Annals of Oncology 13:179-183, 2002
© 2002 European Society for Medical Oncology
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A fistful of Euro
By now we should all have some idea how the roll out of the Euro as a currency of notes and coins, and not just one of prices and accounts, has fared. The German Mark was the first national currency to go, ceasing, as it did, to be legal tender, on 1 January 2002. The Dutch Guilder went next, at the end of January, and the remaining ten national currencies of the Euro zone will all cease to be legal tender by the end of February 2002. To be sure, those living and working in and around the zone have gradually grown used to the idea of the Euro, since it became the virtual currency of Europe’s unified monetary system at the beginning of 1999. But even in our post-Gutenberg virtual era, printing and minting still bring real meaning when it comes to money.So what is the Euro like close up? Show me the money!
The new coins, all 50 billion of them, have one side common to all 12 countries of the zone and a reverse side specific to each country, while the 14.5 billion banknotes look the same throughout the entire Euro area. The coins, which come in 1, 2, 5, 10, 20 and 50 cent or EUR 1 and EUR 2 denominations (one euro is divided into 100 cents), feature on their common sides one of three designs showing different maps of Europe surrounded by the 12 stars of the European Union. The edges are milled and the larger coins incorporate sophisticated bi-metal, copper–nickel, technology which it is hoped will prevent counterfeiting, although the nickel content may provoke skin allergies for some. The seven denominations of banknotes, EUR 5, 10, 20, 50, 100, 200 and 500, all feature windows and gateways symbolizing, according to the European Central Bank, "the European spirit of openness and cooperation", while the reverse features a bridge symbolizing "the close cooperation and communication between Europe and the rest of the world". Special features include raised printing, holographic foil strips and iridescent stripes (on the low-value banknotes) or colour-shifting ink.
One immediate advantages of a single currency will be obvious to any of us who have ever been stuck in the wrong place with the wrong money. And with time, the time lost fumbling to make change with unfamiliar notes and coins will be won back as time not spent in currency exchange bureaus. Some joker has even suggested that Italians will win substantial amounts of time simply by virtue of no longer having to say "mille lire" (thousand lire) several times in any financial transaction.
For the pharmaceutical industry, as with many other industries, another immediate effect will be to draw consumers’ attention to the significant price differentials that exist within Europe. A recent report in The Economist (1 December 2001) suggested that some cancer drugs may sell for 60% more in Britain than in Greece or Portugal, with a more typical drug price differential between these countries of 30–50%. Such increased price transparency may in turn lead to pressure for pricing harmonization and even social policy harmonization. Gateways and bridges indeed.
Research charities try pharma industry trick
In recent times we have become used to reading about pharmaceutical industry consolidation, as the number of major companies becomes ever smaller while their names get ever more hyphenated or obscure. So it was interesting to hear that Britain’s two leading cancer charities have announced (on 11 December), after months of discussions, their decision to merge. With a salutary contempt for both hyphens and obscurantism, the Cancer Research Campaign (CRC) and Imperial Cancer Research Fund (ICRF) will become Cancer Research UK (CRUK?), with the stated aim of "combining their complementary strengths to push through new and effective treatments faster than ever before".
The merger will take effect in early February 2002 making Cancer Research UK the biggest independent cancer research organization in the world, with a dedicated team of 3000 researchers and doctors and an annual scientific spend of £130 million. As is customary with consolidation, the quest for synergy, in order to make more money available for research, optimize efficiency and avoid duplication of roles, will result in loss of jobs. A reduction of ~130 jobs from the charities’ support and administrative staff is foreseen, with this being equally divided between the two organizations.
The Chairman of the Council for Cancer Research UK will be, former House of Lords Health Minister, (Baroness) Helene Hayman, who in more recent times has tackled the UK’s foot-and-mouth epidemic as Lords Agriculture Minister. Professor Andrew Miller, a biophysicist, will act as Interim Chief Executive. At the time of the announcement, and in the same week that Sir Paul Nurse, the ICRF’s Director General received his Nobel Prize, Professor Miller said, "This merger is excellent news for cancer research worldwide and will allow faster exploitation of post-genomic biology to devise more rapid and accurate diagnoses and better targeted treatments. Prevention will also be high on the agenda."
Messages of support for the merger have been received from dignitaries and politicians across the world, including the UK Prime Minister, Tony Blair and former President of South Africa, Nelson Mandela, who is himself receiving treatment for prostate cancer in South Africa.
Industry mergers have often faltered at the difficulties of merging disparate corporate cultures. We hope that will not be the case here and we lend our voice to those supporting the new organization.
"Yours sincerely, wasting away"
So much has been written about George Harrison since his death in late November. He was the "economy-class Beatle", "the spiritual one", "the quiet one". But one subject on which there seems rather too much quiet has been the cause of Harrison’s death. We are happy to try to redress that imbalance by bringing you a quote from Stan Shatenstein the Editor of GLOBALink Tobacco News (http://www.globalink.org/tobacco/) made in a December letter to the Montreal Gazette:
"Mr Harrison smoked for more than 40 years. The throat and lung cancers from which he suffered occur primarily in smokers. ...He died at 58 because he smoked".
Surely, if a rock star had been killed by any other addictive drug we would have been subjected to headlines shouting about its evils. Is tobacco the elephant in our living room to which we have become blinded by familiarity?
Again:
Half a billion of the world’s population today will eventually be killed by tobacco.
Tobacco is killing 4 million people a year worldwide—2 million in developed countries and 2 million in developing countries.
By 2030, if current smoking patterns persist, it will be killing 10 million people a year worldwide—3 million in developed countries and 7 million in developing countries.
In the last 50 years, 60 million people in the developed world alone have been killed by tobacco.
21 million people in Western Europe have been killed by tobacco in the last 50 years.
The title quote for this article? From "When I’m Sixty-four", by the Beatles.
Another legend dies
Of course, some would argue that it is not familiarity that makes us blind to the evils of smoking but misdirection. Less than a week after George Harrison’s death the UK based campaign group Action on Smoking and Health announced the results of a survey that found that about half of UK smokers (46%) think that "smoking can’t really be all that dangerous, or the Government wouldn’t let cigarettes be advertised" (our italics).
Less than a week after that came news that Don Tennant had died. Mr Tennant was at one time Worldwide Creative Director of Leo Burnett, an advertising agency. You may never have heard of Mr Tennant, but you know his work. He is credited with writing United Airlines famous slogan "Fly the Friendly Skies" and creating Tony the Tiger, for Kellogg Co., the Pillsbury Doughboy and what industry magazine Advertising Age has called "the most effective advertising icon of all time", the Marlboro Man. With Marlboro now the bestselling cigarettes in the US, it’s hard to believe that it had <1% of the market when Leo Burnett took on the account in 1954. Still more difficult to believe is the suggestion that it was then regarded as a woman’s cigarette.
Mr Tennant was 79 when he died. No cause of death was announced.
Travelling in the US of A
Going to ASH or the SABCS (‘the San Antonio breast meeting’) one realized the extent of trauma that the 3000 deaths of the twin towers (and who ever talks of the other two planes?) has inflicted on a country such as the USA. Nervous teenagers holding machine guns (when will there be a shooting accident?) are supposed to reassure the traveller. Security measures which were standard in Europe are disrupting ill-prepared airports, with long queues before one can reach the gates. In other airports no such problems exist. Security ‘helpers’ direct passengers to take their laptops out of their briefcases, which is not always easy, and certainly it is not easy to put them back as no surfaces are offered to the harassed traveller who would like not to be sitting on the floor to put the hardware back in its shell. And, as one produces a foreign ID and not a US driver’s license (although anyone of Middle Eastern or Indian continent origin will have the same fate) of course ‘a random check’ of the cabin luggage is requested, right after one has already been searched by gate security. It is hard not to conclude that in making a necessary adjustment in the balance of liberty and security, the USA is overcompensating for past mistakes.
Physician-assisted suicide and pain control
The USA is a continent full of contrasts, where lawyers play a role which sometimes is in the genuine interest of their clients and often is in the shared interest of the two, leading to a paranoid society where drug companies are anxious about litigation, yet advertise for the (ab)use of many products. We now learn about a change in legal thinking, maybe related to an evolution in medical thinking. Over 5 years, the support of assisted suicide among ASCO oncologists has dropped from 45 to 25%.
This fact must certainly in good part be because of progress in pain management and attention to palliative care... Then, in November 2001 Attorney General Ashcroft (changing a position of Attorney General Janet Reno) blocked Oregon’s physician-assisted suicide bill. In a letter to Drug Enforcement Agency Administrator Asa Hutchinson, Attorney General John Ashcroft said physicians who prescribe lethal doses of pain medication to assist the suicide of terminally ill patients are in violation of the federal Controlled Substances Act and could have their prescribing privileges revoked. The Washington Post reported that observers from both sides of the physician-assisted suicide debate—including Oregon Gov. John Kitzhaber, MD and the American Medical Association—expressed concern that the new Justice Department policy might negatively affect the willingness of physicians to prescribe the large doses of strong painkillers required by some patients. Oregon’s attorney general is reported to have said that the state will file a lawsuit challenging the enforcement of Ashcroft’s letter. Hippocrates was confronted with the problem...not a new one, except for the lawyers.
Awards, appointments
At the beginning of December, US President Bush announced that Andrew C. von Eschenbach, MD will be the new Director of the US National Cancer Institute (NCI), succeeding Richard Klausner who resigned in September 2001.
Dr von Eschenbach, a surgical oncologist, goes to NCI from The University of Texas M.D. Anderson Cancer Center in Houston, where he was director of the Genitourinary Cancer Center and director of the Prostate Cancer Research Program. He has also served as vice president for academic affairs at M.D. Anderson and as executive vice president and chief academic officer. It may be of interest to know that President Bush senior, the father of the present President, is the Chair of the the M.D. Anderson Foundation and that the Bush family is very active in helping cancer related organizations in general.
A native of Philadelphia, Dr von Eschenbach earned his medical degree from Georgetown University in Washington, DC in 1967. He completed residencies in general surgery and urology at Pennsylvania Hospital in Philadelphia, then was an instructor in urology at the University of Pennsylvania School of Medicine. He served as a lieutenant commander in the US Navy Medical Corps. Dr von Eschenbach went to M.D. Anderson for a fellowship in urologic oncology in 1976 and was invited to join the faculty the following year. A two times cancer survivor himself, he was a founding member and leader of the National Dialogue on Cancer and, prior to his appointment as NCI director, was president-elect of the American Cancer Society.
After the announcement Dr von Eschenbach said "My goal for the future is to accelerate making new discoveries and delivering targeted therapies as rapidly as possible to cancer patients. I want to extend training and development of young scientists and clinicians who can hasten our progress, and I am keenly aware of the need to reduce the burden of cancer for those in minority and underserved populations."
ASCO President Larry Norton welcomed the appointment. "Dr von Eschenbach’s extensive experience in cancer research, treatment and prevention has prepared him extraordinarily well to head the NCI", he said. "As both a recognized leader in the oncology community and as a cancer survivor, Andy brings a distinctive perspective to this position."
Dr von Eschenbach will be the 12th Director of the NCI since its creation in 1938.
Perhaps not everyone knows that...
...tumor angiogenesis is associated with the recruitment of bone marrow-derived hematopoietic and circulating endothelial precursor cells. This is the conclusion of a study, from the Memorial Sloan-Kettering Cancer Center and Weill Medical College of Cornell University, that used angiogenic defective tumor-resistant Id-mutant mice to show that transplantation of wild-type bone marrow or vascular endothelial growth factor (VEGF)-mobilized stem cells restores tumour angiogenesis and growth. Four weeks after transplantation the mice were injected with either lymphoma cells or Lewis Lung Carcinoma cells. The transplanted mice developed widespread metastasis and died within 26 days, paralleling the tumor growth observed in wild-type animals. Importantly, the bone marrow-derived cells, which were tracked by ß-galactosidase activity, were seen in the vast majority of the vessels formed in the tumors. Reversing the experiment by transplanting Id-deficient marrow back into wild-type mice led to a delay in the growth of the tumor. The authors conclude that bone marrow-derived cells promote the formation of new blood vessels by tumors and may also be required for their formation [1].
...women with cervical adenocarcinoma in situ (AIS) and negative margins may be treated with conservative, fertility-sparing surgery. This is the conclusion of a review, from the University of California at Irvine Medical Center, of all women treated there, between 1985 and 1996, with AIS and stage I adenocarcinoma. Of 131 women treated with stage I adenocarcinoma of the cervix, 20 met the criteria for International Federation of Gynecology and Obstetrics (FIGO) stage IA1 lesions. Of these, 14 were treated with radical hysterectomy, two with simple hysterectomy and four with cervical conization alone, to preserve fertility. Three of the women treated with cervical conization alone have gone on to have children. A further 42 women with AIS were identified, of whom 20 were treated with fertility-sparing surgery. Five women so treated had positive margins, recurring in two, and one developed an invasive adenocarcinoma 5 years after conization. None of the women with adenocarcinoma treated with cervical conization developed recurrent disease after a median follow-up of 48 months. The authors of the study stress that patient education is essential regarding the risks of residual/recurrent disease because lethal recurrent disease can develop [2].
...knowledge of Papanicolaou smear screening and previous behaviors were not shown to be associated with intention to return for screening and follow up, in a recent US survey of adolescent girls and young women. However, modifiable attitudes including personal beliefs, perception of others’ beliefs and cues to obtaining Papanicolaou smears, were associated with intention to return. These are the findings of a cross-sectional survey administered, in a hospital-based adolescent clinic, to a study sample consisting of all sexually active girls and young women who were aged 12–24 years and who had previously been screened by Papanicolaou smear. Enrollment to the survey was 92% (n = 490), with a mean participant age of 18.2 years; 50% were black and 22% were Hispanic. Some 82% of participants indicated that they intended to return, with intention to return being positively associated with positive beliefs about follow up [odds ratio (OR) = 1.07; 95% confidence interval (CI) 1.02–1.11], perception that important others believe that the participant should obtain a Papanicolaou smear (OR = 1.93; 95% CI 1.38–2.74), perceived control over returning (OR = 1.24; 95% CI 1.06–1.46) and having received cues to obtain a Papanicolaou smear (OR = 1.31; 95% CI 1.08–1.60) [3].
...consumption of antioxidant vitamins does not appear to play a significant role in protecting against the development of ovarian carcinoma. These are among the findings of a study that sought to assess the impact of overall consumption of vitamins A, C and E and specific carotenoids, as well as fruit and vegetable consumption, on the incidence of ovarian carcinoma among the 80 326 participants, in the Nurses’ Health Study. The study included a series of questionnaires assessing known or suspected risk factors for cancer and coronary disease sent to married female registered nurses from 11 US states, who were aged 30–55 years. These were mailed biennially from 1976–1996, with food frequency questionnaires being included in 1980, 1984, 1986 and 1990. All participants had no history of carcinoma other than non-melanoma skin carcinoma. A total of 301 incident cases of invasive epithelial ovarian carcinoma were confirmed during this study. Overall, no association was observed between the risk of ovarian carcinoma and antioxidant consumption from foods, or from foods and supplements together. Among those who used vitamin supplements, no association appeared to exist between the dose or the duration of use of any specific vitamin and the risk of ovarian carcinoma. Furthermore, there did not appear to be a correlation between the incidence of ovarian carcinoma and the consumption of total fruits or vegetables, or specific subgroups, including cruciferous vegetables, green leafy vegetables, legumes or citrus fruits. Women in the highest quintile of total vegetable consumption had a nonsignificant (23%) lower risk of ovarian carcinoma compared with women in the lowest quartile of consumption of vegetables (relative risk 0.77; 95% CI 0.48–1.24; P = 0.29). Women in the highest quintile of total fruit consumption had a nonsignificant (27%) increase in the risk of ovarian carcinoma compared with women in the lowest quintile of fruit consumption (relative risk 1.27; 95% CI 0.80–2.02). However, women who consumed at least 2.5 total servings of fruits and vegetables as adolescents had a significant (46%) reduction in the risk of ovarian carcinoma [4].
...arsenic inhibits transcription of the hTERT gene, which encodes the reverse transcriptase subunit of human telomerase. This recent finding, from researchers at Johns Hopkins Medical School, follows the observation that in the leukemia cell line, NB4, arsenic exposure causes chromosomal abnormalities, with a preponderance of end-to-end fusions. The reduced telomerase activity, which may in part be explained by decreased c-Myc and Sp1 transcription factor activities, leads to shortened telomeres in dividing cells resulting in end-to-end chromosomal tangles. The resulting genomic instability may lead to either carcinogenesis or cancer cell death, so affording a possible explanation of the seemingly paradoxical carcinogenic and antitumour effects of arsenic [5].
...survey data from Florida, the first US state to report statistically significant annual declines in youth tobacco use during the 1990s, suggest that possession law enforcement helps to reduce youth tobacco use and may be a critical component of that state’s successful youth tobacco prevention program. For the purposes of the study, several Florida counties were classified as either high-enforcement or low-enforcement counties, with high-enforcement counties dispensing at least twice as many citations to underage smokers as low-enforcement counties. The survey included 2088 students, 1140 from the high-enforcement counties and 948 from the low-enforcement counties. Students in the high-enforcement counties were more likely to say that penalties reduce their willingness to smoke close to schools than were students in the low-enforcement areas. Middle school students were more likely to say that penalties would affect their use than were high-school students. Nearly 49% of students who smoked no more than one cigarette a day said that penalties influence their likelihood of smoking, compared with 23% of students who smoked two or more cigarettes a day and 18% of those who had smoked on the day of the survey [6].
...the profile of AIDS-related lymphomas (ARL) has changed since the introduction of highly active anti-retroviral therapy (HAART), with a lower incidence of systemic and brain ARL. Moreover, the overall prognosis of ARL has improved since the introduction of HAART. These are the conclusions of a recent French study that used the French Hospital Database on HIV to compare the incidence and the characteristics of ARL before (1993–1994) and after (1997–1998) the introduction of HAART in a large population of HIV-infected patients. The authors found that within the database the incidence of systemic ARL had decreased from 86.0 per 10 000 (1993–1994) to 42.9 per 10 000 person-years (1997–1998) [P <10 (–30)]. Similarly, the incidence of primary brain lymphoma had also fallen following the introduction of HAART, from 27.8 per 10 000 to 9.7 per 10 000 person-years [P <10 (–11)]. In a separate analysis of 145 patients with proven lymphoma, taken from three different centers, HIV history was longer in the second period than in the first period among patients with systemic ARL (98 versus 75 months; P <0.01), and survival of patients with systemic ARL also increased (from 6 to 20 months; P = 0.004) [7].
...medical schools should screen applicants for personality disorders before granting them entry; this would help clarify their ethical stance and so help to avoid future ethical disasters. This is the conclusion of a recent study, from the Fiji School of Medicine and the University of Newcastle, Australia. Recognizing that it is probably inappropriate to attempt to assess medical school applicants’ ethical knowledge, moral reasoning or beliefs about ethical issues, the authors examined ways in which attitudes towards ethical issues and ethical sensitivity might be tested. To that end interviews were conducted with 32 academics, general staff and clinicians at the University of Newcastle, Australia, and its hospitals, to find out if they had had professional experience of any unethical behavior among doctors. The participants were then asked to describe these behaviors. They chose similar words, all of which described personality traits, rather than the behavior itself. "Arrogant", "brash", "condescending", "power-seeking", "self centered", "patronizing" and "devious" were some that frequently appeared in the list. The authors suggest that there have always been strong links between the ethical domain and psychiatry, citing the criteria for: antisocial personality, which includes a disregard for, and violation of, the rights of others; and narcissistic personality disorder, which includes a lack of empathy and exploiting other people. The authors admit that screening out narcissists might deprive medicine of future leaders and innovators, but believe that it is possible to distinguish between the doctor who is merely egocentric and unpleasant and the one whose narcissism will lead to unethical behavior [8].
References
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2. McHale MT, Le TD, Burger RA et al. Fertility sparing treatment for in situ and early invasive adenocarcinoma of the cervix. Obstet Gynecol 2001; 98: 726–731.[Web of Science][Medline]
3.
Kahn JA, Goodman E, Slap GB et al. Intention to return for Papanicolaou smears in adolescent girls and young women. Pediatrics 2001; 108: 333–341.
4. Fairfield KM, Hankinson SE, Rosner BA et al. Risk of ovarian carcinoma and consumption of vitamins A, C, and E and specific carotenoids. Cancer 2001; 92: 2318–2326.[Web of Science][Medline]
5. Chou WC, Hawkins AL, Barrett JF et al. Arsenic inhibition of telomerase transcription leads to genetic instability. J Clin Invest 2001; 108: 1541–1547.[Web of Science][Medline]
6.
Livingood WC, Woodhouse CD, Sayre JJ, Wludyka P. Impact study of tobacco possession law enforcement in Florida. Health Educ Behav 2001; 28: 733–748.
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Besson C, Goubar A, Gabarre J et al. Changes in AIDS-related lymphoma since the era of highly active antiretroviral therapy. Blood 2001; 98: 2339–2344.
8.
Lowe M, Kerridge I, Bore M et al. Is it possible to assess the "ethics" of medical school applicants? J Med Ethics 2001; 27: 404–408.
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