The Future of Cancer Care Depends on Trust in the Scientific Community

Maurie Markman, MD

Much has been written over the past 18 months regarding the angst associated with the fallout from the COVID-19 pandemic, including its effect on the economy, decisions to restart essential activities such as in-person schooling, and more recently mandates for vaccination. Unfortunately, but of necessity, the scientific community—particularly national, regional, and local public health officials—has found itself in the middle of much of the controversy associated with the (hopefully) optimal management of the pandemic’s negative effects. To achieve this goal, leaders at all levels of government have had to make difficult and often quite unpopular decisions.

A recent front-page article in The New York Times highlighted the extraordinary pressure being placed on health officials and the devastating personal attacks to which many of these individuals have been subjected as a result of efforts to do their best to protect the public.¹ One official in Washington state, for example, was attacked online, with 1 post suggesting “bringing back public hangings” after she announced a local mask mandate.¹ In a number of settings state lawmakers without public health expertise have assumed responsibility for the functions of trained and experienced experts.

Unfortunately, the scientific community, particularly the critical national health regulatory authorities (FDA, CDC), have likely contributed to much of the confusion through less-than-optimal communication during the pandemic. Factors contributing to the uncertainty include changing recommendations with often confusing explanations regarding complex economic and political topics, and sometimes even contradicting decisions issued by various agencies or their advisors.

Further, efforts to find answers to unresolved, critically relevant questions about the actual origin of the virus responsible for the pandemic have revealed distressing conflicts of interest among members of the international scientific community. This includes concerns of whether the National Institutes of Health may have unknowingly funded research efforts in China to inappropriately, and remarkably dangerously, enhance the ability of coronaviral spread to humans.² It is not unreasonable to suggest that such revelations may serve to heighten concern regarding the objectivity of scientific leaders and public health officials entrusted to protect the public’s interests.

Other concerns noted in scientific literature threaten to further erode trust but have fortunately not yet been highlighted in the mainstream lay press. Some of these concerns appear to be unique to specific regions of the world, including reports of population-based germline analysis in China conducted with woefully inadequate (or completely absent) informed consent,³ and organized crime charges being brought against scientists in Mexico.⁴ However, other issues may be far more relevant in the United States, including disturbing evidence that scientific misconduct is not a rare event, as identified in an anonymous survey of Dutch scientists, 8% of whom admitted to fabrication or falsification of research results within the past 3 years.⁵ The serious inadequacy of scientific peer review is another concern, with a paper published in the journal Vaccines inappropriately concluding that for every 3 deaths prevented by COVID-19 vaccination, we have to accept 2 inflicted by vaccination.⁶

It is now appropriate to inquire how the preceding discussion is relevant within the oncology domain. In the opinion of this commentator, it is not unreasonable to state that a substantial percentage of the advances in cancer management over more than a decade have focused almost exclusively on the development of new antineoplastic pharmaceutical agents. There is certainly nothing wrong with this state of affairs and research in this arena should continue to be strongly encouraged; however, other factors must be acknowledged, including a rise in the aging population which is certain to correlate with a rise in the incidence of cancer and the simply unsustainable financial reality of this situation on individuals, families, and society. Further, as advanced cancers in several settings have become more chronic disease processes, the natural histories of which are increasingly measured in years rather than months, the cost of providing drug therapy for a far more prolonged period of time will challenge the budgets of all payers, including the government.

One critical component of a possible partial solution to this dilemma is a full-force effort in cancer prevention. Efforts should include promoting currently available vaccines (such as human papillomavirus [HPV] and hepatitis) and future vaccines, continuing major societal efforts in smoking cessation, and substantially expanding strategies to combat the raging epidemic of obesity (beginning with first-class research designed to determine how to effectively approach this issue).

One only needs to review the recent literature to understand the remarkable effect of widespread acceptance of HPV vaccination on reducing the burden of cervical cancer to appreciate the critical role that cancer prevention may play in the future in a fiscally sustainable approach to dealing with cancer. In a recent population-based report from the United Kingdom, routine vaccination for girls aged 12 to 13 years and a catch-up program for those aged 14 to 18 years was shown to reduce the risk of cervical cancer by 87% and CIN3 by 97% compared with an unvaccinated population of the same ages.⁷

Smoking cessation, including among individuals who have already developed a smoking-related malignancy, has been shown to be highly effective in preventing cancer or in certain circumstances reducing the risk of recurrence. In a study of 517 smokers with a diagnosis of earlystage (IA-IIIA) non–small cell lung cancer, the median overall survival was almost 2 years longer for individuals who discontinued smoking compared with those who continued the habit after their cancer diagnosis.⁸ Further, both cancer-specific (HR, 0.75) and all-cause mortality (HR, 0.67) was substantially improved in those able to stop smoking.

In conclusion, an important consideration is that evidence strongly supports that approaches to cancer prevention focused on vaccination of individuals who do not already have cancer, or ones that demand changes in well-established behaviors, have little chance of success unless those being targeted are willing to listen to, and ultimately trust, the recommendations being made by members of the scientific community.

References

1. Baker M, Ivory D. Why public health faces a crisis across the US. New York Times. Updated October 20, 2021. Accessed November 18, 2021. nyti.ms/3x0C8kP
2. Menachery VD, Yount BL Jr, Debbink K, et al. Corrigendum: a SARS-like cluster of circulating bat coronaviruses shows potential for human emergence. Nat Med. 2015;21(12):1508-1513. Published correction appears in Nat Med. 2020;26(7):1146.
3. Normile D. Genetics papers from China face ethical scrutiny. Science. 2021;373(6556):727-728. doi:10.1126/science.373.6556.727
4. Reardon S. Attempt to charge Mexican scientists with ‘organized crime’ prompts international outcry. Nature. 2021;598(7882):547-548. doi:10.1038/d41586-021-02816-9
5. de Vrieze J. Large survey finds questionable research practices are common. Science. 2021;373(6552):265. doi:10.1126/science.373.6552.265
6. Wadman M. Journal retracts paper claiming COVID-19 vaccines kill. Science. 2021;373(6551):147. doi:10.1126/science.373.6551.147
7. Falcaro M, Castañon A, Ndlela B, et al. The effects of the national HPV vaccination programme in England, UK, on cervical cancer and grade 3 cervical intraepithelial neoplasia incidence: a register-based observational study. Lancet. Published online November 3, 2021. doi:10.1016/S0140-6736(21)02178-4
8. Sheikh M, Mukeriya A, Shangina O, Brennan P, Zaridze D. Postdiagnosis smoking cessation and reduced risk for lung cancer progression and mortality: a prospective cohort study. Ann Intern Med. 2021;174(9):1232 1239. doi:10.7326/M21-0252