Cancer “diagnoses” are popularly characterized as death sentences preceded by periods of horrible suffering. This characterization, popularized by media of all types (from movie to the pages of the New York Times), is in fact what motivates much of the real problem of cancer … desperation.

What if the conditions for success could be known?

Medicine does not search for truth. It searches for cure. It does not look for the universal, it tries to create exceptions.

Medicine emerged from witchcraft. It has always utilized the most advanced technology of its day. Medical models and reasoning always evolve and that evolution makes the previous model obsolete. One of the foundation models of modern medicine is the randomized controlled clinical trial.

The principal of the randomized controlled clinical trial is that a single observation needs to be validated and reproduced. The clinical trial provides an estimate of how often a particular observation will occur. It tells us that chemotherapy improves survival for patients with non-small cell lung cancer at one year from 20% to 29%. It tells us that FOLFOX treatment for advanced colon cancer gives a median time to progression of 8.7 months, response rate of 45%, and median survival time of 19.5 Months. This is accurate information about populations. It's use for the individual is a difficult problem.

Every person is a unit, no one is 20% or 29% or 45%. The question is...

What makes a target? Our understanding of disease is a model, an imagined defect in a fanciful machine. The workings of the intact organism are understood on the basis of the tools at hand and conform to the models of other world events and inventions. In the 19th century, the microscope became a useful tool and the cell was the agent of health and disease. DNA, the agents of heredity, became the basis of the most advanced therapy in the late 20th century. DNA was the target for chemotherapy, as soon as its importance in heredity was realized .

DNA as a target has fallen out of fashion. Now, we imagine the cell as a network of messages, an internet, with signals, noise and switches. These are the modern targets: growth factor receptors (and their mutations), kinases (and their mutations); the cellular equivalents of antennae and amplifiers.

This is the model that is generating today’s medicines (often ...

1. Benefit the patient, that is the most important thing
     a. That means optimizing the outcome
           i. preserving the highest quality of life
           ii. For as long as possible
           iii. Optimizing the quality of life when prolongation is no longer possible
           iv. Sometimes it means a good death.
2. There is no excuse for not using the most current information
     a. RSS feed
     b. Look it up for every patient, no matter how familiar it feels
3. Honesty
     a. With the patient
          i. Phrasing is important
              1. we all need hope
     b. With the family
     c. With myself
          i. Am I doing my best at all times?
4. The patient is not a vessel of the disease.
      a. Sometimes shrinking a cancer is not a good investment for the patient.
             i. The treatment can lower quality of life
             ii. Sometimes, the treatment can shorten life.
     b. Research can emphasize the impact on the disease to the exclusion of impact on the patient
5. It is at least as important to know what doesn’t work as what does.
     a. Sparing the patient side effects is sometimes the best thing the doctor can do.
6. All assumptions should be questioned.
     a. More intensive, ineffective treatment is not good care
     b. The most dramatic therapy has the same burden of proof as any other therapy
     c. Sometimes a clinical trial is the most appropriate path
           i. But evaluate all of the alternatives