Editorials

Do cancer drugs improve survival or quality of life?

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4528 (Published 04 October 2017) Cite this as: BMJ 2017;359:j4528

Re: Do cancer drugs improve survival or quality of life?

As I am bound still by some level of confidentiality and despite semi-retirement and my remote location, I tend to support this authors thesis wholeheartedly (although my experience dates back to 2004 and earlier). Before that I spent a a lifetime in Medicines Development and Regulation in Europe including many oncological therapeutic agents - including chemotherapy and biological agents such as monoclonals, DNA vaccines and Gene Therapies. The latter two at that time were the most promising but not necessarily safe. Many conventional chemical anticancer drugs are extremely toxic with a wafer thin therapeutic margin with often rather theoretical mechanisms of action. One area I found particularly questionable was the first use of new chemical entities and viral vector in Phase I studies in what might be casually referred to as 'no hope' patients with cancer. The studies were much more about establishing the level of toxicity (safety) than giving the assessor any hope of benefit, yet the consent forms presented hope was offered when there was none of scientific credibility. If I should get terminal cancer I will go no-where near a Phase I study and thereafter I will evaluate if am able the evidence before ANY agent is given to me. If I am unconvinced I will refuse.

Both my mother and father developed colon cancer. My mother was offered firstly experimental surgery (2008) and when we refused, simply diagnostic laparotomy (no laparoscopy offered then). On discovering widespread peritoneal metastases she then required a defunctioning colostomy and was offered rectal radiotherapy - where the benefits were at best dubious and the toxicity undoubtedly significant - on the basis that she might live 6 weeks. We refused on that basis and she lived a fairly happy life for over 3 years eventually dying from later medical mismanagement of a benign condition (pain from an obstructed bladder other than cancer). My father on the other hand alas then perished in 2006 from palliative care he did not need. We have hopefully travelled some way since that time but I would suspect very little and this author confirms this. Whereas we might reference chemotherapies in childhood leukaemia as breakthroughs even here the approach of using differential poisoning is the nearest lay term I can use.

Adjuvants in breast cancer have also played an important part in treatment. The development of modern monoclonal antibodies is also more heartening because of lower levels of toxicity. But still their benefits are often hugely overstated and limited to subsections of patients we can hardly define. As most therapeutics are designed by commercial developers to be 'blockbusters' or highly 'prestigious' agents - and therefore unbelievably expensive for limited QOL, or even life extension. Such research teams approach therapeutic interventions by focusing primarily on commercial success rather than exploratory science. Well that is their modus operandi. Like many established medicines, we largely need to understand the ones we've got rather than the ones we may get. We use these often quite poorly. Patient's understand them even less. There are no magic bullets for anything. There is only greater understanding. And then from the burgeoning population we will create there will be new dilemmas for the planet - aged care and increasing dementia. If we could develop as a profession a more universal palliative approach to many of the cancers we see - following the simple principles of caring, reassuring, counselling and supporting - we might well do more good than ill and accept that life can be short but it is lived to the full.

Competing interests: Former regulator of Clinical Trials and New Medicines, former Consultant and Executive Director of Medicines Development - various organisations.

13 October 2017
Philip James Harrison
General Practitioner
HUTT CITY HEALTH CENTRES - recently semi-retired
Wellington, New Zealand