On the occasion of Pink October (1), a month dedicated to the fight against breast cancer, European Scientist gives the floor to Jean-Philippe Vuillez, university professor and practitioner of nuclear medicine at Grenoble University Hospital. His medical and research activities are focused on oncology. In addition, he was vice-dean of the Faculty of Medicine of Grenoble and President of the French Society of Nuclear Medicine.
The European Scientist : To start off, could you tell us about your professional background and the scope of your work on cancer?
Jean-Philippe Vuillez : I am a nuclear medicine physician, rather than an oncologist, but I have devoted my work to oncology within my field. Nuclear medicine is defined by the use of radioactivity in vivo, in the form of radioactive (i.e. radiolabeled) drugs called radiopharmaceuticals (RPs). These are used in scintigraphy examinations for diagnostic purposes in oncology but are also used in new treatments (called Internal Targeted Radiotherapy) which are currently enjoying great success, particularly in treating prostate cancer. In addition to these clinical activities, I also belong to a unit of France’s National Institute of Health and Medical Research (Inserm) where we develop new MRPs.
TES. : France’s Ligue contre le cancer (League against Cancer) has just launched their Pink October campaign for breast cancer awareness, as they have done every year since 1985. In the wake of the Covid-19 pandemic, is the public still as mobilised against cancer?
JPV. : I certainly think so, and for some straightforward reasons. The first reason is that, pandemic or not, cancer is still with us. The second, linked to the first, is quite tragic: the pandemic’s toll on the health care system, combined with the fact that patients confined in their homes have forgone medical consultations and scheduled tests, or even delayed treatments out of fear, has produced widespread delays in care whose consequences we are only coming to understand now. As a result, alongside other diseases such as Alzheimer’s, cancer has seen a cruel re-emergence at centre stage. This is especially true in the case of breast cancer with Pink October, but it doesn’t stop there.
TES. : Every time the famous American businessman Peter Thiel speaks about technological progress (2), he likes to remind his audiences that Nixon declared war on cancer in 1971 and that progress since then has been frustratingly slow. He concludes that we are not doing enough. Do you agree with his statements?
JPV. : No, not at all. I’m amazed someone would assert something like that, although I suppose those are the assertions of an American businessman who is used to getting immediate results. But cell biology, the mechanisms of cancer, and the possibilities of treatment do not work in the same way as a board of directors! But above all, his observation is entirely incorrect. Progress in medical science (if not in business) has, on the contrary, been spectacular and rapid since 1971, and keeps getting progressively faster.
For example: only thirty years ago, let alone 1971, patients with lung cancer had a life expectancy of just a few months, or a few years at most. Thanks to ‘targeted’ therapies, made possible by incredible advances in molecular biology, as well as immunotherapies, some patients having lung cancer with particular tumour mutations can survive for over ten years. Today, we are able to successfully treat just about 100% of cases of certain cancers, such as Hodgkin’s lymphoma or testicular cancer, which was not in the case in 1971. Similarly, breast or prostate cancer sufferers in the metastatic phase (more commonly known as generalised cancer), who used to have a life expectancy of between six months and two years, can now live with their disease for over ten years and often more, even continuing to function as normal.
As regards my own speciality, a new advance published last year (I’m referring to the “Vision” study) illustrates the dynamism at play. A molecule targeting PSMA (prostate-specific membrane antigen), labelled with a beta minus electron emitting radionuclide (Lutetium-177) is extending the lives of patients with metastatic prostate cancer. That said, we can always say that we are not doing enough because there is always more work to be done. But this is not unique to medical research…
TES. : Several recent studies (3) (4) (5) show that during confinements or for other pandemic-related reasons (like prioritisation at hospitals), cancer-related deaths could have been avoided. Is Covid causing us to miss the forest for the trees when it comes to cancer? Has the pandemic revealed the limits of our research capabilities?
JPV. : I wouldn’t say that. On the one hand, as we already discussed, the pandemic saturated healthcare systems and forced us to prioritise. The emergency treatment of Covid patients has undeniably delayed the treatment of other pathologies, including cancers. But research is not at fault, because even if the pandemic has slowed down research programmes – and it certainly has – this does not have a direct impact on frontline care, while hospital overcrowding has been a real problem.
I believe that important lessons have been learned, and that if such a situation arises again, the medical community will be much better prepared to avoid a repeat of this breakdown in care during the pandemic. But that doesn’t mean the pandemic is causing us to “miss the forest” when it comes to cancers! Rather, it has shown the limits of a system overly dictated by profitability. In order to handle situations like the Covid-19 pandemic, it’s certainly necessary to maintain a system with excess capacity in normal times. This would of course carry an additional cost, but we can assume those costs would be lower than the additional expenses incurred by delays in the treatment of cancers, and of cardiovascular diseases by the way.
TES. : While we may wonder about a possible stagnation in research, we can see fears of “everything being carcinogenic” gaining ground in public opinion. This is particularly true for nuclear energy, which carries a lot of fear (6) around it. As an expert on the subject, what do you think?
JPV. : Once more, we need to quote the eminent Swiss physician Philippus Theophrastus Aureolus Bombast, better known as Paracelsus, who laid down the following fundamental adage of toxicology in the 16th century: “All things are poison, and nothing is without poison; the dose makes the poison.” This applies to everything, but since you mention the fear of nuclear, it particularly applies to radioactivity and by extension nuclear waste, which justifies itself on the supposed inability to manage this waste and the assumption that it is necessarily dangerous.
This phenomenon can also extend to pesticides, endocrine disruptors, and many other issues. But research is progressing in this field, as well, and there is growing evidence to suggest that the effects we observe with high doses on reduced models (such as cells in culture) are not something you can simply cross-multiply to get the same result from small quantities of the same agent. So yes, you can say that just about anything can be carcinogenic, as long as you don’t neglect this quantitative element.
TES. : Can the opinions of certain organisations or agencies contribute to the spread of unfounded fears, and if so, why? The IARC’s decisions on coffee, meat, or glyphosate come to mind.
JPV. : Yes, unfortunately. We are living in a paradoxical era with regard to scientific expertise. On the one hand, pseudo-scientists have caught the attention of the public and even of decision-makers, because they sell false science that has the merit of simplicity (or should I say oversimplification), making it easy to understand and lending decisions an air of certainty: “I understand it” (because it is simple) and “I trust it” (because it has been formulated by “experts”).
On the other hand, real science, and real scientists, face at least two obstacles. The first is that what they have to say is complicated, and it is accompanied by the uncertainties (and doubts) inherent to real science. The second is that real scientists are necessarily interested in fragmentary aspects, because the polymaths like Louis De Broglie who can boast about knowing everything no longer exist!
So, to respond to your question, the IARC (the International Agency for Research on Cancer, located in Lyon but connected to the WHO) does its work remarkably well. But what does that work consist of? In short, it studies whether a given substance is likely to interfere with the cellular mechanisms of carcinogenesis, and if so, how. Most chemical agents fall into this category, and the IARC puts them on a list of “possible carcinogens”. At this stage, the essential quantitative aspects which we have discussed, the metabolic aspects when we go from the cell to the whole organism and the interactions with all the other substances contained in an organism, etc., are not taken into consideration.
The IARC carries out and publishes its work because it is funded to do so, without putting forward anything other than “yes, this substance could interfere with the cellular mechanisms of carcinogenesis, by such and such a mechanism”. But this gets picked up in the media as “the IARC (a serious, scientific body, attached to the WHO!) has demonstrated that substance X is carcinogenic; this substance is present everywhere in food, nappies, cosmetics, and so on…”
And this is how perfectly legitimate scientific opinions, taken out of their context and announced in an educational vacuum, are fed to a public that is incapable of understanding their scope and meaning. The public will only retain the terrifying aspect of it, because cancer is frightening…
TES. : In the same vein, the theme of “cancer and nutrition” is also making steady progress in public opinion. The IARC has recently addressed (7) the issue of the Nutri-Score, an algorithm that is causing much debate among nutritional experts. Can such an indicator influence the fight against cancer?
JPV. : You mention here a notion that greatly concerns me personally, which is the myth that we can eliminate cancers by following strict lifestyle rules. This is true to a large extent; for example, we know perfectly well that smoking is to be avoided, just as doing sports and eating healthily help reduce the risk of cancer. But going too far down this road leads to an extreme vision of existence that I find a bit sad.
Indeed, if algorithms are to dictate my daily life, I think my life would risk becoming very bland and uninteresting. If we consider the food we consume, I prefer (while remaining reasonable, of course) to eat meat when I feel like it, savour a good wine, and enjoy tapas from time to time, without feeling like I am failing an exam. It is very paradoxical, because the unspoken dream of all this is the desire for immortality, and cancer is precisely linked to longevity! We forget that, out of the billions of cells produced daily by a living organism like ours to replenish tissues, it is a constant miracle that we develop so few cancers.
This is why ageing is by far the most important risk factor for cancer, a fact that we often forget. And as much as a 13-year-old child dying of sarcoma is an unbearable tragedy, dying of cancer over the age of 85 is almost physiological, and implies that we have managed to escape cardiovascular accidents, infectious diseases, neurodegenerative diseases… we will push back the age of the onset of cancers, but we will probably never be able to eliminate them, because they are a consequence of life itself. This is not the case with infectious diseases, which can be eradicated in the way smallpox was.
But let’s come back to Nutri-Score, which I don’t have the specific scientific experience to make a judgement on. I will just say that, while it is of great interest for analysing the contents of our plates, we must avoid drawing up a rulebook which makes people feel guilty or becomes counter-productive for the food industry, all while giving people the impression that they can control their destiny by relying on labels (8). I wholeheartedly agree with what Professor Philippe Legrand, an authority on nutrition, has to say (9) on the matter.
TES. : What improvements do you suggest could be made in cancer research, and in raising public awareness?
JPV. : I think cancer research is doing well in terms of researchers and scientific dynamics. There are many impressive and motivated young researchers in the field, for one thing. This does not, of course, mean that everything is going perfectly.
More resources are still required, and I find that researchers are too dependent on donations, even if the work of the Ligue contre le cancer, the ARC foundation, and other associations is commendable and helpful. There should be more university and institutional funding for Inserm, in particular.
But above all, we must give researchers more freedom. Too often they are constrained by the requirements of a particular tender which is, in turn, too dictated by utilitarian or even political objectives. I would like to be sure that we are not prioritising the diseases that represent the largest markets for innovative drugs. Moreover, we must not favour research on products that have been called into question for the wrong reasons (such as the glyphosate controversy), to the detriment of subjects that carry more promise but which do not receive funding because they do not have societal implications.
As for public opinion, we should consider the introduction of health education programmes to explain that; firstly, cancers are diseases inherent to life, secondly, we will as a result never entirely eliminate cancers, often presented as a scourge of humanity, and thirdly, that behavioural change is important to fight preventable cancers when there is sufficient scientific consensus (such as tobacco and lung cancer, hepatitis B and liver cancer) and to do everything possible to delay their onset. With simple, common-sense rules for living, as opposed to unsubstantiated magic recipes or unfounded pillorying of this or that substance which is supposed to lead to an immortality as sad as it is illusory.
Today, learning that you have cancer is still bad news, but it is not a catastrophe because, thanks to science and medical progress, you can live, and live well, for a very long time with a cancerous disease.