Third Session

Wednesday, October 17, 2012

The Emperor of All Maladies: Cancer Therapy Implications

Possible Discussion Questions

  1. Mukherjee writes how in the early 1950s The New York Times refused to print the word “cancer” (or “breast”). Compare this to how we view cancer today. Is there any difference in the way you discuss cancer as a political or news topic and how you discuss a cancer diagnosis among family members and friends?
  2. Looked at one way, Sidney Farber’s early clinical trials with antifolates in 1947 and 1948 were a failure, with all of his young leukemia patients eventually dying of the disease. But with the results of these trials, Mukherjee writes, Farber “saw a door open – briefly, seductively” (page 36). How so? Why do Farber’s trials mark a turning point in the history of cancer research?
  3. “‘Li was accused of experimenting on people,’ Freireich said. ‘But of course all of us were experimenting … . To not experiment would mean to follow the old rules – to do absolutely nothing.'” Review the case of Min Chui Li (pages 135-138), and explain Emil Freireich’s quote. Do you think Li’s actions were ethical? How can doctors and scientists draw the line between reckless, unproven treatment and necessary experimentation for drug development?
  4. How is the early history of chemotherapy linked to the histories of colonialism, the Industrial Revolution, and World War Two?
  5. The 1980 Canadian mammography trial (pages 298-300) was possibly flawed because technicians disproportionately steered women with suspected breast cancer to get mammograms, likely out of compassion. Put yourself in the technician’s shoes: Would you have allocated your friend to the mammogram group? If so, how can trials ever be randomized? Should a trial with a promising new drug be randomized – even if it means forcing some patients to be in the non-treatment group? What if a new treatment emerges for a deadly form of cancer? Should half the study enrollees in the trial be forced to take sugar-pills to document the efficacy of the treatment?

Questions used from the Simon & Schuster Study Guide for use in discussing The Emperor of All Maladies available at http://books.simonandschuster.com/Emperor-of-All-Maladies/Siddhartha-Mukherjee/9781439107959/reading_group_guide.

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2 Comments (+add yours?)

  1. Peter Aiello
    Oct 17, 2012 @ 21:20:20

    1. In the 1950s, cancer was considered a taboo in society, a diagnosis that existed but in many people’s minds was a terminal condition that should not have been spoken of. It was almost if the words associated with cancer were swept under the rug, then maybe the disease would go away. Today, we speak of cancer more or less as a chronic condition, yes, in many circumstances it will shorten the lives of the patients that it afflicts, but we have a much more open societal approach to cancer. Patients are even encouraged by providers to speak with their families and friends and discuss the outcomes that might result because of their diagnosis. When reading in any magazine or newspaper there are countless stories that talk about the reality of a cancer diagnosis, explaining different aspects of this insidious disease.
    2. Before the time of antifolates there was no pharmacologic treatment for the diagnosis of cancer. Even though the early experiments with these drugs did initially fail they opened the door for a second modality in cancer treatment. No longer did physicians only have surgery and then nothing to take care of patients. These clinical trials introduced the medical world to chemotherapy for cancer treatment.
    3. In this case Li was acting on his own suspicions about the cancer he was treating. While it may seem unethical to keep treating a patient for a diagnosis that they were supposed to have been cured of, in this situation it makes sense. Li was “covering all of his bases” so to speak and in the case of the National Cancer Institute I believe he was acting in the best interest of his patients. These were researchers – they were at NCI to push the boundaries of modern medicine and to this logic I believe that Li’s actions were ethical.
    4. The history of early chemotherapy can be traced back to the textile industry in Europe in the 1850s and the development of synthetic dyes for garments. The entire idea of practical chemistry was invented solely for this purpose and eventually went on to create other synthetic compounds used for a variety of different reasons. As time went on and the industrial disadvantages of different countries started to develop, it could all be traced back to the textile industry and the disparities between the different countries within Europe. Colonies were established by European countries for the sourcing of goods to be made in European factories – a direct result of the industrial revolution. World War II was a result of the unequal distribution of wealth between European countries and the conflict that ensued because of it.
    5. It is very difficult for trials such as the Canadian mammography trial to be randomized because of the potential source of bias that can occur as a result of “professional judgment” needed to randomize the patients in the clinical trial. As long as there is a human element to the process of trial randomization there will always be some sort of bias in the study results. I think the issue of chemotherapy trials speaks to a larger issue in medicine today – is it truly ethical to test cancer treatments that we know have a clinical effect against a placebo a treatment that we know will not work or is it better to test these medications against the standard of care. Yes, a new cancer treatment will most likely be more effective than giving the patient nothing but the true test for a medication is does it perform better than what is currently used in clinical practice. It is only this way that we are able to actually determine how efficacious a medication is and it is the most ethical way to test these new medications on our patients. This will ensure that we are not letting patients with malignancy forgo lifesaving treatment.

    Reply

  2. Jena Hallenbeck
    Nov 20, 2012 @ 00:49:33

    1. Today cancer is spoken of much more freely than in previous generations. There are many active societies and charities that publicly support and fund cancer research, diagnosis and treatment. In the 1950’s, cancer was considered a “death sentence” and therefore taboo. Some doctors even withheld the diagnosis of cancer from their patients as to not upset them.
    2. Although antifolates were essentially a failure, a flicker of hope was ignited. The remissions of leukemia using antifolates, although brief, proved to Farber that there was a possibility of a cure. Before this time no other chemical drug had been used to “treat” cancer, this discovery would be begin the development of cancer treatment as we know it today.
    3. In this case I do believe Li’s actions were ethical. Li continued chemotherapy treatment on patients based on a positive hcg level the hormone because he truly believed that the positive test indicated that the cancer was still present. In this case there was no malicious intent.
    4. Chemistry and chemical agents found their way into medical science slowly throughout colonialism, the Industrial Revolution and WWII. Initially chemical dyes that were developed for fabric were used to stain cells for microscopy, then the cure for syphilis was found through an anti-microbial dye, followed by the discovery of health implications related to nitrogen mustard and other chemical gases. These developments in ‘medical chemistry’ became woven into wartime history.
    5. When participating in randomized trials there should be no bias, consequently there should be no “steering” of friends, family or high risk patients. With new technology randomization does not need to be done by the professionals conducting the research and should therefore reduce bias. The questions posed are not easily answered; in my opinion randomized trials should not be performed in situations where the drug or treatment is known to be promising or if the drug or treatment is for an aggressive, rare type of disease. However, if the trial is performed and significant evidence is found early in a trial proving that a new medicine/treatment/etc. is highly effective I do believe that the trial must be stopped and all participants are allowed to benefit.

    Reply

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