What would a cure for cancer mean?

A new book by a Norwegian academic has challenged many of society’s preconceptions about the disease

Public attitudes to cancer, the ‘Emperor of all maladies’ have transformed in recent years. For my parents’ generation, cancer was literally unspeakable – a word to be whispered or euphemised as ‘the Big C’. No other disease inspired such fear and loathing. Nowadays, cancer charities encourage us to speak openly about it. Some even do so with profanities, such as the ‘F–k Cancer Foundation’. In the zero-sum game of ‘my-disease-is-better-than-your-disease’, cancer beats all its competitors for the attention of both public and politicians in Ireland. Ms Averil Power, the CEO of the Irish Cancer Society, has claimed that “a future where no-one dies of cancer is within our grasp”. All we need to reach these sunlit uplands, she argues, is political will and investment. Such hyperbole might be dampened by reading Making Sense of Cancer: From Its Evolutionary Origin to Its Societal Impact and the Ultimate Solution by the Norwegian academic Prof Jarle Breivik.

Obama’s ‘cancer moonshot’

This book had its genesis in a piece he wrote in 2016 for The New York Times. Breivik, Professor of Behavioural Medicine at the University of Oslo, has an academic background in cancer biology, having worked with Gustav Gaudernack, a pioneer of immunotherapy and cancer vaccines. He was prompted to write this essay following President Barack Obama’s announcement of the ‘cancer moonshot’, led by then Vice-President Joe Biden. Obama channelled the hubris of Richard Nixon’s early 1970s ‘war on cancer’ in his final State of the Union address in January 2016, encouraging his fellow-citizens to make America “the country that cures cancer once and for all”. Breivik, while acknowledging the advances in cancer treatment, poured cold water on the moonshot: “Cancer is closely linked to the very process of ageing. In fact, cancer and ageing are two sides of the same coin. The risk of getting cancer increases significantly with age, especially after the age of 50. Accordingly, the longer we live, the more cancer there will be, and regardless of medical advances, we can be very sure that the burden of cancer will increase, not diminish, for decades to come.”

Although more people will be cured of cancer (or live with it as a chronic disease), many people will continue to die of it. Medicine, by increasing human longevity, has paradoxically contributed to the coming cancer epidemic. The ‘war on cancer’ may be unwinnable, but the “innumerable organisations, institutions, and companies”, which comprise the global $135 billion onco-industrial complex, are obliged to loudly endorse this bellicose attitude to the disease: Their very existence depends on the continuation of this attritional war.  

Breivik was alarmed when The New York Times (keenly aware of the upcoming presidential election) changed the title of his essay from ‘What the President should know about cancer’ to ‘Obama’s pointless cancer moonshot’, proving that even the most august newspapers can have red top instincts. He was taken aback by the storm of personal invective directed at him following the publication of this opinion piece: “My attempt to present a nuanced and pedagogical message about the realities of cancer had suddenly been transformed into a tabloid headline with political implications.” When people get really annoyed by such an opinion piece, it is usually because the author has articulated a deeply uncomfortable truth. Breivik kept a careful record of the emails and letters he received, from the nurse who called him “a jerk” to two prominent (un-named) cancer researchers who privately agreed with him. One wrote to Breivik: “The public believes us when we tell them that if they, or Biden in this case, give us enough money, we’ll find ‘a cure for cancer’. This is dangerous for us because sooner or later they’re going to wake up to the fact that we’ve declared war on cancer a number of times and thoroughly lost each war. We should have said no to Biden, but it’s quite clear that most of us are going to blush, take the money, and keep our mouths shut.”

Book

Breivik was not discouraged by the brickbats – indeed, quite the opposite, as he was inspired to develop his argument in book-length form: “Something seems fundamentally wrong with how we understand the problem, and we need to take a serious look at what a solution to cancer actually implies. What will a world without cancer look like, and how do we get there?”

His approach to this question is original and unusual, combining evolutionary biology, genetics and philosophy: “We must recognise that cancer is not evil…. It is a consequence of natural biological processes.”  Breivik’s thesis is that cancer is an evolutionary phenomenon. Most genetic mutations which lead to cancer occur spontaneously, regardless of how we live our lives: “One mutation leads to another, and natural selection favours the most rebellious variants. That is cancer.” We are, he writes, “temporary cell colonies that the genes have made to get to the next generation”; we can slow down mutations a little by healthy living, “but with every cell division, there will be errors in the copying of genes and epigenes.”

Breivik suggests that cancer in old age (over 80) may not be the worst way to die. He cites Richard Smith’s famous 2014 BMJ article ‘Dying of cancer is the best death’. Smith (a former editor of the BMJ) argued that dying of cancer was preferable to dementia or organ failure. Much like Breivik’s piece for The New York Times, his opinion piece caused a global furore: “Nothing else that I’ve ever written has created such a storm,” he wrote years later. (Questioning the war on cancer, it would seem, is akin to doubting the existence of the Deity in previous epochs.)

Treatments

In 2020, George Lundberg (former editor of the Journal of the American Medical Association) interviewed Smith, and asked him if developments in precision oncology and immunotherapy had changed his thinking about cancer. Smith replied: “I have a friend with metastatic malignant melanoma who is kept alive by immunotherapy and would probably be dead if it were still 2014.” Immunotherapy has indeed achieved much in the treatment of some patients with some cancers, but Breivik (who knows a thing or two about the subject) advises us to curb our enthusiasm. Just like bacteria with antibiotics, cancer cells evolve and may become resistant, leading to what evolutionary biologists call ‘the Red Queen effect’. (In Lewis Carroll’s Through the Looking-Glass, the Red Queen explained: “Now, here, you see, it takes all the running you can do, to keep in the same place.”) “Whether it is antibiotic-resistant bacteria, new virus variants, or cancer cells,” writes Breivik, “we must keep running.” In a recent interview, he argued that the cost of cancer therapies (particularly immunotherapy) is driving inequality, both within rich countries and globally. Elderly Norwegians, Breivik observed, expect personalised immunotherapy (even if the survival benefit is a few months), while people in low-income countries can’t access basic cancer treatment. 

All the current modalities of cancer treatment, including surgery, radiation, chemotherapy and immunotherapy, are focused on killing cancer cells. However, Breivik writes: “If we just continue to kill cancer cells, we will, sooner or later, end up killing ourselves…. To cure cancer ‘once and for all’, we must come up with something more radical than killing cancer cells. We must find a way to rejuvenate the body.” He considers the possibilities of stem-cell/gene therapy and organ (human and animal-derived) replacement, but concludes that there are multiple potential barriers, both biological and ethical. While gene therapy and stem-cell treatment might, in theory, eliminate some (mainly childhood) cancers, Breivik argues that the only truly effective means of cheating nature and our evolutionary destiny is to slow down (or completely halt) the main cause of cancer: Ageing. This is not as outlandish as you might imagine; the giant tech companies and several Silicon Valley billionaires have invested heavily in regenerative medicine and biogerontology, and many (including Breivik) think that it is  possible that maximum longevity could be extended to 200 years or more, but at a great cost: “Are we heading for a world ruled by immortal super-narcissists who do not see the value of children and whose only concern is their own money and power?” The biotechnological revolution currently underway will, he argues, change society more fundamentally than the industrial revolution of the 18th Century.

Breivik predicts that “the ultimate solution to cancer” is transhumanism – the AI-facilitated creation of digital selves: “Our identity is liberated from the mortal body, and as long as no one erases us, we have eternal life.” The human body, he writes, “is yesterday’s technology.” This, however, means the end of humanity as we understand it: “Ageing, cancer, and death are fundamental aspects of being human. If we eliminate this circle of life, we eliminate ourselves. We can design bodies that live forever and transfer our identity to the digital world, but we will no longer be human.” Curing cancer means conquering death. Cancer, he concludes, is not an enemy: It is part of who we are.