The case of Gary Kao

Dear Public Editor,

The Times has dragged the name of oncologist Gary D. Kao through the mud, whether deservedly or not, through its reporting on the "rogue" VA prostate cancer unit.

I do not know Dr. Kao. I do not know if he is a bad man responsible for incompetence and cover-up, as portrayed by the Times, or a good man with good intentions who simply made honest mistakes. I do know that he wrote a detailed statement for the Congressional hearing, addressing and contradicting many of the allegations the Times has made.

In your latest article, Walt Bogdanich does not provide any evidence that he even read the bulk of this statement. The title of the article is "Oncologist Defends His Work at a V.A. Hospital," but the article quotes hardly anything substantive that is written in his defense.

In the words of Dr. Kao:

"I have come to the hearing today to answer questions and to submit this written statement in order to correct the record and salvage my reputation. I hope that, through the hearing process, the investigations and through media reports, the truth will emerge. I am not the physician who has been portrayed in the media."

It is clear to me why Dr. Kao feels like he has been misrepresented. I hope the NYTimes has the honesty and courage to critically examine his claims, and retract any part of its expose on the VA cancer unit that it finds to be factually incorrect.

Michael Jin
2nd year medical student, UCSD

The problem with biomedical research

An article in the NYTimes complains that although it's been 40 years since Nixon declared war on cancer, the biomedical research establishment, despite curing cancer in mice multiple times, has not even come close in humans. It proceeds to blame the slow progress on an NIH funding process that ignores "transformative" ideas and favors conservative and incremental ones:

Take one transformative drug, for breast cancer. It was based on a discovery by Dr. Dennis Slamon of the University of California, Los Angeles, that very aggressive breast cancers often have multiple copies of a particular protein, HER-2. That led to the development of herceptin, which blocks HER-2.

Now women with excess HER-2 proteins, who once had the worst breast cancer prognoses, have prognoses that are among the best. But when Dr. Slamon wanted to start this research, his grant was turned down. He succeeded only after the grateful wife of a patient helped him get money from Revlon, the cosmetics company.

Yet studies like the one on tasty food are financed. That study, which received a grant of $100,000 over two years, is based on the idea that since obesity is associated with an increased risk of cancer, understanding why people have trouble losing weight could lead to better weight control methods, which could lead to less obesity, which could lead to less cancer.

“It was the first grant I ever submitted, and it was funded on the first try,” said the principal investigator, Bradley M. Appelhans, an assistant professor of basic medical sciences and psychology at the University of Arizona. Dr. Appelhans said he realized it would hardly cure cancer, but hoped that “it will provide knowledge that will incrementally contribute to more effective cancer prevention strategies.”

Herceptin is a terrible example for transformative treatment. It applies only to a minority of breast cancer cases, and its effect on overall mortality isn't exactly mindblowing: you would need to treat dozens of eligible patients just to prevent one death in the next 2-4 years. The only thing at all transformative about Herceptin is that it is one of the few targeted cancer treatments. Most chemotherapy just aims at blasting away at rapidly dividing cells, causing all those nasty side effects. Unfortunately Herceptin has side effects of its own, but I digress.

I feel bad for Dr. Appelhans. This new assistant professor probably thought he had made it to the big leagues when he got a call from the NYTimes. They asked me if this would cure cancer? Haha, those naive reporters. Let me give them a dose of scientific reality. Little did he know that he would be Exhibit A for mediocre, "incrementally contributory" science. He didn't deserve this. It's not like he wasted tax money for decades to obtain results of marginal importance, a career entirely possible, perhaps even average, in biomedical research. He just wanted to get funded, get published, get tenured. Maybe when he had his own building, he could set his sights on curing cancer.

Clearly the funding process is flawed, broken. Every investigator know this. The good ones, however, do not allow themselves to be crippled by it. They apply for funding with safe, fundable projects, then siphon off money to finance riskier, more exploratory research. If they find something promising, they then have preliminary data to back up their visionary, but more dubious, claims. This de facto system is similar to the Google system, whereby their employees receive some paid time to do whatever pet project on the side. There are thousands of engineers at Google: does Google have thousands of revolutionary new ideas each year? No. Therein lies the problem.

There is a fundamental maxim that needs to be stated: most people are mediocre. There are relatively few producers upon whose backs the art and science of Western civilization have been carried upward, ever so arduously these past few millenia. Being mediocre is not necessarily a bad thing in law, or finance, or medicine, but it is bad in science, or novel writing. As was said of Virginia Woolf -- that she pushed the boundaries of the English language a little more against the dark -- so too does the scientist push the limits of knowledge. There needs to be genius, yes, but also a creative spark, a fire in the belly, and an unyielding desire to let all that can be destroyed by the truth, to be thus destroyed.

It's the people, stupid! Good projects are born from good ideas, which come from the best investigators. Instead of spreading the $30 billion dollar NIH budget thinly so that every member of the professorial class can each have their own fiefdoms, we should be allocating only to those members who can put the resources of this country to their best use. In other words, the National Institutes of Health should adopt the model of the private Howard Hughes Medical Institute: fund investigators, not projects. The limitation of the HHMI model is that the hierarchy of science is too shallow -- there isn't enough management inbetween the head of the lab, and the sea of underlings: the lab technicians, the doctoral students, the postdoctoral fellows. As such these labs tend to top out around a couple dozen members. So in essence, fund the best, give them a building, let them generate the ideas, put the rest in middle management or below according to their ability, and get out of the way.

Wars are won with generals, who have a defined strategy for their campaign, not a bunch of sargeants leading their platoons every which way. If we are serious about the war on cancer, or Alzheimer's, or aging, we need to start fighting it like one.