SUSAN DAVIS, HOST:
And we finish the hour with this weekend's Long Listen. Precision treatments for cancer are hot right now. But one young cancer doctor is pushing back against some of the hype through scientific articles and on social media. NPR science correspondent Richard Harris met up with him recently at a big cancer conference in Chicago, where the doctors squared off in a debate about precision medicine.
RICHARD HARRIS, BYLINE: Soon after I meet Vinay Prasad, we stroll past one of the many glitzy displays that the pharmaceutical companies erect to generate buzz about their products.
VINAY PRASAD: The carpet is so plush in many of these exhibits, you could twist your ankle in it. But this is actually a really gorgeous display. You would win any science fair with a booth like this. You would just crush it. It's bathed in purple light - incredible. Oh, hey. How are you? Good to see you. Good to see you.
HARRIS: A colleague comes up and, after asking me not to quote her on this touchy subject, both thanks Prasad for raising important issues in the field but also implores him not to get so overheated. It's not as bad as you seem to make it, she argues. And she reels off a list of precision-targeted drugs that help people with melanoma, lung cancer and other diseases.
PRASAD: I use those drugs. There are some good drugs. No one said there's no good drugs. The question is, let's be honest. The truth is 8 percent of people benefit from these drugs. Of the 8 percent that get these drugs, 50 percent have tumor shrinkage. 50 percent don't.
HARRIS: And tumor shrinkage doesn't mean cure. The problem, in his eyes, is that the field has gotten so enthusiastic about these drugs that they aren't waiting for actual science to distinguish between the times when they are useful and where they are a very expensive, wasted effort.
PRASAD: A lot of people want to push it to the treatment side. They want to get Medicare to pay for it. They want to get the drugs paid for off label because they don't want to shoulder the cost on the industry side. And that's the root of what bothers me about this.
HARRIS: People who buy health insurance and taxpayers are funding a massive, uncontrolled experiment with these drugs. Nobody's even collecting the data most of the time to find out what might be useful. Prasad, a 35-year-old oncologist who treats patients at the Oregon Health and Science University, says when he was in medical school, he assumed he would spend his career as a community doctor, treating people with cancer. But then he discovered how much of medical practice was based on traditions, rather than actual science.
PRASAD: Even the most respected, charismatic and thoughtful experts often are incorrect.
HARRIS: The more he learned about what's called evidence-based medicine, the more captivated he became.
PRASAD: I found it harder to just observe things that troubled me and not study them. And at some point, I made the decision - the conscious decision - that if it troubles me enough, I want to look at it kind of and study it and try to say something about it. And maybe somebody else will carry the torch and actually fix that problem someday.
HARRIS: He started out publishing analyses in the scientific literature about bad assumptions and bad practices he encountered. His notoriety really took off when he started opining on Twitter. Today, he has more than 20,000 followers. And he has punched out nearly 30,000 tweets. His pointed commentary sometimes gets him tagged as a troublemaker.
UNIDENTIFIED PERSON: Good afternoon. I'd like to welcome you to the 2018 session.
HARRIS: And the sessions and meetings like this are ripe targets. We settle back into seats in the cavernous meeting room where thousands of doctors have gathered to hear the big talks at the American Society of Clinical Oncology conference. The screen during the warm-up presentation flashes random tweets about the meeting, including one of Prasad's. It's a bingo card that features buzzwords surrounding advances in cancer treatment.
PRASAD: The words that are displayed are unprecedented, personalized, microbiome, precision, inflection point, breakthrough, silo, big data...
HARRIS: ...Among others.
PRASAD: I guess it has almost 100 retweets now.
HARRIS: He actually wrote a scientific paper about the overuse of superlatives in scientific presentations and news coverage. He found plenty of uses of the terms game-changer, breakthrough, miracle, cure or home run.
PRASAD: But what really got me was 14 percent of the drugs - the superlative was used based only on mouse or laboratory results. And they'd never given it to a human being.
HARRIS: We lower our voices when the talks begin. Prasad joins the Twitter conversation about the session while keeping an ear tuned to the presentation.
UNIDENTIFIED PERSON: ...Was to develop a paradigm of biomarker-directed chemotherapy.
PRASAD: They're winning my bingo. Did you hear all those words?
HARRIS: Prasad retweeted some sharp critiques of the talks but also tweeted praise for one panelist who added some important caveats to a study that had just been presented. The next day, we meet again at Prasad's main event, the debate over the value of precision medicine.
RICHARD SCHILSKY: OK. Good morning, everyone.
HARRIS: Dr. Richard Schilsky, the oncology society's chief medical officer, steps up to referee the face-off between Prasad and Vanderbilt University oncologist Jeremy Warner.
JEREMY WARNER: So the first thing I have to say is that I'm the underdog.
HARRIS: Warner flashes a cartoon with two dogs, his face plastered onto one on the ground and Prasad's face spliced onto the animal looming above. A cloud of Twitter birds represents Prasad's army of followers. The so-called debate about this multibillion dollar enterprise was civil. Afterwards, Warner reflects on their considerable points of agreement. Warner disagreed, though, about how to accommodate patients' desires for these new medicines before the careful studies show whether they will actually work for their particular type of disease.
WARNER: Yeah. Saying that someone should just be on a clinical trial - I mean, it sounds easy. But it's actually not easy at all.
HARRIS: And Schilsky, the moderator, found he was in considerable agreement with Prasad as well.
SCHILSKY: I enjoyed his remarks very much. I mean, you know, he's a bit of a gadfly. He's a bit of a provocateur. But, frankly, he's taking a very hard and objective look at a very complex area. And, you know, he's calling it out. He's saying, you know, it's, you know - it's what's behind the curtain. And, you know, let's celebrate what really works. And let's look hard at what doesn't. And let's try to develop the evidence that we need to make important decisions for patients.
HARRIS: Plenty of people aren't so accommodating, particularly on Twitter, Prasad notes.
PRASAD: I think it's unfortunate that I'm thought of as a professional troublemaker because the work we do - we really try to find those instances where the evidence and the narrative are divergent and try to ask ourselves, what can we do to bring those two closer together?
HARRIS: Is this good for your career, or is this bad for your career?
PRASAD: (Laughter) To be honest with you, I don't know the answer. I guess I would say I wish I didn't - as a young person, I don't want to have to be the person to be doing all this work. I wish there were senior people who would do this work. Senior people are not doing this work.
HARRIS: The point in the end is not to be cynical about science, he says, but to help this critical field do science better. Richard Harris, NPR News.
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