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Red_Dragon

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Posted: Feb 3, 2018 - 8:56pm

 ScottFromWyoming wrote:
So small picture episode but it sort of encapsulates for me the entire problem.

Up skiing today, a kid broke his arm, probably. Was in quite a bit of pain but only came to see us after at least an hour, he decided he needed some help. 16, on a group ski trip sponsored by a church from a town about 2:30 away. Not a quick trip. I was trying to find someone to drive him, thinking he was from the closer town. But when he started to comment on a tingly feeling in his fingers, which could be a lot of things but of course you think some damage is being done near the break, we called an ambulance. As we're filling out the paperwork, there's a box to tick "Do you have insurance?" Not, "give us the policy number," we don't bill anyone. Just the question, which we proceed to do nothing with the answer so I don't know why we ask. The kid says yes, then 10 minutes later, under his breath, says "I hope we have insurance." I found the chaperone and said maybe he should call and talk with the mom, who'd previously okay'd the ambulance ride. After hanging up with her, we turned the ambulance around and put the boy in the church van for the 2+ hour ride home.

My comment to the chaperone was out of line. Our policy is to not care about anything but providing the best care for our guests. The ambulance might not have done much for him except give him pain relief, which was needed. But what a terrible situation: The ride would cost $5000. If the arm is broken and surgery comes, sure, the family will probably max out the deductible either way so the ambulance would have been paid for. But what if they don't find a break and they send him home with some Tylenol? And the risk of insurance not covering an ambulance ride for a non-life-threatening injury? It shouldn't come down to that sort of thing.

And for us to call an ambulance and not care about the cost of care? That's not right, either. The main problem, at least one of them, is throwing the kitchen sink at all problems in order to later be able to say, "we did all we could." 

=====

Side note, it strikes me as weird, bordering on unexplainable, the number of times we contact a parent and they don't immediately get into a car and come meet us or try to meet the ambulance/transport at the ER. Maybe she was at work and couldn't get away. But if it had been my kid, I would have had a friend or family at the mountain 20 minutes before the ambulance. SOMEbody would have been rollin' as soon as I heard. This kid had been texting with his mom for more than an hour. I don't know but it sure felt like a "well I'll see you when you get here" deal. Again.

 
#medicareforall
ScottFromWyoming
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Posted: Feb 3, 2018 - 8:42pm

So small picture episode but it sort of encapsulates for me the entire problem.

Up skiing today, a kid broke his arm, probably. Was in quite a bit of pain but only came to see us after at least an hour, he decided he needed some help. 16, on a group ski trip sponsored by a church from a town about 2:30 away. Not a quick trip. I was trying to find someone to drive him, thinking he was from the closer town. But when he started to comment on a tingly feeling in his fingers, which could be a lot of things but of course you think some damage is being done near the break, we called an ambulance. As we're filling out the paperwork, there's a box to tick "Do you have insurance?" Not, "give us the policy number," we don't bill anyone. Just the question, which we proceed to do nothing with the answer so I don't know why we ask. The kid says yes, then 10 minutes later, under his breath, says "I hope we have insurance." I found the chaperone and said maybe he should call and talk with the mom, who'd previously okay'd the ambulance ride. After hanging up with her, we turned the ambulance around and put the boy in the church van for the 2+ hour ride home.

My comment to the chaperone was out of line. Our policy is to not care about anything but providing the best care for our guests. The ambulance might not have done much for him except give him pain relief, which was needed. But what a terrible situation: The ride would cost $5000. If the arm is broken and surgery comes, sure, the family will probably max out the deductible either way so the ambulance would have been paid for. But what if they don't find a break and they send him home with some Tylenol? And the risk of insurance not covering an ambulance ride for a non-life-threatening injury? It shouldn't come down to that sort of thing.

And for us to call an ambulance and not care about the cost of care? That's not right, either. The main problem, at least one of them, is throwing the kitchen sink at all problems in order to later be able to say, "we did all we could." 

=====

Side note, it strikes me as weird, bordering on unexplainable, the number of times we contact a parent and they don't immediately get into a car and come meet us or try to meet the ambulance/transport at the ER. Maybe she was at work and couldn't get away. But if it had been my kid, I would have had a friend or family at the mountain 20 minutes before the ambulance. SOMEbody would have been rollin' as soon as I heard. This kid had been texting with his mom for more than an hour. I don't know but it sure felt like a "well I'll see you when you get here" deal. Again.
miamizsun

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Posted: Feb 2, 2018 - 3:15pm

 Red_Dragon wrote: 
how about a bus ticket?
miamizsun

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Posted: Feb 2, 2018 - 3:14pm

 aflanigan wrote:

Certainly there has been a lot of work going on in the last 8 years, but one of the interesting things about the book is that it foresaw pretty well the course researchers into targeted therapies would be taking based on the ever improving understanding of the mechanics of cancer cell biology, and foresaw the ability of the disease to adapt and mutate, developing resistance such that new targeted therapies inevitably have to be followed quickly with alternate new therapies to address the cancers that mutate to develop resistance. You can look at the experience of CML patients with Gleevec; although a relatively rare cancer compared to say breast cancer or lung cancer, patients on Gleevec began demonstrating resistance within a year of it's first use; it took 5 years for the next targeted drug for CML, .dasatinib, to be developed. If a cancer which formerly affected only a few thousand patients a year can develop resistance so quickly, how long will it take cancer cells to mutate enough to develop resistance to targeted therapies for the more common types of cancers such as lung, breast, etc? We're talking about millions of dividing and replicating malignant cells here, vastly increasing the odds of an accidental mutation bestowing resistance; with widespread use of targeted medicines, such resistant mutations will quickly enjoy the same competitive advantage that antibiotic resistant bacteria do and come to predominate in cancer patients rather rapidly, I suspect. I also suspect that for the more widespread cancers, it will become a process of diminishing returns; resistance developing more quickly and in more varieties of resistant oncogenes, each one needing its own therapy; pharmaceutical companies becoming increasingly reluctant to pour research money into drugs which seem to have ever shrinking useful life spans as more and more patients affected by a particular cancer develop resistance and need alternate targeted therapies to survive. I suppose they might in desperation do what pediatricians were doing in response to the development of antibacterial resistant ear infections last century; reviving long abandoned antibiotics such as sulfa drugs in an attempt to find something that the bacteria no longer had resistance to.

Question: what specific breakthroughs have happened since the book came out do you feel invalidates the book's theme of being realistic/skeptical regarding the attainability of a total cure for cancer within the next century?

 
if you search you'll find scads of stuff that have happened

again, i think skeptical is good, bu trying to predict when stuff will happen (if that is what he is doing) is probably just a best guess

this popped up today

Cancer ‘vaccine’ eliminates tumors in mice

Activating T cells in tumors eliminated even distant metastases in mice, Stanford researchers found. Lymphoma patients are being recruited to test the technique in a clinical trial.

JAN 312018 
 

Injecting minute amounts of two immune-stimulating agents directly into solid tumors in mice can eliminate all traces of cancer in the animals, including distant, untreated metastases, according to a study by researchers at the Stanford University School of Medicine.

Levy, who holds the Robert K. and Helen K. Summy Professorship in the School of Medicine, is the senior author of the study, which was published Jan. 31 in Science Translational Medicine. Instructor of medicine Idit Sagiv-Barfi, PhD, is the lead author.

‘Amazing, bodywide effects’

Levy is a pioneer in the field of cancer immunotherapy, in which researchers try to harness the immune system to combat cancer. Research in his laboratory led to the development of rituximab, one of the first monoclonal antibodies approved for use as an anticancer treatment in humans.

Some immunotherapy approaches rely on stimulating the immune system throughout the body. Others target naturally occurring checkpoints that limit the anti-cancer activity of immune cells. Still others, like the CAR T-cell therapy recently approved to treat some types of leukemia and lymphomas, require a patient’s immune cells to be removed from the body and genetically engineered to attack the tumor cells. Many of these approaches have been successful, but they each have downsides — from difficult-to-handle side effects to high-cost and lengthy preparation or treatment times.

“All of these immunotherapy advances are changing medical practice,” Levy said. “Our approach uses a one-time application of very small amounts of two agents to stimulate the immune cells only within the tumor itself. In the mice, we saw amazing, bodywide effects, including the elimination of tumors all over the animal.”

Cancers often exist in a strange kind of limbo with regard to the immune system. Immune cells like T cells recognize the abnormal proteins often present on cancer cells and infiltrate to attack the tumor. However, as the tumor grows, it often devises ways to suppress the activity of the T cells.

Levy’s method works to reactivate the cancer-specific T cells by injecting microgram amounts of two agents directly into the tumor site. (A microgram is one-millionth of a gram). One, a short stretch of DNA called a CpG oligonucleotide, works with other nearby immune cells to amplify the expression of an activating receptor called OX40 on the surface of the T cells. The other, an antibody that binds to OX40, activates the T cells to lead the charge against the cancer cells. Because the two agents are injected directly into the tumor, only T cells that have infiltrated it are activated. In effect, these T cells are “prescreened” by the body to recognize only cancer-specific proteins.

Cancer-destroying rangers

Some of these tumor-specific, activated T cells then leave the original tumor to find and destroy other identical tumors throughout the body.

The approach worked startlingly well in laboratory mice with transplanted mouse lymphoma tumors in two sites on their bodies. Injecting one tumor site with the two agents caused the regression not just of the treated tumor, but also of the second, untreated tumor. In this way, 87 of 90 mice were cured of the cancer. Although the cancer recurred in three of the mice, the tumors again regressed after a second treatment. The researchers saw similar results in mice bearing breast, colon and melanoma tumors.



Red_Dragon

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Posted: Jan 31, 2018 - 6:15am

mail me to the GOP
ScottFromWyoming
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Posted: Jan 30, 2018 - 9:25pm

 Steely_D wrote:

Various reasons. Most doctors aren't unionized and RNs typically are, so there are big contract differences.

The ultimate one comes down to where the buck stops. Someone has to be responsible for the patient care, and it's fantastic when the doc/nurses/pharmacists/dieticians/physical therapists/etc all come together to create a comprehensive care plan. But, in most cases, the doc is responsible for the show, either directly or by monitoring teams of well trained folks who could be nurses, PAs, etc. Despite the many situations where my nurses clearly are smarter than me, if something goes wrong I can not blame them - the buck stops here.

 

Steely_D
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Posted: Jan 30, 2018 - 8:24pm

 haresfur wrote:

Why are doctors treated differently from nurses?

 
Various reasons. Most doctors aren't unionized and RNs typically are, so there are big contract differences.

The ultimate one comes down to where the buck stops. Someone has to be responsible for the patient care, and it's fantastic when the doc/nurses/pharmacists/dieticians/physical therapists/etc all come together to create a comprehensive care plan. But, in most cases, the doc is responsible for the show, either directly or by monitoring teams of well trained folks who could be nurses, PAs, etc. Despite the many situations where my nurses clearly are smarter than me, if something goes wrong I can not blame them - the buck stops here.
haresfur
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Posted: Jan 30, 2018 - 3:34pm

 Steely_D wrote:

I like the simplicity of how Kaiser works, in terms of health care:
1) Health Plan markets and sells insurance but has no doctors or hospitals
2) Kaiser Foundation Hospitals doesn't sell insurance and has no doctors, but has hospital and clinic facilities and support staff (nurses, maintenance, etc)
3) The Permanente Medical Group doesn't sell insurance or own hospitals, but is contracted to provide health care to the Kaiser hospitals.

The holy trinity of comprehensive coverage. 
The government could take over the first bullet point, but the hard part is getting the nation's hospitals and doctors to fall in line with being covered by that insurance. NOTE: this would provide basic care and preventative services. Optional things (cosmetic surgery) would be fee-for-service.
 
Why are doctors treated differently from nurses?
Steely_D
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Posted: Jan 30, 2018 - 3:16pm

 islander wrote:

I know some people who do health insurance for the big A, and the other software Juggernaut in town. There is always a big panic around renewals, and the focus is only on the bottom line, almost nothing on services. If they bring it in house, who will they squeeze for results?

I bet they spend a lot of time and $s studying it, and figure out that a large centralized single payer style system is the best...

 
I like the simplicity of how Kaiser works, in terms of health care:
1) Health Plan markets and sells insurance but has no doctors or hospitals
2) Kaiser Foundation Hospitals doesn't sell insurance and has no doctors, but has hospital and clinic facilities and support staff (nurses, maintenance, etc)
3) The Permanente Medical Group doesn't sell insurance or own hospitals, but is contracted to provide health care to the Kaiser hospitals.

The holy trinity of comprehensive coverage. 
The government could take over the first bullet point, but the hard part is getting the nation's hospitals and doctors to fall in line with being covered by that insurance. NOTE: this would provide basic care and preventative services. Optional things (cosmetic surgery) would be fee-for-service.


islander
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Posted: Jan 30, 2018 - 3:09pm

 cc_rider wrote:

Wow, that could be really interesting. You have to figure each company has a small army of employees who do nothing but chase health care and health insurance issues all day long. Why not bring health insurance in house? Not to mention, they are giving insurers millions of dollars in premiums, and clearly they are not satisfied with the product they're getting. 

What amazes me about health insurance is the mountain of paperwork the insurers pass around. Every visit generates an 'Explanation of Benefits', which doesn't tell me anything new. Wasted resources.

I'd like to see them succeed, and maybe even compete with the big insurers.

 
I know some people who do health insurance for the big A, and the other software Juggernaut in town. There is always a big panic around renewals, and the focus is only on the bottom line, almost nothing on services. If they bring it in house, who will they squeeze for results?

I bet they spend a lot of time and $s studying it, and figure out that a large centralized single payer style system is the best...
cc_rider
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Posted: Jan 30, 2018 - 2:19pm

 kcar wrote:

The piece is very fuzzy on details and some of the rumored ideas sound a bit like small beer:

"The three companies provided few details about the new entity, other than saying it would initially focus on technology to provide simplified, high-quality health care for their employees and their families, and at a reasonable cost."

...

 
Oh, I completely agree, it's not even half-baked yet. I think they saw what they're spending on health insurance, and how many complaints they deal with, and are thinking they can do better. It sounds a bit like they want to self-insure and bypass the insurance companies, but who knows what form it will really take.

It'll be interesting to see, regardless.
c.
kcar

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Posted: Jan 30, 2018 - 2:13pm

 cc_rider wrote:

Wow, that could be really interesting. You have to figure each company has a small army of employees who do nothing but chase health care and health insurance issues all day long. Why not bring health insurance in house? Not to mention, they are giving insurers millions of dollars in premiums, and clearly they are not satisfied with the product they're getting. 

What amazes me about health insurance is the mountain of paperwork the insurers pass around. Every visit generates an 'Explanation of Benefits', which doesn't tell me anything new. Wasted resources.

I'd like to see them succeed, and maybe even compete with the big insurers.

 
The piece is very fuzzy on details and some of the rumored ideas sound a bit like small beer:

"The three companies provided few details about the new entity, other than saying it would initially focus on technology to provide simplified, high-quality health care for their employees and their families, and at a reasonable cost."

...

"It was unclear whether the new venture would make it easier for consumers to understand their health care costs and access medical records, or take on more ambitious changes like the wider use of telemedicine and virtual doctor visits."
...

Even the three companies don’t seem to be certain how they intend to shake up the health care system. People briefed on the plan, who asked for anonymity because the discussions are private, said the leaders of the three companies decided to announce the initiative while it was still a concept in part so they can begin hiring staff for the new company.

...



One of these people  said the new company wouldn’t replace existing health insurers or hospitals, though it’s too soon to say exactly what form it would ultimately take. One idea is an online health care dashboard that connects employees with the closest and best doctor specializing in whatever ailment they select from a drop-down menu, one of the people said.

The three backers of the new company foresee striking deals for employee discounts with service providers like medical testing facilities, the person added.

...

Erik Gordon, a professor at the University of Michigan’s Ross School of Business, predicted that the companies would attempt to modernize the frequently cumbersome process of making appointments with physicians by making it more like booking a restaurant reservation on OpenTable, while eliminating the need to regularly fill out paper forms on clipboards.

“I think they will bring the customer-facing, patient-facing thing into your smartphone,” he said.


cc_rider
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Posted: Jan 30, 2018 - 1:54pm

 aflanigan wrote:

I'm wondering if it could demonstrate in a practical and hard to politically ignore way that the huge overhead that goes to insurance companies as part of the delivery of healthcare is utterly unnecessary for delivering decent quality healthcare.

  I think that's what I really meant to say. Virtually all healthcare providers bemoan the hoops the insurance companies put them through. It's a huge drain of resources away from actually providing care.
c.


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Posted: Jan 30, 2018 - 12:28pm

 cc_rider wrote:

Wow, that could be really interesting. You have to figure each company has a small army of employees who do nothing but chase health care and health insurance issues all day long. Why not bring health insurance in house? Not to mention, they are giving insurers millions of dollars in premiums, and clearly they are not satisfied with the product they're getting. 

What amazes me about health insurance is the mountain of paperwork the insurers pass around. Every visit generates an 'Explanation of Benefits', which doesn't tell me anything new. Wasted resources.

I'd like to see them succeed, and maybe even compete with the big insurers.

 
I'm wondering if it could demonstrate in a practical and hard to politically ignore way that the huge overhead that goes to insurance companies as part of the delivery of healthcare is utterly unnecessary for delivering decent quality healthcare.
cc_rider
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Location: Bastrop
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Posted: Jan 30, 2018 - 12:13pm

 aflanigan wrote: 
Wow, that could be really interesting. You have to figure each company has a small army of employees who do nothing but chase health care and health insurance issues all day long. Why not bring health insurance in house? Not to mention, they are giving insurers millions of dollars in premiums, and clearly they are not satisfied with the product they're getting. 

What amazes me about health insurance is the mountain of paperwork the insurers pass around. Every visit generates an 'Explanation of Benefits', which doesn't tell me anything new. Wasted resources.

I'd like to see them succeed, and maybe even compete with the big insurers.
Red_Dragon

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Posted: Jan 30, 2018 - 12:09pm

 aflanigan wrote: 
#medicareforall
aflanigan
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Posted: Jan 30, 2018 - 11:34am

Ray of hope?

Amazon, Berkshire Hathaway and JPMorgan Team Up to Disrupt Health Care


aflanigan
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Posted: Jan 29, 2018 - 2:57pm

 miamizsun wrote:

of course (philosophically i agree)

sid is a legit source ( i think we went through this sometime back)

the tools for health care are getting better at a rapid rate (diagnosis and treatment)

that book came out in 2010 and quite a bit has changed in that short period

it's impossible to know exactly when breakthroughs are going to happen

but yes i am optimistic about where medicine/health care is going

i think i posted some media about jennifer doudna and george church fairly recently that would be worth a listen too

i subscribe to several sources via youtube and rss

also you can see a lot of stuff that gets shot down over at http://retractionwatch.com/

regards

 
Certainly there has been a lot of work going on in the last 8 years, but one of the interesting things about the book is that it foresaw pretty well the course researchers into targeted therapies would be taking based on the ever improving understanding of the mechanics of cancer cell biology, and foresaw the ability of the disease to adapt and mutate, developing resistance such that new targeted therapies inevitably have to be followed quickly with alternate new therapies to address the cancers that mutate to develop resistance. You can look at the experience of CML patients with Gleevec; although a relatively rare cancer compared to say breast cancer or lung cancer, patients on Gleevec began demonstrating resistance within a year of it's first use; it took 5 years for the next targeted drug for CML, .dasatinib, to be developed. If a cancer which formerly affected only a few thousand patients a year can develop resistance so quickly, how long will it take cancer cells to mutate enough to develop resistance to targeted therapies for the more common types of cancers such as lung, breast, etc? We're talking about millions of dividing and replicating malignant cells here, vastly increasing the odds of an accidental mutation bestowing resistance; with widespread use of targeted medicines, such resistant mutations will quickly enjoy the same competitive advantage that antibiotic resistant bacteria do and come to predominate in cancer patients rather rapidly, I suspect. I also suspect that for the more widespread cancers, it will become a process of diminishing returns; resistance developing more quickly and in more varieties of resistant oncogenes, each one needing its own therapy; pharmaceutical companies becoming increasingly reluctant to pour research money into drugs which seem to have ever shrinking useful life spans as more and more patients affected by a particular cancer develop resistance and need alternate targeted therapies to survive. I suppose they might in desperation do what pediatricians were doing in response to the development of antibacterial resistant ear infections last century; reviving long abandoned antibiotics such as sulfa drugs in an attempt to find something that the bacteria no longer had resistance to.

Question: what specific breakthroughs have happened since the book came out do you feel invalidates the book's theme of being realistic/skeptical regarding the attainability of a total cure for cancer within the next century?


miamizsun

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Posted: Jan 29, 2018 - 9:44am

 aflanigan wrote:
I have been reading Mukherjee's biography of cancer, The Emperor of All Maladies, and am just about finished. The final section actually discusses much of the latest advances in oncobiology which you regularly post about, including the above cancer cell genome project. It is well worth a read.

I get the impression that you are very optimistic regarding technology's ability to dramatically improve medical healthcare outcomes in humans. I would point out that you need to balance such optimism with the reality regarding the uniquely adaptive nature of cancer, and it's tremendously versatile ability to confound attempts at controlling or eradicating it.
 
of course (philosophically i agree)

sid is a legit source ( i think we went through this sometime back)

the tools for health care are getting better at a rapid rate (diagnosis and treatment)

that book came out in 2010 and quite a bit has changed in that short period

it's impossible to know exactly when breakthroughs are going to happen

but yes i am optimistic about where medicine/health care is going

i think i posted some media about jennifer doudna and george church fairly recently that would be worth a listen too

i subscribe to several sources via youtube and rss

also you can see a lot of stuff that gets shot down over at http://retractionwatch.com/

regards


aflanigan
Be ashamed to die until you have won some victory for humanity
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Posted: Jan 29, 2018 - 9:18am

 miamizsun wrote:

New gene editing screens thousands of genes at once for cancer and will scale to whole genome screening

A novel screening method developed by a team at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center — using CRISPR-Cas9 genome editing technology to test the function of thousands of tumor genes in mice — has revealed new drug targets that could potentially enhance the effectiveness of PD-1 checkpoint inhibitors, a promising new class of cancer immunotherapy.

Researchers report that deletion of the Ptpn2 gene in tumor cells made them more susceptible to PD-1 checkpoint inhibitors. PD-1 blockade is a drug that “releases the brakes” on immune cells, enabling them to locate and destroy cancer cells.

“PD-1 checkpoint inhibitors have transformed the treatment of many cancers, and opened the door to the possibility that immunotherapy will form part of the cure for cancer,” says Haining, senior author on the new paper, who is also associate professor of pediatrics at Harvard Medical School and associate member of the Broad Institute of MIT and Harvard.



 

I have been reading Mukherjee's biography of cancer, The Emperor of All Maladies, and am just about finished. The final section actually discusses much of the latest advances in oncobiology which you regularly post about, including the above cancer cell genome project. It is well worth a read.

I get the impression that you are very optimistic regarding technology's ability to dramatically improve medical healthcare outcomes in humans. I would point out that you need to balance such optimism with the reality regarding the uniquely adaptive nature of cancer, and it's tremendously versatile ability to confound attempts at controlling or eradicating it.

Targeted drug therapy based on chemically binding the oncogenes which cause the abnormal cell growth which we call cancer have thus far proven to not be the long sought-after magic bullet. See in particular the final few chapter's of Mukherjee's book. Cancer not only has the ability to trigger uncontrolled cell growth and division, but mutations are also able to give malignant cells other beneficial (to the malignant cells) properties, such as the ability to shut out therapeutic drugs, the ability to inactivate tumor suppressor genes (the body's own built in anti-cancer mechanism for discouraging uncontrolled cell growth), the ability to evade programmed cell death (cellular immortality of cancer cells), the ability to orchestrate production of new blood vessel structure to provide the necessary nutrients for cell survival, the ability to travel throughout the body and invade healthy tissue, and finally the ability to mutate in a manner which allows them to circumvent targeted therapies. This ability has already been confirmed in the treatment of CML (chronic myeloid leukemia) with Gleevec, one of the first targeted chemotherapy drugs. Gleevec was designed specifically to fit into the surface of (i.e. bind) the oncogene (Bcr-abl) to prevent it from orchestrating malignant cell growth. Mutations in the Bcr-abl oncogene changed the topology of the protein in a way that took away the ability of Gleevec to "bind" the protein and thus turn off the uncontrolled cell growth that the oncogene produces. The mutated oncogene effectively changed it's shape so that the drug "key" no longer fit into the slot of the lock, and thus took away it's ability to turn the runaway cell division and growth off.

Our progress in understanding the biology of cancer cells has been undeniable, and continues to grow. But we need to put it into perspective which takes into account not only the mutatability and heterogeneity of cancer, but also the mutatability and heterogeneity of ourselves and our environment. Consider this passage in which Mukherjee imagines the persian empress Atossa (who received one of the first mastectomies to treat breast cancer around 500BCE) transplanted to the year 2050:

In 2050, Atossa will arrive at her breast oncologist's clinic with 

a thumb- size flash drive containing the entire sequence of her cancer's genome, identifying every
mutation in every gene. The mutations will be organized into key pathways. An algorithm might
identify the pathways that are contributing to the growth and survival of her cancer. Therapies will be
targeted against these pathways to prevent a relapse of the tumor after surgery. She will begin with
one combination of targeted drugs, expect to switch to a second cocktail when her cancer mutates, and
switch again when the cancer mutates again. She will likely take some form of medicine, whether to
prevent, cure, or palliate her illness, for the rest of her life.

This, indubitably, is progress. But before we become too dazzled by Atossa's survival, it is
worthwhile putting it into perspective. Give Atossa metastatic pancreatic cancer in 500 BC and her
prognosis is unlikely to change by more than a few months over twenty-five hundred years. If Atossa
develops gallbladder cancer that is not amenable to surgery, her survival changes only marginally
over centuries. Even breast cancer shows a marked heterogeneity in outcome. If Atossa's tumor has
metastasized, or is estrogen-receptor negative, Her-2 negative, and unresponsive to standard
chemotherapy, then her chances of survival will have barely changed since the time of Hunter's
clinic. Give Atossa CML or Hodgkin's disease, in contrast, and her life span may have increased by
thirty or forty years.

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