The recent results from the TAILORx study (a major study published by The New England Journal of Medicine and presented at a meeting of the American Society of Clinical Oncology) means that certain women with particular genomic profiling and early stage breast cancer can safely forgo postsurgical chemotherapy. This is terrific news and a huge win for oncologists and, most importantly, their patients.
Anyone who has gone through chemotherapy knows that it can be tough and debilitating. Potential side effects from chemotherapy include nausea and vomiting, neuropathy, hair loss, fatigue, and infection – as well as early menopause and infertility for younger patients.
In his 1978 paper, titled, Is chemotherapy carcinogenic?, Dr Fred Rosner writes in his opening lines, “surgery, radiation and chemotherapy are presently the major modalities of cancer treatment” (and 40 years later, they still are) and reminds the reader that chemotherapy is a “double-edged sword” that should be used judiciously. This TAILORx study will help us do just that.
Chemo is indeed a double-edged sword. No doubt, conventional treatment saves lives. But cancer treatment often comes at a huge cost – many chemotherapy agents are also known carcinogens and listed on the International Agency for Research on Cancer (IARC) Group 1 list, along with lovelies such as asbestos.
I have not spoken to my oncologist about the recent TAILORx study, but based on my own history, I think it is likely that I too could have avoided chemotherapy.
How does that make me feel? Well, for a start, very grateful to the women who enrolled in the study, many of who were recruited in Ireland, and whose bravery and work with the doctors, scientists and cancer researchers means that thousands of women in the future will be spared going through what many breast cancer patients have to endure.
Do I feel angry that I have taken a known carcinogen that may impact on me in the future? Not at the moment.
But do I feel great frustration that we are still not doing enough around nutrition and prevention? Absolutely.
Most oncologists have very little interest – let alone training – in nutrition, but have an incredibly engaged audience sitting opposite them, dead keen to hear what they think we should do and eat during treatment.
The general advice of “eat a healthy, balanced diet” is absolutely meaningless for most people, especially if you acknowledge that there is no one-size fits-all approach for diets. If we are getting to the stage of precision and targeted medicine when it comes to carcinogenic agents, then surely we can do better when it comes to personalised nutrition that could help us during treatment? Telling someone to eat plenty of fruit and wholegrains can be interpreted in many ways. For some people, they will think that eating lots of bananas, pineapples, mangoes, grapes, potatoes and wholegrain cereals, pasta and bread is ticking that box of “wholegrains and plenty of fruit and veg”.
Unfortunately, the idea that truly beneficial wholegrain can actually be found in a box of cereal or sliced bread is incorrect. And by lumping fruit and vegetables together, you are dodging the important point that the better source of nutrients and phyto-chemicals comes from vegetables (not including potatoes), herbs, spices, dark and bitter greens and lower sugar fruits, like berries and green apples.
It’s also important to remember how we eat. In Nutritionism, Gyorgy Scrinis (professor of food and nutrition politics and policy at the University of Melbourne) suggests that a common feature of Japanese and Mediterranean diets (often hailed as the healthiest diets to follow) is the lack of processed food and abundance of fresh, natural whole foods, based on local and available produce – focusing on quality, not quantity.
He points to the studies by Paul Rozin and Claude Fischler on the exemplary dietary habits of the French – who take great pleasure and enjoyment of food – versus those of Americans who are paradoxically more concerned with health. He also points to the weakness of looking solely at biomarkers when studying disease and diet, rather than the disease itself or outcomes. He suggests that lifestyle and socioeconomic issues must also be taken into consideration. This last point is crucial.
It is well established that those in disadvantaged areas suffer a lot more from diabetes and obesity than those in middle-class areas. That’s a difficult political pill to swallow and the fact is that time-pressed, cash-poor people without cooking skills, time and education about food are not going to take a beef cheek and a bunch of root veg to make dinner for €1.87 per person. No, they will understandably feed their family entirely for €10 for a bucket of chicken and chips in under 20 minutes. Helping people access fresh ingredients that they learn how to cook – cheaply and efficiently – has to start in schools and the community. And even before that. In utero and breastfeeding have a great impact on future health.
Political food writer Marion Nestle suggests that foods that are the most profitable (and the most enticing) are not necessarily the best for health and that dietary advice, by way of the food pyramid, is hard to interpret. She also states that: “Government agencies cannot issue unambiguous dietary advice to eat this but not that without offending powerful industries.”
Keller and Lang (2006) note that conflicts of interest may be present within government departments (agriculture versus health) or between proponents of food-based dietary guidelines and the food industry.
The more you learn, the more complicated it gets.
In a 2015 report by McKinsey, titled, Overcoming obesity: An initial economic analysis, the authors suggest: “Evidence based on the clinical and behavioural interventions to reduce obesity is far from complete, and ongoing investment in research is imperative . . . We should experiment with solutions and try them out rather than waiting for perfect proof of what works, especially in the many areas where interventions are low risk. We have enough knowledge to be taking more action than we currently are.”
I stand firmly behind this: what the hell are we waiting for?
We’re talking food and low-risk intervention. Not cytotoxic drugs.
Diet and lifestyle
It is well established that there are bi-directional links between diabetes and cancer. Same with obesity and cancer. The recent programme on BBC1, The Truth about Carbs clearly outlined that many people – by restricting their “white” and “beige “carbohydrate intake – can make a real difference to their weight, health and blood glucose. Dr David Unwin is a UK GP who has specialised in reversing Type 2 Diabetes for hundreds of patients and has saved the NHS more than £40,000 in his surgery alone through change of diet and lifestyle. His patients have reduced and – in many cases – completely removed the need for T2 diabetes medication; the change in his patients’ blood markers and metabolic health is incredibly impressive.
When will we wake up in this country and acknowledge the growing body of evidence that restriction of processed carbohydrates – especially the white and beige ones – are a good idea for many overweight people. Everyone has a role to play in this: dieticians, endocrinologists, GPs and oncologists.
We must acknowledge that the food pyramid with all of its acknowledged flaws – and with its emphasis on beige carbohydrates and low fat products – is not the way forward if we want to tackle diabesity (diabetes occurring in the context of obesity) seriously and help to reduce the increasing numbers of cancer patients in this country. Cancer patients need support, the most up-to-date information and to be heard.
I am tired of being called “vulnerable”. Every cancer patient I have met is highly motivated and fed up being mocked for being interested in nutritional and lifestyle interventions – including diet, exercise and stress busting therapies, such as yoga or massage – that can help provide comfort and a sense of control when undergoing conventional treatment.
A recent proposal by Fine Gael TD Kate O’Connell to introduce an anti-quackery bill to protect cancer patients is laudable and, I am sure, well intentioned. But in reality, there are many laws to protect consumers from so-called “miracle” and bogus cures and there are no laws against stupidity. If someone believes that paying a psychic healer to rub their big toe with leprechaun crystals will make them better, then off you go. Same for praying to whatever God you fancy. It’s your choice.
But if anyone is suggesting that complementary therapists – who offer acupuncture, nutritional therapy, etc – should be outlawed from treating cancer patients, I say, go to hell. In an Irish Cancer Society leaflet, outlining the alternative and complementary therapies widely available in Ireland, it is summed up perfectly: “Nowadays it is possible for everyone to work together.”
Quality of life
A 2017 paper in the BMJ, titled, “Availability of evidence of benefits on overall survival and quality of life of cancer drugs approved by European Medicines Agency: retrospective cohort study of drug approvals 2009-13” concluded that in relation to secondary cancers, most of the drugs that entered the market had little benefit on survival or quality of life and if there were survival gains, they were marginal.
In an accompanying editorial in the same journal, Vinay Prasad, assistant professor of medicine, Oregon Health and Science University, asked, “Do cancer drugs improve survival or quality of life?”. He wrote, “Although we are approving cancer drugs at a rapid pace, few come to market with good evidence that they improve patient centred outcomes. If they do, they often offer marginal benefits that may be lost in the heterogeneous patients of the real world. Most approvals of cancer drugs are based on flimsy or untested surrogate endpoints, and postmarketing studies rarely validate the efficacy and safety of these drugs on patient centred endpoints”.
He goes on to discuss the huge costs of these drugs – up to €85,000 per patient, per year – and finished up by saying, “The expense and toxicity of cancer drugs mean we have an obligation to expose patients to treatment only when they can reasonably expect an improvement in survival or quality of life. The study . . . suggests we may be falling far short of this important benchmark”.
Cancer treatment is pretty vicious and its proponents need to apply the same levels of scrutiny to conventional treatments that they do to complementary therapies. Advice on nutrition, exercise, sleep and community have an important place in cancer treatment despite being “unproven” in the context of (randomised) clinical trials.
Cancer patients need choice and the best information.
And we need our doctors to honestly discuss and acknowledge the fallibility of western medicine and learn to be more receptive to treatments and lifestyles that cancer patients wish to adopt. By shutting down the conversation and dismissing a patient’s needs, doctors and oncologists will drive patients underground to seek extreme measures that may well put them at risk.
The recent win for women with early stage breast cancer is a good one. Let us build on this and stop fearing what is common sense.
Let us put the needs of the patient first.
This article first appeared on the Irish Times website on July 19, 2018