Politics of CancerPolitics of Cancer

For Dr Samuel Epstein cancer prevention is of utmost importance. Epstein, who is professor of occupational and environmental medicine at the school of public health, University of Illinois Medical Center, has written some 250 articles and 10 books on toxic, carcinogenic, and mutagenic effects of occupational and environmental contaminants.

Epstein's logical proposition, simply put, is that the majority of cancers are caused by environmental exposures. Control this environment, and cancer will be prevented. Money and effort applied to treatment are far less beneficial to society than the same money and effort spent on prevention.

His book, The Politics of Cancer Revisited, presents his views on why the environmental causes of cancer, the majority man-made, are not being seriously addressed, despite adequate scientific methodology and governmental regulation. The losing war on cancer is the result. Epstein also questions the methods and results of many of the well-known standard-bearers in the battle against cancer.

The initial portion of the book is a reprint of the original 1978 version of The Politics of Cancer. That work dealt mainly with the various known or suspected carcinogens, how they came to be suspected and identified, and the difficulty of interpreting industrial data and government policies at the time. Thousands of environmental agents from the petrochemical, insecticide, and plastics industries, to mention only a few, are in our land, sea, and air, and The Politics of Cancer explores the threat. How to identify a potential carcinogen as a true hazard is examined in chapters on animal testing and workplace and consumer product case studies.

Animal testing, Epstein writes, is fraught with difficulties. The variable sensitivity of different species to different chemicals requires varying levels of exposure, some extremely high. This leads to criticism of methods and results by those who are interested in not defining a certain chemical as a carcinogen. Workplace studies have led to identification of arsenic and aromatic amines as carcinogens but not without years of disagreement.

In the second portion of the book, "The Politics of Cancer, 1998," results are said to be no different than those discussed in 1978 despite more sensitive scientific methods, improved industrial data, and ample government regulations. Necessary political action has not occurred, and rich and powerful forces, mainly for economic reasons, have successfully fought change. In 1987, Representative Henry Waxman invited Epstein to write a position paper, "War on Cancer," which was subsequently printed in the Congressional Record. In the paper, reprinted in full in the book, Epstein criticizes the American Cancer Society for failing to support, and at times for being hostile to, critical legislation seeking to reduce or eliminate exposure to environmental and occupational carcinogens. He claims that the society's approach to cancer prevention largely reflects the "victim philosophy," which emphasizes faulty lifestyles rather than workplace or environmental carcinogenesis.

In addition to rounding up the usual suspects, ie, corporations that may have direct monetary gain by fighting change, the author takes aim at the National Cancer Institute (NCI) and the American Cancer Society for misdirecting their funds toward "diagnosis, treatment, and basic genetic research with relative indifference to cancer prevention." Their approach is said to be neither due to ignorance nor based on science, but rather reflects conflicts of interest. Researchers and physicians on the society's board sit on NCI committees and, he says, obtain funding from the society and the NCI; society board members leave the room when funding is discussed, but Epstein considers this measure a "token formality." He writes, "For decades, powerful groups of interlocking financial interest, with the highly profitable cancer drug industry at their hub, have dominated the war on cancer. By linking their priorities with those of major pharmaceutical companies, the NCI has directed its own priorities away from prevention."

This book is a no-holds-barred, take-no-prisoners attack on all who disagree with its author's thesis. As a clinician who treats cancer patients, I feel in conflict with Epstein when he knocks clinical trials, mammograms, and chemotherapeutic agents. He severely criticizes respected names in academic and administrative oncology because their emphasis is different. The book does not disagree respectfully but rather declares political war between a basic preventive approach and a general patient care approach to the cancer problem. The Politics of Cancer offers much valuable information that can be extracted without entering the fray, while those who do appreciate a political battle, whatever their side, will find plenty to raise the blood pressure.

When my fellowship director left academics, I inherited her office, a National Institutes of Health subcontract, a few too many committee seats, and a small library of books and journal articles. Of the library, only a few works remain. Of these, only one, Morgan's fourth edition of the Environmental Protection Agency's (EPA's) Recognition and Management of Pesticide Poisonings, became a trusted friend and advisor, often consulted for help with the management of insecticide, herbicide, and other pesticide exposures.

Over the years, however, I sadly watched my friend slip into senescence. Although he remained as clear and lucent as ever, his advice became increasingly outdated. He continued to advise ipecac to treat most everyone; he continued to decry the use of pralidoxime in patients with possible carbamate poisoning, even when they showed unmistakable nicotinic signs. Mostly, he lost touch with the newer compounds and formulations.

Now the EPA provides a fifth edition, by Reigart and Roberts. Although the text now sports a glossy cover, an Internet Web address (http://www.epa.gov/oppfead1/safety/healthcare/handbook/handbook.htm), and green borders around the pages, this is no radical young upstart. All of the old chapters have been carried forward and updated based on recent scientific literature. The essential elements of each chapter remain consistent, including basic toxicology of the compounds, signs and symptoms of poisoning, consensus treatment guidelines, role of laboratory studies, and molecular structures.

Like its predecessor, the text is appropriate for both emergency consultation at the bedside and leisurely reading at home. Several features make this edition even friendlier. First, important notes, chapter highlights, and lists of commercial products now appear in the wide green borders. Second, there's a more conservative use of bolding and a complete absence of the shouting, bolded, all-capitalized dogmatic proclamations of the last edition.

New chapters on general management principles, taking an exposure history, and occupational and environmental considerations are valuable additions. New compounds appear, with new formulations and trade names of old compounds. The index continues the tradition of listing both chemical and trade names and is comprehensive.

Despite an expanded section on "Organophosphate Induced Delayed Neuropathy," and a new section on the intermediate syndrome, this book, like its predecessor, specializes in the acute toxicity of pesticides, and offers little regarding chronic exposures or chronic effects. Still, the expertise will be valuable in primary care, emergency medicine, medical toxicology, and occupational medicine.

My compliments to Drs Reigart and Roberts. Thanks to their continuation of Morgan's hard work, I have a new friend.

Paul Thagard is professor of philosophy and director of the Cognitive Science Program at the University of Waterloo, Ontario, Canada. He has written several monographs and articles with titles such as "Computational Philosophy of Science" and "Mind: Introduction to Cognitive Science." Professor Thagard also has a web site that he mentions in this book: http://cogsci.uwaterloo.ca. Clearly, the author is a noted scholar in his field. It is therefore with some temerity that I, a retired physician-scientist, comment on his latest book. Nevertheless, these are my thoughts.

This is a fascinating book that records the evolution of the current understanding and treatment of duodenal ulcer. It is also a frustrating book that promises much more than it delivers and fails to reach the goal set out in the preface: "This book is about the causes of disease and the causes of science." The concept of "cause" is introduced early, yet the logical and philosophical difficulties surrounding causation are inadequately described, and, certainly, the "causes" of science or disease remain obscure to the reader.

The book's aims are ambitious. Its historical record is quite accurate, and its prose is good. But it lacks cohesion, introduces unnecessary and distracting topics, and omits steps of logic. It also omits significant published references concerning epidemiology and causation, particularly the important work of Bradford Hill.

The author understandably has been impressed by the importance of the conclusion that the bacterium Helicobacter pylori is responsible for duodenal ulceration in the vast majority of cases. He chronicles Dr Barry J. Marshall's research attempts to establish a pathogenic role for this bacteria, but Thagard's attempts to explain the rationale for what was done miss the mark. He also does not mention that Marshall produced gastritis in himself by ingesting H pylori. Professor Thagard seems to confuse hypothesis with simple conclusions or predictions. I found myself thinking that the book is like a melody sung off-key, ie, not quite correct.

Postmodern, relativist, or deconstructionist views of science (I am using the terms synonymously) are introduced into the author's narrative like grains of sand in an otherwise tasty oyster. To his credit Professor Thagard dismisses one such view, the one that suggests that bacteria do not exist outside of a microscopic field (in a discussion of "Medical Realism").

The view of the philosopher Popper that one cannot prove but only disprove hypotheses does not receive much attention from Thagard nor do distinctions between observational and interventionist experiments. Both of these concepts are important in dealing with concepts of causality. For instance, the best evidence for H pylori being a necessary cause of duodenal ulcer is the ability to cure the ulcer by antibiotics alone. Observing its presence with ulceration cannot define a causal role for H pylori no matter how consistent the finding. There is always the possibility that the presence of the bacteria is a result, not the cause, of the ulcer.

To sum up, this is a well researched tour de force concerning H pylori as a causal agent of duodenal ulcer, but it does not come to grips with the practical or philosophical problems surrounding the concept of causality. Therefore, the book adds little that is new on the title subject.

Paul Rabinow has written an ethnography of intimate workings of the Centre d'Etude du Polymorphisme Humain (CEPH). At the time of the account, Daniel Cohen was working to bring together the remarkable cell lines gathered from families throughout France with economic opportunities for large-scale research that were beyond the scope likely in French public or private funding arrangements.

Rabinow is interested in the issues of "how best to bring capital, morality, and knowledge into a productive and ethical relationship." The collaboration between the Association Française Contre les Myopathies (AFM) and CEPH is described by Rabinow as "a major novelty, a courageous and visionary act." The AFM was a new model of financing for scientific research, drawing on its roots in nonprofit voluntary agencies and "telethons" to generate funding, which was in turn used to contract industrial research in the public interest. Bertrand Barataud of AFM and Cohen collaborated in the design of Généthon, producing a first-generation integrated physical map of most of the human genome at the end of 1993.

Rabinow arrived at CEPH in January 1994, as Cohen was working with Eric Lander of the Massachusetts Institute of Technology and the Whitehead Institute to set up a company, "Millenium." Cohen believed that the funding of venture capitalists was necessary for the scale of research required for genetic therapeutics. French law did not at that time permit the kind of investment represented by venture capital investment in American biotech start-up companies. Cohen was aware that this would be a very controversial alliance in France, so he made a point of being very open with government officials, proceeding with their endorsement. He even welcomed Rabinow, the anthropologist, to be present throughout the meetings and negotiations.

Rabinow manages to describe the unraveling of the CEPH-Millennium deal without vilifying any single individual, describing a complex picture of neglect and financial difficulties at CEPH while Cohen worked on the deal with Millennium. The story is complicated, including a clash not only of egos, but of multiple agendas with the involvement of French politicians and media. Phillipe Froguel, head of the cherished diabetes project, insisted on CEPH's independence at a meeting with a team from Millenium and announced that he was involved in discussions with two multinational pharmaceutical giants. While Cohen tried to manage issues related to access to data and materials for ongoing research, Froguel communicated his objection to the Millennium deal to the French Prime Minister Edouard Balladur, requesting that he intervene to prevent the contract with Millennium and the transfer of DNA and clinical facts to Millennium. On April 1, 1994, the French government asked CEPH to break off contacts with Millennium.

Although the story is told in the other chapters, the analysis in chapters 1 and 4 and the epilogue provides important theoretical and contextual materials. Rabinow uses the work of Max Weber to depict French bioethics as worldly mysticism and Michel Foucault to describe the notion of "biopower" in genomic research as a "more insidious form of power relations that aimed at producing nourishing and administering forces that exerted a positive influence on life." Rabinow also turns to Jacques Le Goff's discussions of purgatory to describe the purpose of his ethnography in terms of a zone of continuing solidarity and hope, "a call to order, an order from which the present is freeing itself." Indeed, Rabinow seems to suggest that many of the ethical debates about the genome project mistake the values inherent in old forms (eg, notions of proper organization of knowledge production) as of continuing importance. This risks foreshortening a search for a better form of life before we can even understand or communally evaluate it through experience. In the epilogue, Rabinow suggests a "nominalist" approach to epistemology and ethics that includes a "sensibility that seeks to shape itself in accordance with a world experienced as contingent, malleable, and open." One can learn much bioethics and science policy from such an approach.

Although hardly light reading, French DNA lays open the power of good ethnography to move beyond description to make substantive contributions to the evolution of new social forms and values.

This book gives us a second chance to familiarize ourselves with the principles and practice of evidence-based medicine (EBM). This decade has reminded us of the importance of scientific evidence as the basis for making clinical decisions. A series of articles in journals such as JAMA and BMJ (British Medical Journal) and books on EBM have been exhorting us to search for published data, appraise them critically, and determine if they are valid and applicable to our own unique clinical situations. This message has permeated our awareness, albeit slowly, replacing familiar experiential, authority-based thinking.

The term EBM gained entrance to medical subject headings vocabulary in the mid-1990s. In 1997,¹ The Journal reviewed two excellent books explicating the tenets and practice of EBM.^{2 - 3} The current title reviewed herein is a rendition of the same theme with a Seattle spin—the three editors and all but two of the 20 authors are from the University of Washington or its neighboring institutions.

Of the 17 chapters, a majority deal with the importance of asking appropriate questions, searching the literature for evidence, evaluating published articles, and reconciling the gathered evidence to the problem at hand. The authors emphasize techniques on optimal use of not only MEDLINE but also secondary data repositories such as the Cochrane summaries, Bandolier, Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research), National Guideline Clearinghouse, and other derived data sets. We learn how to evaluate articles on meta-analysis, systematic reviews, quality of life, decision analysis, economic evidence, and clinical guidelines. Examples, case illustrations, and tables accompany succinct readable chapters. The authors have dealt with basic statistical concepts such as 2 × 2 tables, odds ratios, likelihood, and number needed to treat in moderate detail. There is an excellent glossary, a table of Web addresses for accessing secondary evidence sites, and well-cited recent reference lists for each chapter.

More than 60 years ago, T. S. Eliot lamented the loss of wisdom from an excess of knowledge and information. This is true for individual clinicians today; finding and evaluating evidence from a surfeit of publications is quite time intensive. The EBM orthodoxy recognizes this. Several secondary resources have responded to this need for filtered knowledge. They evaluate primary literature and summarize the evidence for practitioners, policymakers, and managers. This book, better than its predecessors, lists most of these resources. The chapter extolling the merits of a Computerized Patient Record System in successful use at Veterans Affairs' medical centers is a fine coda. As a satisfied user of such a system, I, too, hope for its adoption on a wider scale in future.

Any major work on EBM follows the above track in large measure; thus, this book is not exceptional in that regard. Earlier examples are the books by Sackett and Muir Gray, the McMaster series in JAMA appearing through the 1990s on "How to Use" and "How to Evaluate," and Greenhalgh's 1997 BMJ articles on "How to Read a Paper." These have given us a robust lattice for practice of EMB. These forerunners were more comprehensive in their discussion of statistical concepts. In fact, individual authors of this book acknowledge and cite liberally from these original treatises. Understandably, the tenor of EBM discussions is becoming comfortingly familiar but not yet trite.

Are there helpful dissimilarities, then? Yes. Discussion of secondary data resources, screening testing, recognition of policymakers' perspective, inclusion of chapters on cost effectiveness, and a chapter on the ambiguous practice of presenting the same data in differing formats set this book apart from its forebears. The editors recognize correctly that political and social priorities may decouple evidence-based practice from policy designing. They and others wonder if there is a national will in the United States to apply the lessons learned from evidence and technology to setting program imperatives.^{4 - 6}

I found an otherwise informative chapter on diagnostic tests marred by confusing figures with possible formulaic errors, and elsewhere misspelling of an oft-quoted name and an incorrect reference citation. These nettlesome errors do not dilute the overall merits of this book. Most recent books dealing with EBM or evidence have allowed easy access to authors or editors via e-mail and Web addresses. Readers and reviewers immensely benefit from this connectivity; the editors graciously acknowledge and follow through on their readers' input. In keeping with current trends, I would like to see this missing feature—electronic interactivity with readers—introduced in future.

In summary, here is another chance to acquaint yourself with the principles of EBM in case you missed the earlier publications. If you have read the earlier works, then this book will reinforce and expand your knowledge base. Bite-sized readable text, clear tables, figures, and a listing of abundant Web resources are notable quality features. If you have been following the swell of EBM literature, then this book represents a convenient compilation of scattered publications. If you have not been a follower, then this is an excellent book to start your journey. The intended readership, primary care providers, can readily extend to all clinical specialists and policymakers. With books like these, learning EBM has become easier, but practicing it, for various reasons, is still the harder part.