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Letter to the Editor
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To the Editor:
According to Siddhartha Mukherjee, world-renowned oncologist and Pulitzer prize-winning author of The Emperor of All Maladies and The Gene, there are two basic ways for cancers to arise. First, by externally inflicted DNA damage, including from radiation, viruses or toxic exposures. The second and arguably (although controversially) more common way is through internal replication error, ie, DNA copying mistakes. Apparently, some transcription errors are easy to make, and they produce a predictable array of common cancers. According to a recent study, more than 95% of brain, bone, breast and prostate cancers arise in this manner — that is, from mistakes. That’s the reason why a person can do all the right healthy-living things and still get the dreaded diagnosis. At the level of basic, unintentional, pure molecular biology, making mistakes is inevitable. It’s what you do.
Of course, what kills you is not the mistake — it’s the inability to correct it. Increasingly, we’re learning that “quality control” is a major function of our immune system, which serves not only to protect us from external invaders, but also from internal systems gone rogue. The epidemiological and autopsy literature are quite clear on this point: Many, if not most, people are walking around with some nascent neoplasm, some disgruntled collection of wayward cells holed up somewhere. We often die with them, not from them, because our quality control system functions tolerably well. Until it doesn’t. When we can’t keep the errors in check, fix them, mitigate them or confine their spread, that’s when it all comes crashing down.
So, too, with ophthalmology. The major problem with our specialty today and, in fact, the whole enterprise of modern medicine is not, as some tabloids would have you believe, the prevalence of medical mistakes. Diagnostic slip-ups, missteps and complications are — on some deep, theoretical, metaphysical level — inevitable. (After all, if a bunch of inanimate molecules under the unimpeachable direction of the laws of chemistry and physics can’t always get it right, what chance do you have?) But when we pretend otherwise and act as though error-free medicine is not only an attainable goal but our own personal brand of care, that’s when the real problems start. If the culture of medicine is to deny or conceal our mistakes, then we have no quality control system, which is akin to having no immune system. That’s when things become cancerous.
It’s not my idea (although I wish it were) that ophthalmology should have a journal called I Wish I Hadn’t Done That, dedicated to busted experiments, failed treatments and surgical complications. Every ophthalmologist in the world could meaningfully contribute to such a publication. Certainly, I could write the first article.
- References:
- Ghosh S, et al. Theory Biosci. 2018;doi:10.1007/s12064-018-0261-x.
- Mukherjee S. The Emperor of All Maladies: A Biography of Cancer. Scribner; 2011.
- Mukherjee S. The Gene: An Intimate History. Scribner; 2017.
- Tomasetti C, et al. Science. 2015;doi:10.1126/science.1260825.
- Welch HG. Should I Be Tested For Cancer: Maybe Not and Here’s Why. University of California Press; 2006.