January, 2012
The X-Factor
By Michael J. Katin, MD
The year 2011 has come to a close, and, as often happens, the number one news story of the year did not occur until the month of December. This was not, as some might believe, the announcement of the Katy Perry-Russell Brand divorce , but was actually the decision of the editorial staff of Science to revoke a paper published in 2009 linking a virus, XMRV, to chronic fatigue syndrome. XMRV was not a Winnebago with satellite radio , but was an abbreviation for Xenotropic Murine Leukemia Virus-Related Virus. The findings had not been able to be replicated, and the question was raised as to whether the virus was, in fact, a contaminant . As if that weren't enough, only a few days later the Proceedings of the National Academy of Sciences published a retraction by the seven authors of a second publication, from 2010.
That news item stands out on its own merits, but calls attention to a problem that radiation oncologists have been having for decades. Efforts to glamorize our profession have not been very successful. We treat diseases that have been around for years and are never as interesting as those that have recently been discovered. Among these recent diagnostic entities are chronic fatigue syndrome and fibromyalgia. Millions of people may or may not be affected by these, and billions of dollars have been dedicated to their treatment.
One problem is how to diagnose a disease that does not have a pathognomonic identity. This was the case with acquired immune deficiency disorder, which was first identified due to symptoms,, rapid deterioration, and death, and then later was determined to be caused by HIV . This then allowed specific treatments to be developed to finally control this disease. This is why the discovery of a virus linked to chronic fatigue syndrome was a major accomplishment.
Some may remember that for years this disease was attributed to the effects of Epstein-Barr virus, which is fairly ubiquitous and difficult to prove as a causative agent even though it received blame in much of the literature. Anyone who has worked long hours can be chronically fatigued, with the question as to whether this is simply due to tiredness or due to another cause. It often affects celebrities, who usually work much more intensely over much longer hours than humans. A short list of these would include Randy Newman, Cher, James Garner, and Morgan Fairchild. It is tragic to consider the unwritten masterpieces that Mr. Newman could have generated to add to "Short People" and "You've Got a Friend in Me" . Would Cher have been able to make "Moonstruck II" or record "Gypsies, Tramps, Thieves, and HHS Bureaucrats?" Once XMRV was identified it should have been a matter of time before a treatment could be devised. On the other hand, isn't it possible that people can just get tired and not be as creative every single year as they were previously?
In fact, XMRV was also "found" in blood specimens of persons with fibromyalgia and atypical multiple sclerosis. Now that this has been discounted, a specific treatment for these diseases may be delayed. Despite the lack of better identification of the disease process, there has been approval of a drug for symptomatic treatment of fibromyalgia. In 2008, the FDA added fibromyalgia as an indication for the use of pregabalin This was on the basis of two randomized placebo-controlled trials that showed decreased symptoms in patients treated with pregabalin. On November 18 of this year, however, FDA commissioner Margaret A. Hamburg removed the indication for the use of bevacizumab in patients with advanced breast cancer since increased survival was not proven even though disease-free survival was increased. Furthermore, in the same month there were publications indicating a role for bevacizumab in ovarian cancer , with approval for that indication having been granted earlier that month by the European Commission, but, again, with anticipation that this will not be the case with the FDA . It is also noted that a year's treatment with avastin would cost approximately $100,000.00.
All this activity has the field of Radiation Oncology left in the lurch . We almost never make it into the news . Is there a conspiracy to divert limited funds for medical care to every other specialty? Perhaps our reimbursement wouldn't continue to be cut if we had an exciting new enemy such as XMRV to fight or if we had a bunch of new diseases to treat?
It shouldn't be too difficult to raise our profile. One solution might be to rename our treatment techniques. In just this past year, drug companies have gained approval for drugs with catchy names which probably generated a lot of money for consultants but which don't, however, usually have anything to do with their indications. Just a few of these are Xgeva, Jakafi , Lovaza , Forfivo XL , Zytiga , Xalkori , and my particular favorite, Firazyr .
In fairness, we should be able to give new identities to 3-Dimensional Conformal Therapy (Xcon-D3), electron beam therapy (Tronbyma) and, of course, IMRT (Xzzyytr). Most importantly, we need to go back to reclaim that special aura of mystery when X-rays were first named. We had use of that letter before the first Xbox was sold, before the first issue of X-Men , before FedEx made its first delivery ,before DMX , before the first episode of X-files , before the first Xanax was consumed, before the first X games , and before the first genXer was born. Sorry, protons. High energy X-rays need to be marketed as Xtraordinary, with treatment at a price that's not Xtravagant, with side effects that are not Xcessive, and with results that are Xceptional. Xcellent! Madison Avenue, please feel free to help us with this.
Before our specialty becomes Xtinct .
