hospitals is a personal concern of mine, and I don’t entirely buy the explanation that this difference is due to different sorts of patients seen at these locations.
7. There are lots of reasons, good and bad, that health care in the U.S. is so expensive. Carle has billed my insurance company around $60,000 so far, and I expect the 5-year total (the length of cancer surveillance, should I make it all the way through) will be close to $150,000. So why is all of this so expensive? Here’s a list of five things that I (perhaps somewhat unjustifiably) blame my health care costs on, in order from least to most annoying:
1.  We’re getting better at treating certain sorts of illness, and treating these sorts of conditions costs a ton of money. Treating solid tumor cancers and chronic heart conditions in particular requires lots of technology, lots of hours from medical staff, and so on. I don’t really think there is any great solution to this, though, and this is a problem for any health care system (and not just the U.S. one). From my point of view, of course, this is a perfectly worthwhile use of health care dollars J.
2.  U.S. physicians earn a lot more than their international peers do, and a lot more than people with similar educational backgrounds in the U.S. do. This is true even when one accounts for the high price of medical school, the underpaid internships, the long hours worked, and the price of malpractice insurance. This doesn’t bother me a ton, since I think the added cost here is pretty negligible when compared to other factors (and it does help us attract a lot of talented foreign doctors, many of whom have been involved in my treatment), but it does bother me whenever I hear physicians trying to provide some sort of “moral” defense for their astronomical salaries. I accept that this is the way life is, but I don’t think this means it ought to be that way. I think centralized health-care system do somewhat better than the U.S. in this regard, since the government is in a better position to influence physicians’ salaries (whether or not it directly pays them).
3.  We don’t ration health care dollars effectively. There are all sorts of reasons for this—doctors who provide unnecessary treatments on a “pay per treatment” basis, insurance plans and/or HMOs willing to commit millions of dollars of treatment toward the care of patients with little hope of recovery, physicians who choose less effective, but more conservative treatments to avoid “blame” (or lawsuits!) for adopting more effective, but higher risk treatments, and so on. I think the U.K. is moving in the right direction on this, with a governmental standards board setting guidelines for treatment based on expected cost/life-year-saved. Like it or not, we have limited health care resources, and the current U.S. private/public system is not terribly effective at spending these dollars where they do the most good. (There are exceptions , of course: both the VA and Medicare achieve much better cost : outcome ratios than do private health plans. Mayo Clinic is a good example of a private institution that seems to do many of these things right.).  
4.  Insurance companies might only make 5% profits, but they’ve been spending 15% trying to decide whom to deny coverage to. This is obviously an inefficient way of spending of health care money, which everyone (right-wing politicians, left-wing politicians, insurance company executives, and so on) acknowledged from around 1972 until 2008, when it became the centerpiece of Obama’s health care plan. I have my suspicions about the specific form the individual mandate took (in that it requires payments to non-governmental, for-profit entities), but there’s no way of addressing this source of inefficiency without some sort of governmental mandate. If the current one ends up being ruled unconstitutional (while I hope that it is not, I do have some sympathy for those think it might be, since I don’t think political expediency implies constitutionality), I think there are other versions which could easily pass Constitutional, commerce-clause muster (e.g., national health insurance on the Canadian model) if we could somehow find the political will to make them happen. I’m already worried about what the insurance company will try to bill me for (my current worst-case scenario includes all the treatment I’ve gotten while admitted to the hospital over the weekend, which I’ve heard horror stories about). I don’t necessarily blame insurance companies for this; after all, they have absolutely no reason to want to spend 15% of their money denying coverage. The problem is almost entirely one of bad governmental policy, and it seems to be unique to the U.S. (since nearly every other developed nation has some sort of mandate, though none of them allow private insurers to profit off of it).
5. Pharmaceutical companies make nearly 20% profits, and they make them largely on the backs of U.S. consumers, since we pay way more for drugs than nearly everyone else in the world does. The money these companies do spend on research tends to be on “me-too” drugs of marginal efficacy (second-generation anti-depressants, statins, etc.), and even this research is (in effect) heavily subsidized by public research universities and teaching hospitals, who pay to train the staff, employ the researchers when they are not doing drug-company research, and so on. Unlike all the other categories above, I don’t really have much nice to say here (especially given the amount of money I’ve paid for drugs like Neupogen). The U.S. model of health care encourages this sort of bad behavior by (1) refusing to allow the government (by far the largest purchaser of drugs) to bargain for lower drug prices, (2) granting large numbers of patents to drugs of debatable utility (e.g., if there is already a drug on the market that does the same thing, or if the research supporting the drug’s effectiveness is equivocal), and (3) allowing drug patents to last too long. Again, I don’t see this as a problem of “those greedy drug companies"; the problem is largely one of ineffective government policies.
8. It’s surprisingly difficult to adjust beliefs to the actual evidence—it’s much easier to be too optimistic or too pessimistic. I think I said and/or wrote this before, but I’ve found it very difficult to adapt myself to the idea of having a 85% chance (or 90% chance, or whatever) of being alive in 5 years. Instead, I spend about 85-90% of the time assuming I will be fine, and then am convinced 10-15% something will go terribly wrong. As far as I can tell, this is pretty typical for cancer patients, but I still wish I could do a bit better. It seems like there were certain things I would make it a point to do (Write a memoir? Prepare a living will? Take up playing the piano? Learn to hit a decent two-handed backhand?) if I could just convince myself that there was a realistic, though fairly improbable, chance that something bad could happen. Constantly believing that either the best will happen or the worst will doesn’t really goad one on to useful action, though. The formal epistemologist in me (who likes to represent degrees of beliefs with numbers from 0 to 1) wonders how to represent these sorts of whacky belief states.
9.  So far, I’ve found that cancer has served to reinforce most of my most deeply held beliefs, instead of causing me to revise them. Before this whole thing started, I’d spent a fair amount of time writing and teaching about issues in health care ethics, the philosophy of science, the philosophy of religion, and so on. So far, I’ve found that my personal experience with cancer has tended to reinforce things I already thought, with the biggest difference being that I’m much more cranky when I assert them (though this might be a product of the nausea and fatigue). I have no idea of this is typical, but my guess is that it can’t be too uncommon, even though deathbead conversion stories are undoubtedly make for better TV. Confirmation bias (the tendency only notice the “evidence” that supports your pre-existing beliefs) is pretty universal among humans, and I think it’s especially common in stressful situations. This all being said, the whole experience has been valuable to me in terms of making me realize all the things I’ve really liked about my life so far (mostly the people, but the books, sports, and traveling weren’t too bad either) and the things I’d really like to do when I get done with all of this (have children, write a book, get back into teaching someday).
10. In general, I think people are pretty decent. I’d like to think I’ve always had a fairly positive view of other people, but I think having cancer has definitely reinforced for me how fundamentally decent most people are. All of my family and friends have been wonderful (thanks, everyone!), and so has just about everyone else with whom I’ve the opportunity to interact—medical staff, other cancer patients, coworkers, etc. In any case, this last point probably isn’t a terribly philosophical one, but it seemed worth saying.