Simplistic criticisms of cancer therapy by Dr. Margaret Cuomo

I wondered how long it would take for someone critical of current cancer care to capitalize on the recently reported health misfortune of a celebrity. The answer, unfortunately, is “not long at all.” I will admit, however, that the source of that use and abuse of the misfortune of a celebrity was not the usual suspect; i.e., Mike Adams, whom I’ve taken to task on many occasions for gloating over celebrity deaths and illnesses, such as those of Tony Snow, Patrick Swayze, and Elizabeth Edwards, as “evidence” that conventional medicine either doesn’t work or kills.

The celebrity to whom I am referring is Robin Roberts, co-host of Good Morning America (GMA), who recently revealed that she had been diagnosed with myelodysplastic syndrome (MDS) and will be undergoing a bone marrow transplant soon. Her MDS appears to be a rare complication of her treatment for breast cancer that she underwent in 2007. I searched the website and, shockingly, didn’t find a single use and abuse of Roberts’ plight. I did, however, find someone capitalizing on Roberts’ plight at—where else?—that wretched hive of scum and quackery, The Huffington Post. It’s an article by Margaret I. Cuomo, MD forwarded to me by one of my readers and entitled Why Cancer Treatment Is Fatally Flawed, and it uses Roberts’ case as a lead-in to promote Cuomo’s forthcoming book, A World Without Cancer: The Making of a New Cure and the Real Promise of Prevention, to be released in October.

As always, I find it extremely distasteful when someone takes advantage of the misfortune of another in order to promote her work, and, let’s face it, that’s exactly what Dr. Cuomo is doing in this article. She has a book coming out, and Ms. Roberts suffered a complication that Dr. Cuomo can jump on to illustrate her point (and, not coincidentally, publicize her book). So Dr. Cuomo jumps right on the case. She begins by pointing out that Roberts had said that she had “beaten breast cancer” and had openly discussed her experiences during treatment, after which she labels it “appalling” that Ms. Roberts’ treatment for breast cancer probably caused her MDS. Of course, MDS is an uncommon complication of breast cancer therapy, occurring in approximately 0.2% of cases. Assuming that Dr. Cuomo underwent standard adjuvant or neoadjuvant chemotherapy with cyclophosphamide, doxorubicin, and a taxane, her risk would be roughly the same. The overall tone of Dr. Cuomo’s article makes it sound as though MDS is a much more common complication than it is. In fact, it’s silly of her to imply from Roberts’ extreme misfortune in developing a rare complication from chemotherapy and radiation that our system of cancer diagnosis and treatment is hopelessly “broken.”

Leaping to silly conclusions based on one case appears to be what Dr. Cuomo is about, though:

To those of us in the medical field, this comes as no surprise. The list of drugs that can cause MDS is long — including mechlorethamine, or nitrogen mustard, etoposide, teniposide, chlorambucil cyclophosphamide, and doxorubicin, all of which are commonly-used chemotherapeutic agents. Ionizing radiation, which may also be a part of breast cancer treatment, increases the risk for MDS. Most people, however, don’t realize that cancer treatments can be as devastating and potentially deadly as the cancer itself. As actor Cynthia Nixon so aptly put it in the powerful Broadway revival of Wit, the play by Margaret Edson portraying the journey of a woman suffering from advanced ovarian cancer: “My treatment imperils my health.”

Why is it that our current methods of cancer treatment consist of so many toxic drugs and radiation therapy that are capable of increasing our risk for developing second cancers? Is this the best that we can offer cancer patients in 2012?

Her second question is certainly not unreasonable. We physicians ask that question all the time, and certainly those of us who do cancer research ask it. It’s the very motivation that drives us. The first question, however, strikes me as incredibly naive. As I’ve explained time and time again, cancer is hard. It’s really, really complicated. It’s hundreds of different diseases, and in fact each cancer, thanks to the power of natural selection, is by itself dozens, if not hundreds, of diseases, stymying our best efforts thus far to develop personalized therapies based on targeting oncogene products and other important proteins in the cell. New findings in genomics are humbling indeed to cancer researchers.

Whenever someone like Dr. Cuomo asks a question such as, “Why is cancer therapy so toxic?” i want to grab her by the lapels, shake her, and tell her, “Because that’s all we know right now that works! When we discover something better, we’ll use it!” Seriously, does Dr. Cuomo think we would use such toxic treatments if they didn’t work or if there were a better way? She’s sounding a lot like alt-med purveyors in much of this article, implying that cancer researchers are either too wedded to their own therapies or don’t want to come up with something better. It’s just that, no matter how smart we are, cancer, unfortunately, has thus far been smarter. It’s not as though we like this situation, or accept it, but that’s just the way it is for now, at least until we can figure out something better.

It’s also not as though Dr. Cuomo has anything better to offer. She thinks she does, but if her HuffPo article is any indication, her book is certainly not likely to provide any answers. She might think that it will, but it doesn’t. Think I’m being too harsh? Then take a look at this passage by Cuomo:

The evidence is clear: The system designed to study, diagnose and treat cancer in the United States is broken, and it is in urgent need of reform.

The solution, I believe, lies in a critical restatement of our mission. Prevention of cancer should be a national goal. A recent study in Science Translational Medicine reported that at least 50 percent of all cancer cases are preventable. Smoking and obesity are responsible for a little over one-half of all cancers. The effect of diet, nutritional sources and physical activity levels require much more attention and public health advocacy. Environmental exposures have been inadequately investigated as cancer agents. In the case of MDS, at least 13 cancer risk factors, including organic chemicals (such as benzene, toluene, xylene), heavy metals, herbicides, pesticides, fertilizers, exhaust gases and petroleum and diesel derivatives, are listed by the National Cancer Institute.

And then take a look at Dr. Cuomo’s proposed solution:

It is time for a bold new approach to the “cancer culture” as we know it. If our cancer treatment puts us at risk for the development of a second cancer, there is something fundamentally flawed about that approach. “Above all, do no harm” should always be our guiding principle in the treatment of any disease, and especially in the case of cancer. Research dedicated to effective new screening tools for cancer, and new methods of treating cancer early, before it has a chance to spread, are needed now.

I was half-tempted to ask you, my readers, to list all the wrongness in this last paragraph, but that would involve my restraining myself from listing the wrongness myself, and you all know that I normally can’t restrain myself. So I won’t. The best I can say about Dr. Cuomo’s proposal is that, as a cancer biologist and oncologist, she was probably a good radiologist back in her day. Early detection? Seriously? That’s the best she can come up with? Clearly, she has never heard of lead time bias. Relying on ever earlier detection is a recipe for overdiagnosis and overtreatment. Indeed, using current technology now, as many as 1 in 3 mammographically detected breast cancers could be overdiagnosed and that as many as 1 in 5 such cancers might spontaneously regress. These observations do not mean that screening is useless, as quacks like Joe Mercola try to argue, but they do mean that the interplay between early detection, improvements in survival, and overdiagnosis and overtreatment are complex. Beyond a certain sensitivity level, it is not at all clear that diagnosing breast cancer earlier will actually result in improvements in survival. It very well might, but there is a price to be paid, and that price is overdiagnosis and overtreatment. In other words, Dr. Cuomo’s solution is a simplistic solution that we might expect from a radiologist who hasn’t taken the time to understand cancer biology. Of course, the really disappointing thing is that radiologists should understand better than anyone else the issues of overdiagnosis that result from too-sensitive test being used to screen asymptomatic populations.

Then there’s the issue of prevention. Obviously, preventing cancer is better than having to treat cancer, but what, exactly, does “prevention” mean? For example, how, specifically, does Dr. Cuomo propose to get everyone to stop smoking and lose weight to realize that magical 50% reduction in cancer incidence? We’ve been trying to get people to stop smoking for nearly 50 years, and we can’t seem to get the number of people who smoke much below around 20% in this country. It’s not for lack of trying, either. Massive public health campaigns trying to persuade people to stop smoking have been pretty much a constant feature in my life as far back as I can remember. Lifestyle changes are very difficult, and smoking is addictive. It’s also not as though we haven’t been trying to get people to eat better and lose weight for at least as long, and yet we have more obesity now than ever before. Twenty years ago, Arnold Schwarzenegger was chair of the President’s Council on Physical Fitness, a council that first came into existence in the 1950s during the Eisenhower administration in order to encourage people to eat better and exercise more, and, of course, that’s not the only government program designed to encourage more fitness. Again, getting people to change their diet and lifestyle is very, very hard, perhaps harder than developing new targeted therapies.

Then, of course, that leaves the evil chemicals, which must be giving us all cancer, if Dr. Cuomo is to be believed. Of course, it’s not as though we’ve been ignoring those, either. Not too long ago, the President’s cancer panel issued a very long report on that very issue. It was a mixed bag, with some reasonable ideas and some highly dubious ones (i.e., that cell phones are in any way a risk factor for cancer). I say this as someone who actually does think that research into environmental factors causing or contributing to cancer is worthwhile, but also as someone who gets annoyed by people who claim without evidence that chemicals caused their tumors.

So what we have here is a radiologist, who happens to be the daughter of Mario Cuomo and the sister of the current governor of New York, Andrew Cuomo, who for whatever reason has decided that, even after not having practiced radiology for quite some time and now working primarily as the president of the Italian Language Foundation in Manhattan, a nonprofit dedicated to promoting Italian language education in the United States, she is somehow uniquely qualified to pass judgment on the entire cancer care system in this country. Amusingly, she appears to be married to Howard Maier, who is known for producing the “Buns of Steel” video series. (I’m sorry; I just couldn’t resist mentioning it after I learned of it.) Why has Dr. Cuomo now decided to write a book assailing the “cancer culture” as “broken” and, if this HuffPo article is any indication, to promote unimpressive solutions? I have no idea. Perhaps she’ll explain in her book. For now, the only explanation I’ve been able to find is this:

As a diagnostic radiologist who has watched patients, friends, and family suffer with and die from cancer and who was deeply affected by the enraged husband of one patient, Dr. Margaret I. Cuomo is inspired to seek out new strategies for waging a smarter war on cancer.

Don’t they all? Unfortunately, what Dr. Cuomo has proposed, at least in this article, doesn’t strike me as particularly “smart.” It strikes me as simplistic. Of course, I’d love to be proven wrong. Maybe Dr. Cuomo knows something that I don’t.

I wonder if she’ll send me a review copy of her book.