In a memorable quote towards the end of his life, Isaac Newton said that if he had seen further than others it was because he stood on the shoulders of giants. His mighty push helped the scientific revolution gather pace, and by the end of the 19th Century, some people were wondering whether the work might be nearing completion. But then came quantum theory and everything was up in the air again. At a meeting in the 1920s attended by many luminaries such as Albert Einstein and Niels Bohr, the chairman came out with a truly great mixed metaphor. Having mentioned the shoulders of giants, he continued, “Today, ladies and gentlemen, we are privileged to sit side by side with those giants on whose shoulders we stand”. Not quite as dignified as Newton perhaps, but you know what he meant.
Things have moved even faster since then, across an ever-widening range of study, although no-one talks any more about science being finished. In 1999, John Maddox, editor of the famous journal Nature, filled a 450-page book with the title What remains to be discovered. An even bigger one could be written today. At about the same time, The Lancet, one of the world's oldest and most respected medical journals, burst its banks. The weekly journal, founded in 1823, was no longer sufficient to contain all the quality material coming its way, which overflowed into new catchments—monthly Lancet journals (numbering 17 at the latest count) with a more specialist focus. The Lancet Oncology is a millennial, with its preview issue in 2000. I was honoured to contribute a Last Word column to that issue, and for the next 5 years.
The trouble with such a deluge of scientific material is how to distinguish the giants from the pygmies. Or, to put it another way, as the wall of science gets higher, the individual bricks tend to get smaller and smaller, making it harder to tell whether we have made progress. Have things really moved forward over the last couple of decades, or were we just keeping ourselves busy putting asymptotically thin bricks on the wall, but not making it any higher?
It can certainly feel like that on a bad day, although a glance back through 20 years of The Lancet Oncology confirms that genuine progress is still with us, even if it can be a bit unevenly spread. Perhaps even more reassuring is the fact that throughout its history, The Lancet Oncology hasn't forgotten that it is a medical journal: a place where patients and their experiences of disease and treatment are as important to the meaning of published oncology as the binding efficacy of a new drug to its molecular target. Even the best basic science in the field is only as good, in the end, as its usefulness and consistent application. And it is here, in the development of robust patient pathways that reliably work in the organised chaos of real-world health care delivery, that I feel we have advanced furthest in the past 20 years. Cancer care, and of course all of medicine, is about the quality of our life (and death) experiences, as much as it is about bald figures of long-term survival and years of life “saved”. Medicine is indeed an art of the possible, as much as it is the application of science to ourselves.
This strange time of COVID-19 has provided a dreadful reminder that science and progress are not necessarily inextricably linked. I have been shocked by the way in which unverified science has been politically leveraged to cause wholesale restructuring of health care systems, without assessment of the consequences. What is the moral equation that sidelines actual patients today in favour of potential patients tomorrow, who may or may not be treatable? Whatever happened to “First do no harm”? How could 20 years of gains be simply swept away? There's a word we use when drastic actions are taken on the basis of poor understanding: negligence.
But the scientific approach is really the only way we can find a centre of gravity for truth, and this period too will pass. Medicine must be scientific, but humanely so. The Hippocratic aphorism is still on the money: Life is short, but our art is vast, opportunity fleeting, experiment perilous, and judgement difficult. The Lancet Oncology embodies the best of scientific oncology, understanding that this means spanning the scales from molecule to society. Here's to a brighter future.
© 2020 Richard Duszczak