Why haven't biologists cured cancer?

https://www.writingruxandrabio.com/p/why-havent-biologists-cured-cancer

by zdw • 2 years ago

83 101 2 years ago

I don't have anything to add, but still wanted to say thanks for sharing. One of my friends passed away earlier this year due to cancer and one of the questions I've kept wondering about has been about our slow progress in curing cancer. (Which admittedly stems from my own utter ignorance on the subject!)

Edit: I've thought of something worth adding. I've been told that certain datasets related to biology and chemistry are normally paywalled. I wonder if restricted access to information due to copyright is also hampering the field's ability to iterate more quickly. It seems like a field that's serious about rapid iteration could make as much data and information available to the public to encourage increased collaboration and propagation of knowledge. Is Nature still considered the most prestigious journal?

jghn4• 2 years ago

It's important to understand that there'll never be "a cure for cancer". Cancer is not a single disease. It's more like a meta-disease. There are tons of different types of cancer and the path for treatment is not the same.

We've made tremendous progress in the last 20-30 years. There are some cancers that *are* effectively curable. And others still vex us just as much as they always have.

Terr_• 2 years ago

Compare: "When will we finally cure parasites", or "limb injuries".

dennis_jeeves2• 2 years ago

It's important to understand that there'll never be "a cure for cancer". Cancer is not a single disease. It's more like a meta-disease. There are tons of different types of cancer and the path for treatment is not the same.

I'll make an even border generalization. Cancer is one of the hallmarks of aging. And aging itself somewhat loosely defined will include all types of cancer and what are typically regarded as non-cancers, like Alzheimer's.

Maxatar2• 2 years ago

Saying we can never cure cancer because it's not a single disease doesn't quite strike me as accurate.

I'm not an expert so feel free to correct me, but my understanding is that there are plenty of other animals, such as the naked mole rat, that are effectively immune to all forms of cancer because while it might not technically be one disease, all forms of cancer share enough characteristics that there exist a small group of genes that are able to suppress it or develop an immune response that effectively prevents a tumor from growing.

roger10-4• 2 years ago

I often wonder this myself. Maybe it is just that difficult a problem. Or maybe it's because Big Pharma doesn't have strong motivation when the treatment is more lucrative than a cure (Tamoxifen treatment can continue for up to 10 years after radiation and chemo for breast cancer, Diabetes treatment life-long, etc.). Maybe it's some of both.

jseliger• 2 years ago

One of my friends passed away earlier this year due to cancer and one of the questions I've kept wondering about has been about our slow progress in curing cancer. (Which admittedly stems from my own utter ignorance on the subject!)

A lot of that "slow progress" is due to the FDA's intransigence and conservatism, even in the face of patients like me who are dying already anyway: https://jakeseliger.com/2023/07/22/i-am-dying-of-squamous-ce...

See also "The dead and dying at the gates of oncology clinical trials" https://jakeseliger.com/2024/01/29/the-dead-and-dying-at-the... and my wife on what trying to enroll in clinical trials is like from the patient's perspective: "Please be dying, but not too quickly: a clinical trial story" https://bessstillman.substack.com/p/please-be-dying-but-not-...

We could and should be moving faster. I'm dying anyway, so if a treatment doesn't work or even harms me, I'm not much worse off than I was before the treatment.

LarsDu883• 2 years ago

The little anecdote about Peter Thiel about shitty physicists going into biology reminded me of a chapter from Richard Feynman's book, "Surely Your Joking Mr. Feynman".

So it turns out Richard Feynman, after working in Los Alamos on the first nuclear bomb, and before going on to win a Nobel in Physics, actually did a stint as a biologist at CalTech. In fact he was doing some of the earliest work on ribosomes... so fundamental that he could have been the first person to discover that most all ribosomes were functionally equivalent:

"It would have been a fantastic and vital discovery if I had been a good biologist. But I wasn't a good biologist. We had a good idea, a good experiment, the right equipment, but I screwed it up: I gave her infected ribosomes the grossest possible error that you could make in an experiment like that. My ribosomes had been in the refrigerator for almost a month, and had become contaminated with some other living things. Had I prepared those ribosomes promptly over again and given them to her in a serious and careful way, with everything under control, that experiment would have worked, and we would have been the first to demonstrate the uniformity of life: the machinery of making proteins, the ribosomes, is the same in every creature. We were there at the right place, we were doing the right things, but I was doing things as an amateur -- stupid and sloppy."

So one of the world's best physicists almost became one of the world's most prominent molecular biologists, but actually fucked up the experiment for practical reasons.

I think this really underscores how not every problem is fundamentally a math problem... In the real world, especially with biology there's a shit ton of practical tedious things to deal with that can hamstring even the most brilliant experiments.

bitwize• 2 years ago

Cancer is among the stickiest of medical wickets, for several reasons:

* Cancer is not a disease, it's a family of diseases, with a wide spectrum of causes, symptoms, and treatments.

* Cancer is, fundamentally, a mutiny of your own cells against the rest of your body. Because cancer is fundamentally a part of you, it can shanghai some of the resources your body normally uses for itself, like blood vessel infrastructure. It can also masquerade as a healthy part of you, for example to your immune system. Hell, part of your immune system can become cancer (as in leukemia)!

* Cancer metastasizes, which means that even if you get rid of the main tumor, a few of those rebellious cancer cells can use your circulatory or lymphatic systems to start new rebel colonies elsewhere in your body, which means you could be fucked all over again. Treating this form of cancer can be an arduous, painful, sickness-inducing process of chemo- and/or radiotherapy.

We are closer than ever to "a cure for cancer" with things like immunotherapy treatments which can program your immune system to target the specific kind of cancer you have. Unfortunately, most of these need to be tailored per patient, which procedure is neither cheap nor routine. And it still doesn't always work for all cancers!

the__alchemist2• 2 years ago

Lovely article. The part that resonates most with me is towards the end: What some software developers would refer to as "friction". Medical tests are high friction for reasons the author hinted at. I'm optimistic some of the cfDNA or fragmentome cancer screenings will be useful for catching cancer early. If you try to dig on the topics, you'll find that the projects (GRAIL etc) are proud their methods and datasets are proprietary. The ones that play the political and business game best are getting funding for trials.

It seems there is a steady stream of progress in biology and its medical tie-ins, but it is slow and cumbersome. Unrelated: It seems like a lot of the techniques in biology are discovered partly by chance (ie dedicated work in an area that bears fruit, perhaps not in an expected form). Ways to leverage various bacteria, phages, proteins etc to provide insight, or perform a manipulation. The molecular biology techniques we have available seem like a tiny fraction of what we could discover. And in a way, it seems as much engineering or tool-making as science.

LarsDu883• 2 years ago

This idea of "curing cancer" as if cancer was a monolithic disease really needs to die.

Cancer is just a catch-all term for somatic cell mutations that become unmanageable. There are as many ways to get "cancer" as there are ways to mutate cells into these sort of uncontrollable states. And there are cures for multiple cancers today (Imantinib, Herceptin, etc). There actually have been enormous recent strides in drugs like PD-1 inhibitors that do have a broad spectrum affect against cancers, but I think outside of this one particular example, the real math problem is how do you expect to contain a mutational state of a cell with 10000x ways to reach that state with a single, or even handful of drugs?

melling• 2 years ago

Yeah, I always make sure to say cancer(s) so we can skip the “it’s not one disease “ digression. It adds nothing to the conversation.

According to Craig Venter, early detection is what we need to eliminate cancer(s): https://youtu.be/iUqgTYbkHP8?t=15m37s

lolinder2• 2 years ago

"It's not one disease" certainly preempts a lot of uninformed takes, but that in itself is a major contribution to the conversation we ought to be having. If your interlocutor is still thinking about cancer as a disease and not a large category of diseases with different causes, different characteristics, and therefore different solutions, there isn't much point to continuing that conversation until the situation has been clarified.

ekianjo• 2 years ago

early detection? there are not enough diagnostic tools that are already applied systematically right now for patients who have known cancers. this kind of idea is great on paper but hardly scales.

the__alchemist2• 2 years ago

100% re early det. Some projects to look at: GRAIL, PanSeer (blood cfDNA next-gen sequencing), and several ones looking at the fragmentome. I imagine an effective solution will take the form of something like this, but cheap and convenient enough so that everyone can get it done regularly.

"cancer isn't a single disease"is often used as a thought-terminating cliche.

Zenzero10• 2 years ago

Yep. (Doctor here)

Im not sure who the target audience is for the article, but it strikes me as one where if the author were more knowledgeable on the subject, they would have many of the answers to what they are asking. It reads to me like someone writing "why are there still bugs in programming? Is it because of too many buttons on the screens?"

Im in agreement with you that most people don't grasp just how medicine as an area of study is unfathomably complex. It mimics a fractal in the sense that the deeper we go in trying to understand things it just opens up a wider scope of investigation.

petermcneeley12• 2 years ago

Most of the body is cells. Most of cancer would be rogue cells. Cancer can be cured if you can:

1. Identify rogue cells 2. Destroy the rogue cells.

You can use technology to do both and pretty much ignore biology.

Eric_WVGG• 2 years ago

nice little comic about that — https://phdcomics.com/comics/archive.php?comicid=1162

inglor_cz• 2 years ago

"This idea of "curing cancer" as if cancer was a monolithic disease really needs to die."

I respectfully disagree. Maybe our problem is that of attitude, which you also exhibit when saying "with a single, or even handful of drugs". Drugs as such may be a dead end.

Once upon a time, we decided to study cancer from a biochemical and genetic point of view and look for drugs, which may actually be suboptimal. To give an analogy, what if you tried to debug a faulty program using a beeper instead of a debugger with screen. It would be a nasty work and it would take long. This is not an intrinsic problem of software ("fundamental undebuggability of 10 thousand errors"), it is "just" a wrong approach to debugging.

We are not the only mammals, we can look around nature and learn from it. What do we see when we study cancer in other species? Mammalian species that are highly resistant to cancer (whales, bats, naked mole rats etc.) seem not to rely on drugs or their biochemical equivalents, but rather kill cancerous cells biologically, with help of their immune systems.

Notably, if a species is highly resistant to cancer, it tends to be highly resistant to all sorts of cancer at once, or, at the very least, to many sorts of cancer at once, which indicates that a common suppressive mechanism for cancer ("cure" or "preventive cure") is well within the realm of possibility and that for all their biochemical diversity, cancer cells can be universally recognized and whacked in an efficient way.

The same actually holds about young people. Our own species is highly resistant to almost all cancers at once when young, and incidence of most cancers tends to grow with age along a very similar curve, which, again, indicates some commonalities under that extreme biochemical diversity.

Most of the progress in fight against cancer in the 21st century comes from biological approaches, not from better chemicals. The chemical approach may be fundamentally flawed.

Yeah, a "cure" in form of a chemical drug is likely impossible. But a "cure" in a form of a genetic treatment etc. may well be possible.

Anyone down for adding some whale genome to theirs? :)

pieter_mj• 2 years ago

Cured, no. But largely preventable, yes. With a paradigm shift from genetic to metabolic.

avinassh• 2 years ago

Can you elaborate? Are there studies showing changes in metabolism preventing cancer?

biophysboy2• 2 years ago

Contrary to the political priors of VCs, I think the real answers are pretty mundane:

1. Funding. Drugs have a low probability of success and a long lag time. Investors think in discount rates. A high-risk venture like biology is less appealing than an advertising-based tech platform with zero marginal costs.

2. Costs. Biology uses a LOT of proprietary instruments, kits, and chemical reagents. A lot. It also needs a lot of manual labor that would be difficult to roboticize.

3. Time. Biological experiments operate on biological timescales. Code takes seconds to run. Cell cultures take a day to grow. Even fancy new multiplexed sequencing assays take a while. You have the library prep time, the sequencing, and the downstream analysis. Its a long process. Now imagine waiting years and years to see if a drug in clinical trial prevents Alzheimer's.

4. Complexity. How do you make an equation for a giant network of weakly-interacting parts? Biology is a very "data-driven" field for this reason. The introduction of new microscopy, chemical conjugation techniques, and high-throughput assays has only made things worse. I genuinely hope some black box AI will be able to help us make sense of this mess and cure cancer. But medicine is full of interventions and incomplete prior histories, which will make naive association models hard to use.

sameoldtune• 2 years ago

What haven’t software engineers fixed all the bugs?

grishka4• 2 years ago

Because of this unfortunate idea in our industry that any software product constantly needs new features and is never done.

Ekaros• 2 years ago

But now we have miracle cure of AI. Just have to pass all the programs through that and have it fix them perfectly each and every time. No more bugs if developers just did this simple step...

grishka4• 2 years ago

This article is a good illustration of what's wrong with the current predominant approach in biology — it's all about genes and proteins, it's all way too reductionist to yield any meaningful higher-level outcomes. It's like trying to understand and manipulate an alien technology equivalent to a computer running a React web app, except you're only ever looking at and manipulating individual transistors in the CPU.

As Michael Levin said it, "reductionism is aptly named, it reduces what you can do". Do check out his research btw, it's some seriously impressive stuff. According to him, cancer, in particular, is simply a result of a group of cells electrically disconnecting from the surrounding tissue. He was able to force them to reconnect in one of his experiments, curing the tumor without killing anything.

alan-hn2• 2 years ago

Its interesting how your example perfectly illustrates reductionism in action. There are so many things that can go wrong, which is why cancer is such a heterogeneous group of diseases. There are many mutations that can happen which can lead to cancer growth and they have nothing to do with electrophysiology.

grishka4• 2 years ago

That's the thing with Michael's research, he injected an oncogene into a tadpole, and then made the tumor cells reconnect with the surrounding tissue and become healthy again, all while the gene was still strongly expressed.

cyberax2• 2 years ago

Levin's work smells like bullshit.

And it's also just as reductionist, trying to represent everything as electrical interactions.

grishka4• 2 years ago

Not everything, only morphogenesis, which is currently unexplained either way. And it does make sense for cancer to be a morphogenesis defect, because that's essentially what it is, it's cells "forgetting" that they are part of a larger whole that has goals more important than their own ones.

croes2• 2 years ago

So Peter Thiel is an idiot.

Biology especially human biology is a lot harder simply because experiments have bigger ethical issues.

Even if you have desperate cancer patients there are limits how and what you can test.

And we have others fields where all these brilliant people according to him are working and all the money goes and the problems are also not solved.

biophysboy2• 2 years ago

Every one of Peter Thiel's opinions is a dark provocative secret. He's very predictable

ackbar03• 2 years ago

I was kind of surprised he was gay

Sanzig• 2 years ago

It's not just ethics. Biology is just plain complicated. It's a science which tries to reverse engineer the results of billions of years of natural selection.

A human body belonging to a lucky person might live the better part of a century, all the time which it grows, heals itself when injured, processes food into new resources, hosts an example of the best known thinking machine in the world (the human brain), and literally has the machinery to produce one or more additional human beings. These are capabilities which are incredibly difficult to replicate artificially, so much so that producing a robot that could do even half of these things remains firmly in the realm of science fiction. And it wasn't designed, it was evolved, so it's about the worst mess of spaghetti code you could imagine. It's simply a hard problem.

croes2• 2 years ago

But ethics is the reason it's harder to experiment on a complicated matter.

In physics you can totally shatter your test object to get to the inner functions.

You can't do that with living creatures especially humans.

Murskautuminen• 2 years ago

Thanks for sharing a great article. Overall, I think the path to develop a drug is very multi-dimensional, cost and time intensive and very slow. Some other elements to add to the article:

- The preclinical drug discovery phase was not mentioned much. This phase involves discovering/designing/creating an actual drug against a potential biological mechanism/target uncovered by biology/genomics. Although this is generally seen as a more tractable element of the drug development path, it can still be very difficult and requires many years of additional research. Even so, some targets are well known to have great potential in disease, but it has been very difficult to generate a selective and potent drug against it. This phase typically does involve more "theoretically defined" research (although it is still messy) with chemists, biophysicists and pharmacologists, which fit more into the article's mention of the "mathematician". Yet, in line with the article, these often-talented people cannot always create a suitable drug for a given target. Providing further evidence that it is not "just" a lack of mathematically talented individuals.

- The reasons for drug failures in the clinic can be more numerous than alluded to in the article. Some drugs are very toxic, not only because of off-target side effects, but potentially also due to on-target side effects. In deadly cancers, this might not be so much of a problem, but it can still be a limiting element when we combine drugs to limit the surfacing of drug resistant cancer cells.

- As mentioned by others, cancer cells are cells from our own body, and they utilize our body's functions in excessive or highly altered manners to grow. However, blocking these functions selectively in cancer cells can be difficult (especially if non-genetically) as these functions often are still present in all other cells.

- Cancer metastasizes, cancer cells can spread across the body and generate new tumors elsewhere in the body. This can be almost anywhere, and it can be very difficult to detect early metastases in a patient. Hence, stopping treatment too early, even though the doctors might not see any cancer cells and the treatment has strong side effects, means you could redevelop cancer. Moreover, some metastatic sites might be in locations that are hard to reach for a given drug, hence they might not be fully targeted by a given drug.

- Full-blown cancers typically do not develop solely because of a single driving genetic alteration. Instead, a series of 2~5 genetic/biological alterations from a potential pool of dozens of genetic factors in combination leads to an aggressive tumor. Note though that it can be true that a single genetic alteration is dominant and drives a large part of cancer growth. Even in a single cancer type (e.g. colon cancer) the combination of 2-5 alterations leading to aggressive cancer can be different. Moreover, even within a single patient, different metastatic sites might evolve on their own and acquire different combinations of these driving factors. Hence, to truly treat some cancers targeting multiple drivers would be ideal, and each patient might require a relatively unique approach.

- Cancer cells are genetically unstable and can rapidly alter their genetic makeup. The DNA of normal human cells consists of two sets of 23 chromosomes that are well-organized and add up to ~3 billion DNA base pairs (the code of life). Cancers show very variable chromosome numbers and some advanced cancers can have more than 100 chromosomes. Moreover, cancer chromosomes can be heavily altered, where pieces of other chromosomes integrate into others, translocate, bridge, reconnect. It can be a total soup of >10 billion DNA base pairs. Moreover, these changes are different for each cancer, so every cancer patient will be more or less unique. This genetic instability also allows cancer cells to rapidly mutate and adapt/develop resistance to a given drug treatment.

thesimpleone• 2 years ago

There have been many cures that get buried due to not being able to make money from them

jghn4• 2 years ago

Citation needed

qup• 2 years ago

Yeah, hard to see why anyone would pay for it

jyscao2• 2 years ago

Not sure about the many cures that have been buried. But chemotherapy & radiotherapy, both of which do more harm than good, are two huge money makers indeed.

nitwit005• 2 years ago

You imagine investors pour money into medical research, ask the researchers to produce a cure, and then bury the results?

Doesn't exactly sound like a money making scheme.

sdsd• 2 years ago

Kinda reminds me of that software law, where any hardware gains are negated by bloated software. Any medical discoveries are negated by deteriorating diet.

declan_roberts• 2 years ago

You're being downvoted but there's truth to it. Post-scarcity society has made calories so abundant that we're having a difficult time keeping weight-related diseases down across the globe.

INGSOCIALITE• 2 years ago

$$$$$$$$$$

ALittleLight• 2 years ago

This reminds me of the company Loyal - a startup aiming at medical approaches to longevity by first treating pets/dogs. It's easier (I assume) from a regulation/moral standpoint to test therapies on animals instead of humans. I wonder if developing therapies for animal cancers first could be profitable, to bring in investment and prove a theory, and then expand to humans in a similar way.

jghn4• 2 years ago

It's easier (I assume) from a regulation

You'd be surprised. One of their larger challenges has been that the regulatory environment is very murky. It's definitely not anything goes, but it's not as well roadmapped as it is for human drugs.

kopirgan• 2 years ago

Even the improvements in 5yr survival could be the fact that detection has improved. Cancer detected much earlier then before naturally improving the 5yr numbers.

dsign• 2 years ago

That we haven't cured cancer is a problem of culture. And I'm not talking about that culture that we put in paintings and films, but about the more fundamental one that tells everybody what's the proper way to live a life. That base level of culture that tells people they should have kids and buy a car and a house (though not necessarily in that order), and go to a grill party from time to time. That part of culture that tells people is better to die of cancer than risk a leak of something dangerous from a laboratory, or letting the ayatolahs produce biological weapons.

In Vinge's novel "Rainbow's End" there is a particular fragment about how they had automated biological research, with robots at big connected research factories making all the experiments. Such factories would go a long way to shorten the "long cycles" the article mentions, and they perhaps would democratize bio-sciences research. I don't think there are any technological obstacles to building those factories; robots have been employed at factories for a long time and there many robots already used in expensive biological labs. But note the word "expensive". In cultural terms, "expensive" means "big commitment that has to be more important than anything else that can be bought with that money.". This is the cultural part I refer to. As a society, we discuss many things, but biological research is very, very low in that awareness list. In Europe, for example, putting spyware on people's phones is way higher in the agenda. And thus, the public would never approve a 20% (or any other number) of the government budget going towards biological research, unless they had material evidence that that money would indeed cure cancer. For the same reason, they wouldn't use use 20% of their savings to invest on biotech. But if, by the right means, those perceptions could be changed, we would see a revolution in biology and really substantial breakthroughs in life-expectancy.

317070• 2 years ago

I love the ambition, but also like to point out that today we still have smokers, that you can find cigarettes everywhere and that the number of smokers are on the rise again.

jyscao2• 2 years ago

This lecture[0] by Robert Austin, a physicist who has done extensive work in biomedical including cancer-related research, proposes a fundamentally different theory for how cancer develops and progresses. Namely, the mutational theory of cancer is wrong, and also the now conventional treatments we have for treating cancer patients, that is chemotherapy and radiotherapy, are often worse than the disease (both modalities promote metastasis of cancer as they evolve and migrate away from the source of the toxic stressors). Highly recommended to anyone who has an interest in the subject.

[0] https://www.youtube.com/watch?v=Q7iWB6xbkwQ

DataDive• 2 years ago

As someone who has been involved in and seen how cancer research is done, it is no surprise that progress is slow.

The "skilled", "famous" and "influential" scientists in cancer research spend almost all their time fighting for grants, undermining each other, jockeying for influence, exaggerating their own importance, publishing phony papers etc.

Underpaid novices, trainees, grad students, and postdocs with little prior experience do the actual work in the lab.

It is much, much worse than a reasonable person would imagine!

Why haven't biologists cured cancer?

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