The Truth in Small Doses

Why We're Losing the War on Cancer-and How to Win It

Clifton Leaf

• Publisher: Simon & Schuster
• Year: 2013
• ISBN:
  9781476740003
• Topic: Medicine
• Subtopic: Oncology

A "brilliant" ( Fortune ), eye-opening history of the war on cancer, The Truth in Small Doses asks why we are losing this essential fight and charts a path forward. Over the past half century, deaths from heart disease, stroke, and so many other killers have fallen dramatically. But cancer continues to kill with abandon. In 2013, despite a four-decade "war" against the disease that has cost hundreds of billions of dollars, more than 1.6 million Americans will be diagnosed with cancer and nearly six hundred thousand will die from it.A decade ago, Clifton Leaf, a celebrated journalist and a cancer survivor himself, began to investigate why we had made such limited progress fighting this terrifying disease. The result is a gripping narrative that reveals why the public's immense investment in research has been badly misspent, why scientists seldom collaborate and share their data, why new drugs are so expensive yet routinely fail, and why our best hope for progress—brilliant young scientists—are now abandoning the search for a cure. "Through flowing prose Leaf delivers, alongside facts and data, stories on personalities involved in research, the fascinating process of solving an unusual and highly deadly cancer in Africa, and the heartbreaking realities of cancer treatment in children today. Leaf's extensively investigated treatise will resonate with researchers and patients frustrated by the bureaucratic woes he delineates. Public policy makers, grant reviewers, and pharmaceutical researchers alike must consider Leaf's indictment and proposed solutions" ( Publishers Weekly ). The Truth in Small Doses is that rare tale that will both outrage readers and inspire conversation and change.

Part One

The Burden

Chapter 1

Counting

Joe Hin Tjio couldn’t believe his eyes. Staring down at the jumble of filaments on the glass slide, he counted again. And again. And again until he was sure.

Few lights were on at the Institute of Genetics, a low-slung, redbrick building on the outskirts of Lund. Beyond Tjio’s first-floor window was only darkness. This was the Skåne region of southern Sweden, where the ground was swept flat and the winter night made the landscape colder and emptier still. It was 2:00 a.m., three days before Christmas 1955. For Tjio, a thirty-six-year-old visiting professor, that meant prime laboratory time.

He was a strange fellow—moody, defensive, prone to emotional outbursts. Effortlessly, he could turn an offhand comment from a colleague into a personal slight. The most minor of disagreements could evolve into a long-lasting feud. His Swedish coworkers, for the most part, shrugged off the behavior, attributing Tjio’s hypersensitivity to the traumas he had suffered as a young man.

Born in Java in 1919, in what was then the Dutch East Indies, to Chinese parents, Tjio (pronounced CHEE-oh) was a Peranakan, the name given to second-, third-, and later-generation Chinese Indonesians, who often spoke a patois of Malay and Chinese. The word translated to “local-born” or “descendant”—though it was hard to imagine Tjio descending from anywhere. He was a rootless amalgam: a Dutch-educated Chinese Indonesian, employed in Basque-speaking Spain, on sabbattical in Sweden, married to a woman from Iceland. He could move fluidly between French, English, German, and Dutch, languages he’d learned at the severe colonial schools where he’d spent his youth. He spoke Japanese as well, though for him that language conjured up bitterness and anger.

Tjio had just turned twenty-two years old when the Second World War stormed into the Indonesian archipelago. The Japanese Imperial Forces invaded much of Southeast Asia, and Tjio, along with thousands of others, was sent to a squalid, bamboo-fenced internment camp, where he was imprisoned for three years and tortured by the guards. Even the war’s end offered little respite, as Indonesian authorities accused Tjio of being a Communist and detained him—until he’d at last managed to get on board a Red Cross boat for “displaced persons” bound for Holland.

He had studied plant breeding before the war, hoping to create a strain of potato resistant to disease. And after a brief study in Holland, he had landed a job at a Spanish university in the northern city of Zaragoza.

Now, Tjio was, once again, a world away from anything that could be called home. He had come to Lund to work in the laboratory of an accomplished geneticist named Albert Levan. And here in the dead of night, in the euphoria of discovery, the emotional, itinerant cell biologist from nowhere in particular had no one with whom to share his extraordinary news.

Again and again Tjio counted the tiny bended strands. They were human chromosomes, taken from the embryonic cells of an unformed lung. Thanks to a bit of chemical manipulation, he had managed to “freeze” the chromosomes in the midst of cell division—a point at which the cell’s DNA was held in tightly wound, compacted coils. Ordinarily, this particular stage of the division, known as metaphase, was fleeting. But the young scientist had treated the slide with colchicine, a deadly poison found in the stem and seeds of the disarmingly beautiful autumn crocus. The poison had stopped mitosis in its tracks. Now, the wiry strands—each one a unique packet of genes—were dense enough to be seen with a light microscope. It was a marvel.

Twenty-three pairs of chromosomes. Forty-six in all. Clear as could be.

If he’d made no mistake in the preparation of the slide—and mistakes, he knew, were easy to make in this delicate art—the finding was startling. More than that, it was momentous. The textbooks would have to be rewritten.

Theophilus Shickel Painter had shown, in 1921, that human cells had two roughly matching sets of twenty-four chromosomes, for a total of forty-eight. (The sole exception to the rule being the germ cells, sperm and egg, each of which had only one set.) Painter, a zoologist who’d spent most of his career at the University of Texas, had been a pioneer in mammalian chromosome studies, or cytogenetics, as the discipline was starting to be known. A careful scientist, ever attentive to detail, he was an authority in the field.

If Tjio was right, that meant Painter was wrong—humans had two fewer chromosomes than previously believed.

Tjio, aware of the historic nature of the moment, snapped a few photographs through the microscope. On the bottom left-hand side of one of these photomicrographs, he inscribed, Human cell with 46 chromosomes observed 1955 on December 22nd at 2.00 a.m. He annotated a second photo in French. In the coming days, he would ceremoniously give these mementos to friends.

It took until late January, however, for him and Levan, his laboratory boss, to do the backup experiments required to make their case to the world. By then they’d inspected the nuclear DNA of cultured cells from four separate embryos, making 261 counts in all. In nearly every case, they could clearly make out forty-six strands. The researchers prepared an article and submitted it to the Swedish journal Hereditas, which published the piece in its next issue.

In what would be the biggest professional battle of Tjio’s long career, he argued bitterly with Levan over who would be “first author” on the paper—an honor that, then, typically went to the lab chief. Tjio tearfully threatened to destroy all the work he’d done if his name wasn’t listed first, daring his boss to reproduce it. Levan eventually conceded.

There was no hint of this Sturm und Drang in the title of the article that ran in the April Hereditas, nor even of the provocative conclusion inside. But within months of the publication of “The Chromosome Number of Man,” it became clear that an earthquake of sorts had occurred. The ground of human cytogenetics had cracked. What was for more than three decades considered by scientists around the world to be “normal” (forty-eight chromosomes) wasn’t normal at all. Several labs quickly reproduced the results of the Swedish group, and the revised number was reset in stone. In less than a year, the established wisdom changed.

More remarkable, however, was that a fair number of chromosome researchers (even some in Lund) had already come to the same conclusion—but had kept quiet. After the Hereditas article was published, several researchers wrote Tjio and Levan to confess that they, too, had spied only forty-six chromosomes in their cell preparations, but had thrown out the results because they were in conflict with established knowledge. Photographic evidence of the true number had, in fact, been published long before. A black-and-white photo of the human karyotype (the complement of chromosomes divided in matched pairs) in a widely read textbook of the day, by the eminent British geneticist Cyril Darlington, clearly showed forty-six chromosomes. The photo caption, however, read forty-eight.

The belief was so powerful, so set in the culture of biological research, that at least one respected scientist continued to find phantom chromosomes in normal human cells even after several labs had verified the correct number. Masuo Kodani, writing in the prestigious journal Science shortly after Tjio and Levan’s paper, acknowledged that forty-six chromosomes were certainly “possible” in man, but claimed there were other acceptable totals, too. Kodani reported that he’d found forty-eight of the gene-carrying strands in a full third of the Japanese men he had studied. In one case, he’d found forty-seven strands. Kodani, to put it kindly, had been confused. Chromosome counts in normal, healthy human beings—or in any other species, for that matter—do not vary from one individual to the next. (A critical exception comes with cancer, a hallmark of which is a change in the chromosomal counts of cells. Such change, called aneuploidy, is often dramatic.)

By year’s end, if there were additional doubts or confusion about the “new” number, they were unlikely to be published in a serious academic journal. Just like that, scientific truth had changed. The sun didn’t revolve around the earth. The earth wasn’t flat. And human cells carried twenty-three—not twenty-four—pairs of chromosomes.

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In the long, twisting history of science, the chromosome upheaval of 1956 barely registers. High school science teachers don’t teach it. It is not standard fare in biology textbooks. Among the great frame-shifts in human knowledge—from Newton’s gravity to Planck’s quantum and Pauling’s chemical bond—Joe Hin Tjio’s late-night discovery has gotten the attention of a footnote.

But this minirevolution in science ought to stand out in part for its pedestrian nature: Chromosome researchers before Tjio and Levan didn’t need their eyes opened to anything. They just needed to trust themselves enough to believe what they’d already seen.

Over a period of at least thirty years, many scientists—people trained to challenge conventions, to mistrust their own ingrained biases, to sharpen their instinct of skepticism—refused to question a finding that they had suspected was wrong. They’d accepted as incontrovertible fact something contrary to their own investigation and experience.

The question is, why? Why had so many scientists abandoned science when confronted with dogma?

This is the question that hovers over cancer research today. For the past several decades, reports of shining advances in cancer biology and treatment have streamed into newspapers, magazines, and television sets the world over. But during that time, there has been only minor change in the prospects for most people with active disease: survival numbers have barely improved; new cases keep mounting; death counts continue to rise.

Cancer doctors see this in their own clinics, despite offering their patients the newest, smartest drugs and treatment options in the oncology arsenal. Many of these same physicians, however, will tell you that they believe significant progress is being made in the war against cancer—for that is the story they’ve been hearing and reading, too. But that is not because they have witnessed it themselves.

The mythology extends from outrageously rosy assessments of the drug pipeline to the distortion of critical cancer statistics. And the cultural imperative to believe that we are winning is so powerful that when someone openly questions our progress, he risks a public shunning.

That is what happened to John Bailar.

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I had spoken to the man twice, at length over the phone, before he agreed to an interview in person. We met at his office at the National Academy of Sciences building in Washington, not far from the White House.

John C. Bailar III is six feet four inches tall with a barrel chest. His thick, white hair shoots straight up from the top of his head like a forest of birch trees. His voice is a resonant baritone. Physically, he is something of a giant—which made his tentativeness at our meeting all the more surprising. Something about the man suggested vulnerability. His gait was careful, his words and tone measured.

Some of this aura of caution, no doubt, was the product of his academic heritage. Bailar was not merely trained to be a research scientist; he was genetically engineered to be one. His mother taught mathematics. His father—John Jr.—winner of the Priestley Medal, chemistry’s highest honor shy of the Nobel, was an acknowledged pioneer in inorganic chemistry and author of a classic textbook. And both of Bailar’s grandfathers had been professors: his mother’s father taught economics at Purdue; his father’s father taught chemistry at a small Colorado college.

As for John Bailar III, there seemed to be the briefest hope of reprieve from a life of scholarly analysis and serial publication. After getting an undergraduate degree in chemistry, he enrolled at Yale to become a physician. But then, with his MD in hand and a two-year hospital stint completed, Bailar decided to trade the clinic once and for all for a career in research. He was back in the family business.

The realm that called to him was known as biometry (or biostatistics), and it intersected all of the academic fields he had come to love—bringing a detached, mathematical analysis to human biology, medicine, and epidemiology. Bailar, who would go on to earn a PhD in statistics from American University, found in the National Cancer Institute the perfect place to practice his new art.

He soon emerged as a star on the institute’s lush, woody campus in Bethesda, Maryland, heading up the NCI’s demography section. He then took charge of the government’s Third National Cancer Survey, conducted from 1969 through 1971. If Joe Hin Tjio was the consummate outsider, John Christian Bailar III was an unquestioned member of the club. The bullet points on his résumé said it all: editor in chief of the Journal of the National Cancer Institute for six years, statistical consultant to the New England Journal of Medicine for eleven years, lecturer in biostatistics at Harvard’s School of Public Health for seven. By 1986, the fifty-three-year-old researcher was a respected leader in his field.

Then he publicly questioned our progress in the fight against cancer.

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His doubts had been building for at least a decade, since shortly after President Nixon declared a national “war on cancer” in 1971. “Sometime during the 1970s, I began to have increasing questions about the effectiveness of the cancer research program as a whole,” Bailar told me in 2004. “When I left the NCI in 1980, I thought that it was best not to say much, at least for a while.”

By 1986, however, he felt as if he could not wait any longer. With Elaine Smith, an epidemiologist at the University of Iowa Medical Center, Bailar wrote a piece that May for the New England Journal of Medicine entitled “Progress Against Cancer?”

The headline, a sheepish fraction of a question, belied the devastating argument that would follow. Measuring cancer incidence and death in the United States back to the year 1950, Bailar and Smith found “no evidence that ...

Table of contents

• Cover
• Dedication
• Prologue: How Did We Get Here?
• Part One: The Burden
• Part Two: The Myth of the Magic Bullet
• Part Three: The Cancer Culture
• Part Four: The Way Forward
• Acknowledgments
• About Clifton Leaf
• Notes
• List of References
• Index
• Copyright