Cancer – and avoiding the blame game

Curiosity, or a need to know why stuff happens, is a ubiquitous and basic human instinct. It fuels much of our behaviour, and underpins both the origins of religion and the success of science.

So what to make of it if you or one of your children has the very difficult diagnosis of cancer? One side of your brain will tell you to ask the oncologist or to Google possible causes. The other, more emotionally engaged and very entrenched side, will maybe signal that it’s all your own fault. Or if not, then somebody else’s.

For parents of children with cancer, it’s a very understandable reaction. The dilemma is compounded by the propensity of most of us to anticipate and seek simple solutions, however incredible.

Journalists and their sub-editor headline writers may sometimes, and inadvertently, fuel this expectation. It’s a familiar narrative – this sense that someone or something is to blame. In the Hollywood movies I was brought up with, there was always a black-hatted villain.

And what do we, as cancer scientists, offer the parent or patient in their distressed state? Although not a clinician, I’ve had to confront this several times, both in the past and more recently when I have been accused of laying the blame on parents whose children have developed leukaemia.

But surely, someone is to blame? 

The most palatable answer to ‘what caused my cancer or my daughter’s cancer’ would probably be comparable with learning the tubercle bacillus microorganism caused a case of tuberculosis.

It’s a specific bug, invisible, selfish and unavoidable. It is nobody’s fault and there is a specific antidote. But of course the biological reality is more complex, even for infectious diseases. So what kind of message does our cancer community send out?

Well, sometimes at least, it gets transmitted like this:

This just doesn’t cut it.

So, bring on the conspiracy theorists and, in the US especially, litigation: it’s the electricity pylons at the bottom of your garden; it’s pesticides on your vegetables; it’s some poisonous chemical in the water. And don’t even try to explain that risk is all about dose.  Human beings tend to have no intuitive feel for such things.

My sympathy lies very much with the patient or parent. They are emotionally fragile and desperate for a credible answer. What can be worse than losing a child to cancer? It was partly through imagining that scenario with my own children that I opted to begin research into leukaemia many years ago.

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When science and pride collide 

In the past, I have been accused of blaming mums of children with leukaemia for not sending their infant children to playgroups, which is protective for acute lymphoblastic leukaemia (ALL). More recently, after coverage of my research into the causes and natural history of childhood leukaemia, I have been assailed for elaborating on a number of variables that appear to influence risk of ALL in early life.

These include, for example, caesarean birth, brief or absent breastfeeding, small family size and minimal social contacts in infancy. These variables all act on our acquisition of the microbiome which primes the infant immune system. It makes sense, scientifically, and is based on a substantial body of evidence.

But to some mums it’s tantamount to blaming them for having kept too clean a kitchen – and it makes them angry. I feel as though something is being lost in translation.

One recent email to me on this topic began: ‘F*** you, f*** you Dr Greaves.’ I did eventually have an interesting and positive exchange of views with this angry and distressed mum who had lost a child to leukaemia. I hope it helped.

Not dissimilar responses are engendered when we talk about reproductive lifestyle and breast cancer risk. It is too easily interpreted as blaming the victim.

In reality, virtually all human cancers are, as epidemiologists Sir Richard Doll and Sir Richard Peto suggested several decades ago, multi-factorial in causation with a mix and interplay of exposures, inherited susceptibility and chance.

The paradox of progress - will foresight ever be enough?

Anthropologists have long recognised that patterns of prevalent diseases, in time and place, track with particular cultures and societies. Rates of cancer, as with infectious diseases, obesity and diabetes, are a mirror reflecting culturally framed lifestyles.

And it has always been so. For example, bladder cancers in Egypt are associated with schistosome infections from drinking infected water and suffering chronic inflammation. Who was to know that?  These endemic bladder infections are there in Egyptian mummies from 3,000 plus years ago.

Some 150 years ago, stomach cancer was the most common cancer in Europe, as it was until very recently in Japan. Adding salt to preserve food and reduce risk of infection would seem a good idea. It’s not intuitively obvious that salt would greatly increase cancer risk. Or, conversely, that refrigeration would reduce the risk of stomach cancer.

But why should Western affluence and generally much improved lifestyles ferment particular cancers – melanoma, bowel cancer, breast and prostate cancer, childhood acute lymphoblastic leukaemia? Is it a paradox of progress? A mismatch between our contemporary lifestyles and our genetic adaptations to very different historical circumstances? And, if so, who is responsible?

I think it is likely that lack of microbial infection in infancy is an important risk factor not only for childhood acute lymphoblastic leukaemia but also perhaps for type 1 diabetes and allergies, all prevalent in modern, post-industrial western societies.

But protecting our newborns from microbial infections, among them a minority that are pathological, has had an enormously beneficial impact.

Evolution by natural selection is the foundation law of biology. It is therefore not a surprise that it has great relevance to cancer. The ICR's Centre for Evolution and Cancer seeks to resolve this relationship.

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In Dickensian times here in the UK some 25 per cent of infants died of infectious causes. It is still similar today in many impoverished parts of the world. Driving down these death rates in the developed world has been a triumph of modern living standards, antibiotics and, especially, the work of engineers in giving us plumbing, sanitation and clean water.

But maybe these advances have had paradoxical and unintended consequences for the wellbeing of some of our children. We were not to know that the immune system has evolved with a requirement for benign microbial exposure. There is no blame there at all is there? So don’t blame or shame parents. And, please, don’t shoot the messenger.

It is not anyone's fault

Of course it’s different when we consider the tobacco industry knowingly plying an addictive, carcinogenic drug. There, we do have a black-hatted villain. But are smokers complicit in this? Yes and no.

Turns out, as our colleague at the ICR Professor Richard Houlston discovered, patients with smoking-associated lung cancer are more likely to have inherited the addictive variant of the nicotine receptor.

So, parents to blame? Of course not. That variant has an impressive pedigree; it started with Neanderthals more than 30,000 years ago. The genes we inherit are the product of an evolutionary lottery over which we exercise no control.

For people with cancer themselves, or whose children have been diagnosed with the disease, there is no personal blame – any more than getting an infectious disease like malaria is your fault. We need to offer that firm reassurance in clear and unambiguous language, alongside the best possible treatment.

For the rest of us, all potential patients or parents of potential patients, the message is that we can do little about inherited susceptibility for most cancers or for chance events, including the randomly arising mutations that drive cancer, but we can modify culturally defined exposures and so reduce risk.

And that is not just down to self-help. The answer to cervical cancer is not sexual abstinence but an HPV vaccine. The answer to breast cancer is not getting pregnant as young as possible; we need some kind of hormonal prophylaxis.

Similarly, the answer to childhood leukaemia is not dirty kitchens or universal day care for all three-month-olds – but maybe, just maybe, giving babies some kind of microbial booster might do the trick.