Big Pharma @ MindSay 
"There is nothing new to be discovered in physics now. All that remains is more and more precise measurement" - Lord Kelvin, ~1900
Ok, I could be mistaken about proton therapy.
Even Lord Kelvin missed a few future possiblities that physicists discovered in the last century, including the very existence of protons (the term was coined by Rutherford, and it first appeared in print in 1920).
Still, I believe that universal proton therapy is premature. The road side of medical technology is littered with "advances" that should have marked progress but didn't. For each type of cancer there may be some (likely small) subset of patients for whom the astonishingly precise measurement of radiation dose and volume can result in incrementally improved cure rates through local control, while still minimizing morbidity. I prefer a few proton facilities equipped with the latest IMPT where carefully selected patients could only be treated as part of clinical trials designed by experts from all disciplines. I would prefer studies designed to objectively measure quality and quantity of life, not surrogates like psa's and imaging shadows. I also prefer world peace.
The technological imperative has once gain prevailed, and the age of proton therapy is upon us. Unintended consequences will occur, though not easily predicted.
The first unintended consequence of proton prolifertion will be an expansion in the total number of patients treated. Because protons are perceived to result in few side effects, a belief among caregivers and patients will be fostered that there is nothing to lose by treatment. If significant morbidity is cut in half but double the number of patients are treated, the total morbidity will be unchanged. Currently proton therapy costs twice as much as photons (at least). Under this set of assumptions costs will quadruple at a time when health care costs in general are exploding.
Quadrupling costs would be justified if survival and quality of life were incrementaly improved. How likely is this to be the case for prostate cancer? About 15% of patients who are diagnosed with prostate cancer die from the disease, and autopsy studies suggest the actual number of prostate cancers is much higher than the 190,000 diagnosed. Natural history studies indicate that a diagnosis of early stage prostate cancer has very little effect on survival ("natural history" means "untreated"), yet these are the cancers most amenable to "cure". But try telling a patient he has "mild" cancer and then advocate watchful waiting. His first question will be: then why did you look for it? His second is likely to be: how can I find a new doctor?
Anatomic stage provides a measure of disease progression. SEER data (crude as it is) based on historic stage shows that 91% of prostate cancer cases are diagnosed while the cancer is still confined to the primary site or after the cancer has spread to regional lymphnodes (localized or regional stage); 5% are diagnosed after the cancer has already metastasized (distant stage) and for the remaining 4% the staging information was unknown. The corresponding 5-year relative survival rates were: 100.0% for localized/regional; 31.9% for distant; and 79.1% for unstaged. Not much room for improvement exists for stage I cancer, at least in terms of survival, and no local treatment will improve survival for those who present with distant spread.
The trick is to find the small subset of intermediate risk prostate cancer patients (perhaps about 15% of the total) who still have local disease at diagnosis but who have a relatively poor prognosis, and then to treat them without vastly expanding the total number of people treated. Since risk stratification has a large element of subjectivity built in, I suspect the latter condition will not prevail.
A second unintended yet inevitible consequence of creating capacity to treat 1600 plus more patients per year (as in the case of th NIU faciltiy) in a market that already has ample radiation treatment capacity will be another escalation in the medical marketing wars. Loma Linda has advertised nationally for years, making claims for protons that push the evidence based envelope.
A roughly fifty year cycle seems to exist for medical hucksterism. In 1850 when the famous gastrophysiologist Wlliam Beaumont recruited a new physician to his private practice in St. Louis he placed a small ad in local newspapers announcing that his new partner had special expertise in diseases of the eye. Beaumont was immediately viciously attacked by colleagues and nearly drummed from the corps of the local medical society.
The then newly created (1849) American Medical Association had borrowed heavily from Thomas Percival's treatise (A Scheme of Professional Conduct Relative to Hospitals and other Medical Charities 1772) on medical "ethics" when it drafted its code of conduct. Advertising was eschewed. By 1900 US newspapers were full of boiler plate ads for patent medicine, medical devices and doctors claiming superior skills or unique services. By 1950 the rules of 1850 had regained the ascendency and physicians were "allowed" only a briefly run "toombstone" in newspapers to simply announce their presence in a community.
By 2000, the advertising cycle was in full upswing again. The "ethical" prescription drug industry (the adjective had been applied to distinguish what has become "big pharma" from the snake oil salesman) went from no ad's aimed at the general public in 1950 to near the top of the spending list by 2000. Last year, Glaxo was the 7th largest spender on ads, spending $2.4 billion, and Johnson & Johnson came in 9th with $2.3 billion in spending, placing the health care giant ahead of Unilever, Toyota and Sony.
Percival's code had been drafted at the behest of a London hospital in an attempt to regulate the relationships between physicians and hospitals and among the physicians themselves. In 2008 individual physicians were largely out of the ad wars. Rather, health care "systems" now "market" themselves with claims that they are either more caring or more skillful (and usually both) than their competitiors.
And so the proton facilities with their $100+ million in bonded indebtedness will advertise for patients. They will compete with each other on a local, regional and national level. It is not accidental that NIU's new facility is across the street from DuPage Airport and its 8000 foot runway, and in the shadow of Fermi Lab's Wilson Hall. (Ironically, Fermi Lab is in a state of decline, having been eclipsed by the more powerful accelerator in Cern.)
NIU has announced that it will enter into an agreement with the Northwestern University Faculty to provide the clinical expertise at its new center. A search of the Northwestern cancer center web site (http://pubs.cancer.northwestern.edu/abstracts/search?do_pagination=1&page=1) for faculty publications containing the word "proton" yielded 59 hits. But none of the 59 papers seem to have anything at all to do with treating patiients with protons. Basically, NIU, which lacks a medical school, will credential and privilege physicians to use its clinical facility. How will NIU judge the compentency of these physicians and what experience with proton therapy will be required? Who at NIU has the clinical experience and expertise to make these decisions? How will prospective patients be informed about these issues? Advertisements?
Check this site to see how the M.D. Anderson Proton Center (for-profit) is to be marketed by M.D. Anderson Cancer Center, which "leased" its name to the center. http://hcrenewal.blogspot.com/2005/10/m-d-anderson-cancer-center-leases-its.html First the marketing agreement to promote the center, then the science to see if it is actually better.
The protonless health care systems will tout their competing services, such as their daVinci robots, brachytherapy, imrt guided photons and expertise in medical oncology. The have-nots will not so gently point out that "to a man who only has a hammer, the whole world looks like a nail" and that proton-only facilities are dominated by mad physicists and unidimensional clinicians. They will do this until they install their own $15 million proton machines. Then they will advertise protons. All this collateral spending will cost many millions.
A third unintended consquence will be to ensure the continued immortality of Will Rogers, who said: "When the Okies left Oklahoma and moved to Califormia, they raised the average intelligence level in both states."
The Will Rogers Phenomenon will occur when both of these conditions are met: The element being moved is below average for its current set. Removing it will, by definition, raise the average of the remaining elements. The element being moved is above the current average of the set it is entering. Adding it to the new set will, by definition, raise the average.
Proton therapy will be declared superior by it's proponents. These proponents will obtain transrectal ultrasounds, transrectal MRI's, CT's, psa's, psa velocity, free psa and other tests to "stage" patients. Historically many of these tests were unavailable or not done in the photon era. More staging most often results in up-staging, which meets the conditions of the Will Rogers Phenomenon.
For example, prostate biopsies from a population-based cohort of 1,858 men diagnosed with prostate cancer from 1990 through 1992 were re-read in 2002 to 2004.The "new" Gleason score readings (high scores indicate poor prognosis) were an average of 0.85 points higher (95% confidence interval [CI], 0.79–0.91; P < .001) than the same slides read in 1990 to 1992. As a result (thanks to Will Rogers), Gleason score-standardized prostate cancer mortality for these men was artifactually improved from 2.08 to 1.50 deaths per 100 person years—a 28% decrease even though overall outcomes were unchanged.
Given the right pathologists and a little staging leeway, most any new treatment will look great. Perhaps surgery looks better than radiation for younger men with prostate cancer (at least according to one widely quoted paper) simply because surgery results in very accurate staging.
For those who prefer more formal cost-effectiveness methodology (like insurance companies), analysis indicates that proton therapy for prostate cancer does not appear to be cost-effective when measured by commonly acceptable parameters, according to a study by researchers from Fox Chase Cancer Center (JCO 2007; 25: 3603-3608). Quality-adjusted survival was similar for both modalities in each age group as measured by QALY: The incremental cost effectiveness ratio was calculated to be $63,578/ QALY for a 70-year-old-man and $55,726/QALY for a 60-year-old man.Quality-adjusted survival was similar for both modalities in each age group as measured by QALY: The incremental cost effectiveness ratio was calculated to be $63,578/QALY for a 70-year-old-man and $55,726/QALY for a 60- year-old man.
"When even the brightest mind in our world has been trained up from childhood in a superstition of any kind, it will never be possible for that mind, in its maturity, to examine sincerely, dispassionately, and conscientiously any evidence or any circumstance which shall seem to cast a doubt upon the validity of that superstition. I doubt if I could do it myself." - Mark Twain
I am a skeptic, in spite of Mark's good advice. The problem is, time will not tell. Prospective randomized trials comparing survival for surgery, brachytherapy, photons and protons for intermediate prognosis prostate cancer patients will not be done. Carbon ion radiation may replace protons, and might be the next half-way technology to usurp the technological imperative. Neither Lewis Thomas nor Thomas Hardy would have been surprised if it happens.
I don't use Paris Hilton brand edible makeup, nor do I starve myself and shave every inch of my body hair to fit into tiny thong bikinis fit for only my-size barbie dolls. I'm an antisteryotype, an antisocial, and an antidrug for anyone who wants an antihit. I read magazines like Adbusters, like Utne. I read books like Palahnuik, like Huxley, like Orwell. I meditiate and self-medicate and all those things girls on 7th Hevan would lead you to believe was sinful.
How much do I actually get out of any of this? What is counterculture when there is no more culture to rail against? Trends shift, and just as liquid, their antitrends must shift. Where is the malignant culture so described to me, that I believe so vehemently in? All I do as a child is go to school, come home, refuse to do homework on the grounds that I have already learned what is being taught, eat, and sleep. All the malignancy I see is being presented by two or more opposing forces. Neither actually wants things to change, for without the other force to fight against, how would they exist? Without the 'squares' without 'geeks','losers','goths', and scores of other labels for the less, the inferior, How would the superior keep themselves as such? Likewise, How can the rebel exist when there is no longer anything to rebel against? losing battles we fight. As soon as we defeat one enemy, another takes its place. Nazis, Gooks, Commies, now Terrorists. Perpetual opposition is the way to tip top condition, applying not only to countries and their economies, but to anything you can possibly think of. Wolves. Deer. Fast food chains and resteraunt chains. Runway designers whose clothing is never meant to be worn anywhere but a runway, and designers like Ralph Lauren and Issac Mizrahi who peddle directly to soccer moms and dads, teenage girls and boys alike. War is being fought between Starbucks and Panera Bread, not for coffe, or for bread, but for who can attract the most college students to spend their afternoon sipping chai and working on their laptops.
War is being fought in drugs. The drugs you grew up with and the drugs I am growing up with are from opposite sides. Children only a few generations ago grew up on Tobacco, Alcohol, Weed, LSD, Cocaine. Those were the lords of the drug world. I grew up on Paxil, Adderal, Ritalin, Wellbutrin, Concerta, Topomax, and a host of the same chemicals under different names. These are the Drug Lords now. You call them Big Pharma, but honestly, they are just more organized and effective in advertising and distribution than the underground drug business is now. The one small difference between them, one above the law, the other below it, makes all the difference in their emnity.
A thousand thousand conflicts, raging in the world, in the cultural ether. Raging inside our own minds. The last war and the first war, Between ignorance and awareness, between information and disinformation. That one will keep going until we blow ourselves up. Silly. We love our facts so much and ignore the principles until information becomes ignorance. School is memorizing dates, never learning from the past we're condemned to repeat. Disinformation is so easy and so beautiful. Rightly spun, you can barely tell the difference between learning and memorization, between your own opinion and the opinion you've been told to have. School has become endless. Political correctness washing every fact clean of all blame, of all truth.
As I type this, it's interesting that I'm failing two classes and squeezing past the rest, except for Art. Teachers don't like it when you research yourself, when you contradict them or the textbook, when you say you read that book already and would prefer its memory stay untainted by analyzing and comprehensive questions meant to draw you slowly along to the teacher's own opinion. Teachers don't like to hear it when you say you didn't do your Algebra because you were up all night trying to write your own fractal equations. Teachers complain. The faculty puts you in remedial education, as if that helps any. When you flunk that, they send you to a school full of every other apathetic smart kid in the state classified as "behavioral issues: oppositional/defiant"
And it's great to finally be around your own people. In a bubble nice and safe from culture, from education. Not from drugs, you'd better believe that a good deal of these kids are high as a kite a good portion of the day, and the rest are on medication by their own or their parents will. Take away the drugs, I don't know what you'd have. We'd no longer be content, the false security, the numbing of the mind would be stripped away. We'd have to contend with a world that wants us to take sides in fights we never asked to be in. Sometimes I wonder what we would do. Would we form our own side of the fight? or would we kill ourselve like it seems most people do when they realize they have to choose between two very unappealing styles of life? I'm not sure. Sometimes I'm glad the drugs delay this decision. But the instant we run out of money for them, the second we sober up and face the world, we will have to make a choice. Do we fight for individuality on behalf of the masses, or fight for anonymity on behalf of the individual? Do we send our money to starving kids in Africa because the man with the white beard pulled out heartstrings? Or do we give money to Uncle Phil to support his addiction to painkillers and alcoholism?
I lost my train of thought. It's the ADD, officially. In real life, I found something more interesting to do than rant. Have a nice day, Kids.
Live it up.