Harold Varmus, one of the first researchers to define cancer as a genetic disease, described it as “a distorted version of ourselves.” Unlike a infection caused by a virus or bacteria, which can be annihilated in order to restore health, tumors are the result of a malfunction by the very same mechanisms that keep us alive. Fighting them involves performing a complicated balancing act between the damage sustained by the cancer and the damage that is caused to the patient. In recent decades, research has enabled scientists to more accurately separate the healthy cells from the tumoral ones, to better understand what causes cancer, and to attack it more efficiently and with fewer side effects.
Miguel Martín is the head of the Medical Oncology Service at Gregorio Marañón Hospital in Madrid and president of the Spanish Research Group on Breast Cancer (Geicam). Martín, a native of Valladolid, has been performing balancing acts throughout his career, both in terms of patient treatment and in the management of other conflicts involving the fight against cancer.
While Martín acknowledges the usefulness of pharmaceutical companies, he is also highly critical of a system that fails to explore therapeutic solutions that do not guarantee economic profit, even if they have the potential to improve people’s lives.
Working through Geicam, which he has presided for the last 25 years, Martín is trying to compensate for these perverse effects of the market by defending research. “The research that begins now will benefit the patients of 20 years from now,” he says. “But it requires investment, a lot of time and the cooperation of many people to make progress.” This expert also defends preventive treatment that, together with a healthier lifestyle, could drastically reduce the impact of breast cancer.
Question. How can academic research cover the needs of patients through treatments that do not offer economic profit and therefore do not interest the pharmaceutical industry?
Answer. In Spain we have good basic research, but that is not an end in itself, it has to help patients. Clinical research is funded and supported by the pharmaceutical industry, which is the only one able to put a new drug on the market. Normally the industry purchases a drug that is starting clinical development, or else acquires the small company that created it. Then it invests large sums in developing a drug that they know is going to work, or at least has very good prospects of doing so. If the study is positive, they put the product on the market and approve it for a specific condition, say rheumatoid arthritis or breast cancer. At that point they begin to recoup the money they invested, many times over.
But besides that use, there are many other ways in which the drug could be employed, and its application could be vastly improved by modifying the conditions under which it is used. But often, once a drug is already on the market and making money for one application, the company does not spend any more on seeking other applications.
That is something that could be done by independent groups such as Geicam, which think of patients’ interests and not just shareholders’ interests. But a clinical trial costs a lot of money, around €15 million or €20 million, and since the industry is not interested, there are drugs that remain only partly developed. Government agencies should make an effort to encourage academic studies of drugs that are already on the market, in order to optimize already existing pharmaceutical products.
The French government, for instance, financed a study by independent researchers to see if there was a different way of using trastuzumab, a drug sold to treat breast cancer. [...] We need this in Spain too, but it’s been impossible, because the politicians in charge would not contemplate it when we suggested it.
Q. Why is that?
A. One of the problems is that Spain would have to coordinate all the regional governments, since healthcare is devolved to the regions. It’s a big problem. We have 17 countries inside one, whereas France is just one country.
Q. What could be done to improve the situation?
A. In English-speaking countries, it is possible for a non-healthcare company to invest in a research project and make it tax deductible, which is a win-win situation for everyone. In Spain, there is a proposed bill that’s been lying inside a drawer for 15 or 20 years and nobody is taking it out, because it means that some companies would pay fewer taxes, and the point here is to extract the most out of all the taxpayers. If we don’t invest in research, our country will always play in the little leagues and be dependent on other countries. And that costs money. It’s a short-sighted vision.
Q. Can living in a specific area of Spain increase one’s chances of surviving cancer?
A. Sadly this point could be improved on. Not all regions offer the same possibilities. We have already denounced this situation. Access to cancer treatments is different depending on where you are, and this is a very serious problem because it means that a patient in one place can have fewer options than a patient somewhere else, and equal rights are the basis of the health system. Health is the number-one expenditure in nearly all the regions together with education. It’s a huge amount of money, and some may be tempted to make savings. And I’m not talking about inefficient treatments. In the past it’s happened with efficient treatments.
Q. Is there any aspect of breast cancer prevention that is not being applied but would be especially useful?
A. If cancer shows up, it’s better to treat it, but it’s much better if it doesn’t show up at all. Every day I see the example of breast cancer. Nearly all women are cured, but the physical and emotional effects are quite significant. Curiously, we have medication that prevents breast cancer, we know that it works, yet nobody uses it.
Q. What medication is that?
A. Nobody knows quite how they work, but there are at least three: tamoxifen, exemestane and anastrozole, which are used to treat breast cancer, and we know that if taken from the age of 50, they reduce breast cancer cases by half. But we haven’t managed for even 5% of women who should take it, to take it. Authorities do not see the problem, and there is no education effort to show that this is doable, and that it must be done in partnership with primary-care doctors.
There are other forms of prevention, such as educating children by encouraging physical exercise and a healthy diet, or reducing tobacco and alcohol consumption as much as possible. Although for some tumors there is not chemo-prevention as such, exercising and staying away from tobacco and alcohol reduces the risk of tumors.
This is an abridged version of the original interview that appeared in Spanish.
English version by Susana Urra.