Thursday 12 May 2016

Curing hubris

I was going to call this piece Curing Cancer, knowing that my readers in Germany and Russia look to me for advice about dealing with their osteosarcomas and lymphomas. But it's not about that, because it's really a story of hubris in the medical profession: not only did nobody get cured, they all died. You might read my notes on Compassionate use / Expanded Access to prep for this story  . . . or not.

Hubris from the Greek ὕβρις: an overweening arrogance inviting disaster. It's the central theme of much of the canon of ancient Greek theatre,  Back then they had gobshites and big-headed tools just like now and, being civilised, their neighbours preferred to leave the comeuppance to the gods rather than deal with it directly with a course anger-management therapy. A straight-forward murder worked for the Greeks as well - Agamemnon, for starters.

When I started working for money in an Immunology Lab at the turn of the century, one of the biggest revelations was that surgery didn't cure cancer. Previously, I had the idea that god the surgeon went in with the knife to remove the tumour and the chemo- and radio-therapy mopped up the fragments which he [it was always a he] had missed.  That was mostly nonsense - the surgery was often just a shovel and bucket to reduce the size of the mass so that the immune system could move in and do its job without being overwhelmed. Natural Killer cells spend their entire working day identifying cancerous cells and blasting them to death - NK cells have the evenings and weekends off, of course, it's a strong union.

Fifteen years of education later, I now know a lot more about the triggers of the inflammatory response and indeed what is the inflammatory response. I fires up when the body's integrity is breached: by external threats like nematodes, bacteria or fungal pathogens or by cancer the enemy within. Viruses "of course" are, in this context, either-or-both. Both potentially pathogenic and the probable cause of almost all cancers. The most lovely and amazing thing about the immune system is how finely balanced it usually is. Lots of blokes of my age have lumps in their prostate but most of them will die with those lumps rather than of them. The immune system is working to keep things, including lumps in my prostate, under control. When you take in a 10 million Campylobacter jejuni in that dodgy chicken burger, the immune system can rapidly ramp up to deal with them.  It <metaphor alert!> recognises barbarians at the gate and recruits some licentious soldiery to repel them. Maybe, people have argued, the innate immune system is a general response and, while the immune cells are mopping up Campylobacter they duff up a few by-standing cancer cells.  We sort of know this is true because of Guillain-Barré syndrome, which I went on about in Dec 2013.

A tuthree years ago, Muizelaar & Schrot, a couple of doctors in California thought that they could tilt the process to cure cancer. Their cunning plan was to gee-up the immune system of people suffering from glioblastoma, an aggressive brain tumour, so the NK cells would coming whoopin' and hollerin' across the blood-brain barrier and do a number on the tumour. How to stimulate the immune system? Why not, they asked, infect the unfortunate patients with Enterobacter aerogenes, a relative of Escherichia coli.  There was plenty of E. aerogenes about because it is a notorious cause of hospital-induced infections: from catheters, titanium hips and the like.  There was some evidence that this 'treatment' was not totally irresponsible and bonkers: from a 2004 study by Bert Vogelstein [who has tremendous street-cred in cancer circles] in mice.  But all the positive evidence in humans was from samples so tiny as to amount to anecdotes. We have Ethics and Oversight Committees and Institutional Review Boards (IRB) to stop doctors having a brilliant idea . . . that has to work . . . because I have just thought it up . . . and applying their inner certainties to real people quietly dying in a hospital bed. It's just bad manners to jangle these unfortunates up when they have enough on their plate with the pain, the grief, the rage and putting their affairs in order.

A recent study has found that medical error, including arrogance, hubris, and failure to communicate, is the third most common cause of death in the USA.  In the old days, the doctor would have the humility to say, there is nothing [further] we can do and leave the room.  Now, after a decade of House and Scrubs, it is much more difficult to don't just do something, stand there.

No comments:

Post a Comment