/ 7 June 2013

Comment: Death knell for cancer research

One of the most distressing developments in the field of cancer research has been the recent news that scores of cancer researchers will be leaving the country's foremost research institution, the Medical Research Council (MRC), at the end of this year owing to a management decision to cancel all intramural cancer research at that institution.

The reason given for this drastic and highly retrogressive step is that the MRC does not regard cancer as one of the top 10 causes of death in South Africa. According to the MRC's green revitalisation report, if cancer is split up into all the different kinds, such as breast, prostate, melanoma and so on, not a single subgroup is large enough to claim a numerical place among the top 10 causes of death – of which Aids related illnesses is ranked as number one.

This is in sharp contrast to the 2010 "cause of death" figures recently released by Statistics South Africa, which has grouped the different cancers together as one disease in position number four. 

Cancer is one of the worst pathologies that can affect humankind because it is so difficult to cure or prevent. Worldwide, 12-million new cases of cancer are diagnosed every year, and more people die globally of cancer than Aids related causes, tuberculosis and malaria combined. Nevertheless, there is general consensus that research followed by appropriate action is the only way humankind will ever rid itself of cancer.

However, cancer is not the main cause of death and disease in South Africa. As the epicentre of the Aids pandemic, there are about six times more deaths linked to HIV than to cancer. But that doesn't mean that we can simply write off cancer as if it is a disease of no consequence in South Africa. It remains a scourge that affects children and adults across the spectrum of our society and it is predicted that incidence will at least double within the next 20 years owing to ageing and increased prevalence of associated risk factors for cancers tied to economic transition, such as smoking, obesity, physical inactivity, poor diet, reproductive factors and exposure to carcinogens and epicarcinogens. 

Vaccinations are helping to address the liver cancer epidemic in the country, and are about to be introduced to address an epidemic of cervical cancer. We are still searching for answers on oesophageal cancer, which mainly affects thousands of black people in the Eastern Cape and other parts of the country.

Meanwhile, rapid urbanisation is leading to an increase in cancers related to lifestyle and environmental carcinogens and experts have warned that some of the complications of HIV are already becoming evident in growing incidences of blood cancers. These cancers are developing as a direct consequence of the HIV pandemic. 

We have also been warned that South Africa, like the rest of Africa, is facing a tsunami of chronic diseases that includes cancer.

Downsizing cancer studies
Against this background, it is astounding that the country's official medical research institute is downsizing cancer studies to the extent that a small, publicly funded, nongovernment organisation, namely the Cancer Association of South Africa (Cansa) now remains the dominant institution providing funding for cancer research in this country.

Cancer research has never been afforded a very high status in South Africa – unlike for example the MeerKAT Square Kilometre Array radio telescope project in the Karoo or the R8-billion that was fortuitously spent on trying to perfect a pebble bed reactor. The total expenditure on cancer research in South Africa is not much more than R20-million a year. This has consisted of about R15-million from the state for the MRC's intramural and extramural cancer research projects, whereas Cansa awards about R6-million a year to cancer researchers at universities, research institutions, and intramural projects on environmental factors that could cause cancer. This amounts to 38 cents per South African per year. 

In contrast, cancer is the top biomedical research priority in the United States. 

It is difficult to assess that country's total expenditure on cancer research because there are so many different funds. Nevertheless, taking the National Institutes of Health, the National Cancer Institute and MD Anderson Cancer Hospital together, about $5.7-billion or R51-billion, amounting to about $18.2 or R164 a person, is spent in the US on cancer research per year. This is 432 times more than in South Africa per person, per year.

This begs the question: If South Africa spends so little on cancer research compared with the US, is it really worth doing any cancer research in South Africa at all? 

It will be futile and short-sighted to embark on a massive search for a cancer cure in South Africa. We simply don't have the capacity or the resources to match cancer research efforts in the industrialised world. To date, we have made no contribution in this regard even after Cansa spent R10-million to find a cancer cure. 

This is not surprising because South Africa has not yet fully researched and developed a single allopathic (scientifically proven) drug from A to Z. It is estimated that it now costs $1-billion to create a new drug and it is not likely that such capital will be invested in South Africa for a product that may not even be a great success. 

New anti-cancer drugs are extremely expensive – in the region of R1-million a year – and need to be taken continuously because they do not necessarily cure but only control cancer. 

The best that can happen is that South Africa discovers a promising lead compound – the patent rights to which can be licensed to an overseas pharmaceutical company.

Cancer prevention
However, we are in an excellent position to advance cancer prevention in this country. With the greatest genome diversity in the world, highly contrasting environments, population groups, urban and rural lifestyles, and both developed and developing economies, South Africa is a unique matrix in the world. 

Most cancer scientists agree that 90% of all cancers are caused by environmental factors and 10% by genetic factors. This being so, it has been found that certain cancers are highly prevalent in certain groups in South Africa and not in others. 

For example, colon cancer is 10 times higher in white people than in black, whereas oesophageal cancer is much higher in black people than in white. Prostate cancer appears to be four times higher in white people than in black people. 

We don't know the fundamental reasons for these differences but they will surely lead to deeper insight into the causative factors and hopefully better prevention. For example, there is some speculation that colon and oesophageal cancers may be caused by specific viruses. This offers another window of opportunity to our cancer virus experts, who are already held in high esteem internationally, and could make major and unique breakthroughs for the benefit of the whole world.

The ultimate aim of cancer prevention is to legislate against carcinogens in the environment that cause cancer. For instance, our tobacco legislation has been hailed worldwide and it is clear for all to see that smoking is decreasing in South Africa.

Other important environmental carcinogenic agents include oncogenic viruses such as HIV-1, human papilloma virus (HPV) and human hepatitis B virus.

Natural and artificial chemicals are ranked as the third cause of cancer and involve DNA-damaging chemicals such as cadmium, uranium, aflatoxin and dozens of manmade chemicals, such as bisphenolA (BPA), that act as endocrine disrupters. These may also have an epigenetic (slight genetic changes), non-damaging effect on DNA but nevertheless contribute to forming cancer cells many years after exposure. In South Africa, BPA-containing baby bottles were banned in 2011.

The cancer risk can also be lowered by optimal nutrition, especially that found in natural products such as canola oil and long-chain omega-3 fatty acids, which are found in fish oil, broccoli and curcumin (which is in turmeric). 

The department of health has taken a number of steps to prevent cancer, such as mandatory vaccination of all babies against the hepatitis B virus – which will lead to the eradication of liver cancer – as well as the imminent vaccination against HPV, which will eradicate cervical cancer. Likewise, the enrichment of mealie meal with essential vitamins and trace elements and the pegging of trans fats at 2% are major steps on the road towards cancer prevention. 

Legislation eradicating the fungal toxin and cancer-causing aflatoxin in food has also helped to enhance the status of South Africa as a cancer-preventing nation. By working in partnership with the health department, our researchers have made major contributions towards the success of measures such as these. It is sad and tragic that their ongoing efforts have been brought to an abrupt end.

We still have the opportunity to become one of the top five countries in the world when it comes to cancer prevention research and action, but we need to re-examine our current stance on cancer research, and we need a much stronger commitment from everyone involved for this vision to become a reality.

Dr Carl Albrecht is a veteran cancer researcher based in Cape Town and the head of research at the Cancer Association of South Africa. The views expressed in this article are entirely his own