Azra Raza is an oncologist, and professor of medicine and director of the Myelodysplastic Syndrome Center at Columbia University, New York. She was married to Harvey Preisler, another eminent oncologist, who died of lymphoma in 2002. Her new book, The First Cell, argues against the current preoccupations of cancer research and treatment. Instead of trying to destroy the last cancer cell, says Raza, we should invest more money in preventive treatments that enable us to detect the first cancer cell.
What made you decide to become an oncologist?
I have been interested instinctively in natural things since as long as I can remember. As I grew older, I really wanted to study Darwinian evolutionary biology. Then I wanted to study molecular biology. But there was no way for me to study science in Pakistan, where I grew up, so the only entry into science was through medicine, and I went to medical school. Once I had a clinical experience with patients, I knew this was something I would have to dedicate my life to.
When I came to the US at 24, oncology was laughingly referred to as a sub-speciality into which mostly Indians and Pakistanis and foreign medical graduates entered, because nobody who could have a choice of something better wanted to do it. But I really wanted to do it, for intellectual and emotional reasons.
Is it fair to say that your book argues that the multibillion-dollar medical research into cancer is largely wasted?
That would be too strong a statement, because it is largely useful, but not from the perspective of the patient. It is extremely useful in advancing our understanding of biology, of physiology, of pathology and immunology. The tremendous advances we have made thanks to cancer research are undeniable. The only problem I have is that in terms of drug development, and finding better options for our patients, we are failing spectacularly.
You say no one is winning the war on cancer. To what do you attribute the successes, for example, in breast and prostate cancer?
Its down to basically two things: early detection, and better use of existing therapies. But my contention is that no major new treatments have arrived on the scene in the past 15 to 20 years for either breast or prostate cancer.
You describe standard cancer treatment as slash-poison-burn, which is a somewhat dismissive description, but you acknowledge that it accounts for the fact that 68% of all cancers in the US are cured today. Is there a danger of underestimating that advance?
I hope not, but why do we have to use such stone age methods? The problem is that for thousands of years we have been taking our health for granted and only acting when disease strikes. But a lot of diseases are silent killers: suddenly, somebody would get chest pain and within minutes they would be dead. So cardiologists became smarter and tried to anticipate when somebody had heart disease and prevent it from happening. And as a result, mortality from cardiovascular diseases has gone down by 70%. Cancer mortality [in the US] went down by 26% in the past three decades, but it was mostly because of anti-smoking campaigns and screenings that were put in place 40 years ago. We can do better. We must do better.
Does the commercial setup in American medicine distort research in favour of pharmaceuticals rather than prevention?
Yes, it distorts, but also it can be used for a different purpose. At least their stated goal is to make money. Think about them investing their very hard-earned, precious resources into an enterprise which currently has a 95% failure rate for experimental drugs. And the 5% that succeed should have failed because they are basically palliative, providing months of improvement in survival. Why dont we set a different goal, which has a higher rate of success? We could constantly monitor the human body by imaging devices, by new technology, and then look for footprints of any perturbations caused by disease, whether its for Alzheimers, cancer, diabetes, whatever chronic disease were talking about. Basically, we set a new goal and then financially incentivise the new goal. The exact criticism that applies to the American medical system as a commercial enterprise also, weirdly enough, accounts for its tremendous success.
You are not a fan of cancer research on mice. Whats the problem?
We clearly know that a lot of strategies we try in cancer have failed miserably. For example, in the 1990s there was a huge wave of excitement, as it was felt that just choking off the blood supply of cancerous tumours will end up curing cancer. This was hyped up to such a degree that it went from laboratories to TV screens overnight and everybody wanted to enter these trials. But once it was brought to the bedside, it did not have the same spectacular success. My objection is, you cannot create a tumour that did not exist, artificially give a healthy mouse a tumour, then treat it with a drug, see that it disappears, and expect that the same will happen in a decrepit, crippled, immune-compromised human individual. This kind of extrapolation has failed us over and over, not just in cancer.
Your husband, an oncologist who died of cancer, advised you not to get too close to your patients. Was this to protect your own mental health?
I suppose there is a criticism about getting too close. But in 40 years in medicine I have yet to meet an oncologist who didnt care about his or her patients. Whether they like it or not, we get involved. We feel very upset. I mean, we are all humans; we cant stand each others suffering. And people who have gone into medicine, there has been a reason for them to enter this field one is that they are motivated to help do something about it.
Henry Marsh, the neurosurgeon, praised your book but suggested it might be guilty of the same unrealistic optimism you criticised for causing so much suffering. Is that a reasonable observation?
Henry Marsh is welcome to his opinion. Because he is my reviewer I obviously cannot say anything negative, but he himself has admitted in writing in the New York Times that he often performed neurosurgery when he knew it was of no use, because he found it too painful to tell the truth. You know, if somebody like me made that statement, a brown female from Pakistan, I would be laughed off the planet. I would have my licence suspended tomorrow. Now hes saying that I have a hubris in thinking that prevention and early detection will be helpful, and we will find ways to do it. Maybe hes right. But lets take off our blinders and see the problem for what it is.
What single piece of advice would you offer to someone with advanced cancer?
Dont give up hope. Dont give in to despair. But combine somehow what Antonio Gramsci [described as the] pessimism of the intellect with optimism of the will.
You quote a lot of great writers in your book. Is there a book that you recommend to patients?
I love fiction: it has taught me more than probably anything else in life, because reading fiction allows one to stand in the shoes of others. And thats where real empathy and compassion can begin from, because you learn to understand that many situations are so complex that the only answer is that there is no answer. I suggest all kinds of wonderful authors who are my favourites, but theres no one book that I recommend, though I love Don Quixote and Moby-Dick. I think that its a very human exercise to share ways of dissipating immense anxiety about looming mortality.
The First Cell And the Human Costs of Pursuing Cancer to the Last by Azra Raza is published by Hachette US (28). To order a copy go to guardianbookshop.com or call 020-3176 3837. Free UK p&p over 15, online orders only. Phone orders min p&p of 1.99