Intended for healthcare professionals

Opinion

What is the meaning of cancer?

BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2510 (Published 07 November 2023) Cite this as: BMJ 2023;383:p2510
  1. Richard Smith, chair
  1. UK Health Alliance on Climate Change

Cancer enters our lives almost every day. Somebody we know has cancer. We are tested for cancer. A famous person dies of cancer. Food we enjoy is found to cause cancer. The media announce a breakthrough in cancer treatment. There are constant questions about the causes of cancer, whether it can be cured, and the costs of treatment, but one question never seems to be asked: “What is the meaning of cancer?” Indeed, many people may think it a silly question, but Jarle Breivik, a distinguished Norwegian cancer researcher, discusses exactly that question in Making Sense of Cancer: From Its Evolutionary Origin to Its Societal Impact and the Ultimate Solution, which has just been published. In attempting to answer the question Breivik has written a book that reminded me of the writings of the physicist Carlo Rovelli: the book tackles complex scientific questions in a lyrical, highly readable and enjoyable way, bringing in philosophy, broad learning, and different visions of the future.

“Few things in life seem more meaningless than cancer,” writes Breivik at the beginning of the book before exploring the many ways it can be understood and describing how cancer includes so much of life: “Cancer is often associated with death but is also very much about life. It is about the basic principles of biology, the intricate dynamics of living organisms, body and soul, tears and love, culture, politics, and money. Cancer is alive.”

Breivik created something of a storm by publishing a piece in the New York Times that was headlined to suggest that cancer would never be cured, never eradicated. Many cancers are “cured,” or at least kept at bay long enough for people to die of something else. Survival from many cancers has been greatly lengthened, and I, like many others, know people who live years with cancers that would have killed them in months when I was a junior doctor. But there is a big difference between curing cancers in individuals and curing or eradicating cancer.

“If the goal is to cure cancer ‘once and for all,’” writes Breivik (a cancer researcher, remember) “we are certainly not doing a very good job at it.” Despite the huge, global funding for cancer research, the hundreds of thousands of cancer researchers, the pharmaceutical companies making huge profits from cancer treatments, and the Nobel prizes awarded for cancer research, there is more cancer than ever—for the simple reason that it is a disease of older people. It is, indeed, argues Breivik, one of the main ways we are programmed to die; and, as dying is a cardinal feature of being human, the only way we can finally defeat cancer is by ceasing to be human. I’ll come back to this.

Breivik describes four levels of understanding of cancer, with the lowest level being to see it as an enemy, a fearful monster, even something evil, that must be defeated. Richard Nixon’s doomed War on Cancer has its origins in this way of thinking, but, writes Breivik, “If we want to understand cancer, we need to see beyond the fearful monster.”

The next level of understanding is to think of cancer in relation to its many causes—smoking, radiation, alcohol, food, pollution, and many more; “the list is,” writes Breivik, almost inexhaustible.” Perhaps if we could avoid all these causes we could defeat cancer, but we’d have no life. “We get cancer from living,” and age is the most important risk factor for developing cancer. “A centenarian who has not been diagnosed with some form of cancer has just not been thoroughly examined—and it is probably best to leave it like that.”

A higher level of understanding of cancer is to consider the cellular and genetic mechanisms that lead to cancer. This is the favoured way of thinking of the many scientists who work on cancer and the hundreds of charities that raise money to support their work. Cynically, I might observe that cancer has been a great boon to molecular biologists, and perhaps dementia will prove to be a cash cow for neuroscientists. This level of thinking sees cancer as a technical problem, and given enough time and money we will learn how to turn off cancer cells or kill them more effectively.

The next step on the ladder is to see cancer as a developmental process. Cancer cells must be considered, like everything in biology, in the context of evolution. The cancer cells develop by natural selection and spread around the ecological system of the body just as finches spread through the Galapagos Islands.

We humans have had the effrontery, the hubris to think of ourselves as at the centre of the universe and the summit, even the endpoint, of evolution, but in reality we are the creation of genes, genes who are not interested in us. “We are,” as Breivik puts it, “the genes’ means of transportation—their vehicles.” Cancer arises because of how we are divided into germ and somatic cells: our bodies are “temporary cell colonies” (with the emphasis on temporary) designed by genes to reproduce and pass on the genes through the germ line. Once we have reproduced we are no use to our genes, and they have programmed our cells and us to die. All the cells in our body are evolving towards cancer cells.

Breivik used to work on immunotherapy and describes what has been called “the universal cancer vaccine” that activates T cells to kill almost any type of cancer cells. All types of cancer treatment—radiation, chemotherapy, surgery, or immunotherapy—are about killing cells, and, as Breivik writes, “If we just continue to kill cancer cells, we will, sooner or later, end up killing ourselves.”

To rid the world of cancer we must make our bodies immortal or get rid of the body altogether and become digital beings. The contents of our brains will be uploaded into ever more sophisticated computers and our bodies discarded. We might even bring back those of the dead who led fully documented lives. We would be powered by solar energy and wouldn’t need food, water, or oxygen and could stop destroying the planet. We could be transported at the speed of light to other planets.

This vision, which excites many, particularly the very rich who are intolerant of death, means the end of humanity as we know it. “Aging, cancer, and death are,” concludes Breivik, “fundamental aspects of being human. If we eliminate this circle of life, we eliminate ourselves.” Our difficult choice is the end of cancer or the end of humanity. Breivik, a cancer researcher, opts for humanity, but others, I’m sure, will opt for the end of cancer. But most of those battling in the war on cancer have not, I fear, understood the consequences of victory, which is why Breivik’s book is so important.

Footnotes

  • Competing interest: RS has not met Jarle Breivik and has no financial interest in his book but was sent a copy months ago, has corresponded with Breivik, and provided a quote for the marketing of the book. RS is mentioned in the book and came to Breivik’s attention because of his notorious blog arguing that cancer is the best way to die.

  • Provenance and peer review: not commissioned, not externally peer reviewed.