【经济学人】医疗保健：围剿癌症 [英国媒体]

Health care：Closing in on cancer

医疗保健：围剿癌症

Science will win the technical battle against cancer. But that is only half the fight

科学将打赢抗癌技术战，但还有下半场



THE numbers are stark. Cancer claimed the lives of 8.8m people in 2015; only heart disease caused more deaths. Around 40% of Americans will be told they have cancer during their lifetimes. It is now a bigger killer of Africans than malaria. But the statistics do not begin to capture the fear inspired by cancer’s silent and implacable cellular mutiny. Only Alzheimer’s exerts a similar grip on the imagination. 

数据十分严峻，2015年880万人死于癌症，人数仅次于心脏病。约40%的美国人一生中会被诊断出癌症。目前在非洲，癌症死亡人数已超过疟疾。但数据体现不出无声无息、无法逆转的癌细胞突变带来的恐惧，只有阿尔茨海默病使人有类似的恐惧。

Confronted with this sort of enemy, people understandably focus on the potential for scientific breakthroughs that will deliver a cure. Their hope is not misplaced. Cancer has become more and more survivable over recent decades owing to a host of advances, from genetic sequencing to targeted therapies. The five-year survival rate for leukemia in America has almost doubled, from 34% in the mid-1970s to 63% in 2006-12. America is home to about 15.5m cancer survivors, a number that will grow to 20m in the next ten years. Developing countries have made big gains, too: in parts of Central and South America, survival rates for prostate and breast cancer have jumped by as much as a fifth in only a decade.

面对这样的敌人，可以理解人类着力于科学突破治愈癌症的潜力，这样的期待是对的。由于近些年出现基因测序、靶向治疗等一系列技术进步，癌症患者的生存率越来越高。美国白血病的五年生存率几乎翻了一番，从1970年代中期的34％增加到2006-12年的63％。美国有1550万癌症幸存者，未来十年将增至2000万。发展中国家也取得了巨大进步：在中美洲和南美洲的部分地区，乳腺癌和前列腺癌的生存率仅在十年内提高了20%。

From a purely technical perspective, it is reasonable to expect that science will one day turn most cancers into either chronic diseases or curable ones. But cancer is not fought only in the lab. It is also fought in doctors’ surgeries, in schools, in public-health systems and in government departments. The dispatches from these battlefields are much less encouraging.

从纯技术角度讲，科学最终会将多数癌症转变为慢性或可治愈性疾病，这是合理的期待。但抗癌战场不仅在实验室，还有医生手术室，学校、公共卫生体系、政府部门，这些战场的情况不容乐观。

Cell-side research

细胞研究

First, the good news. Caught early, many cancers are now highly treatable. Three out of four British men who received a prostate-cancer diagnosis in the early 1970s did not live for another ten years; today four out of five do. Other cancers, such as those of the lung, pancreas and brain, are harder to find and treat. But as our Technology Quarterly in this issue shows, progress is being made. Techniques to enable early diagnosis include a device designed to detect cancer on the breath; blood tests can track fragments of DNA shed from tumours. Genome sequencing makes it ever easier to identify new drug targets.

首先是好消息，当今许多及早发现的癌症可得到有效控制。上世纪70年代初，英国75%的男性前列腺癌患者活不过10年，如今80%的患者能活过10年。其他癌症的更难以诊断和治疗，如肺癌、胰腺癌、脑癌。但正如我们的《科技季刊》所展现的，人类在这方面正在取得进步。能实现早期诊断的技术包括呼吸检测癌症设备；血液检测跟踪肿瘤脱落的DNA片段。基因组测序更易识别新的药物靶标。

The established trio of 20th-century cancer treatments—surgery, radiation and chemotherapy—are all still improving. Radiotherapists can create webs of gamma rays, whose intersections deliver doses high enough to kill tumours but which do less damage to healthy tissue as they enter and leave the body. Some new drugs throttle the growth of blood vessels bringing nutrients to tumours; others attack cancer cells’ own DNA-repair kits. Cancer may be relentless; so too is science.

20世纪癌症治疗的三驾马车仍在不断改善，即手术、放疗、化疗。放疗医师可制造网状伽马射线，交叉点释放的剂量足以消灭肿瘤。但当射线进入和离开人体时，会对健康组织造成一定伤害。一些新药阻止血管生长，避免向肿瘤输送养分；一些药物攻击癌细胞的DNA修复工具箱。癌症可能无情，科学也是如此。

The greatest excitement is reserved for immunotherapy, a new approach that has emerged in the past few years. The human immune system is equipped with a set of brakes that cancer cells are able to activate; the first immunotherapy treatment in effect disables the brakes, enabling white blood cells to attack the tumours. It is early days, but in a small subset of patients this mechanism has produced long-term remissions that are tantamount to cures. Well over 1,000 clinical trials of such treatments are under way, targeting a wide range of different cancers. It is even now possible to reprogram immune cells to fight cancer better by editing their genomes; the first such gene therapy was approved for use in America last month.

最令人振奋的是免疫疗法，这是最近几年出现的新疗法。人类免疫系统有一套能被癌细胞激活的制动装置；第一种免疫疗法使制动装置失效，让白血球能够攻击肿瘤。该疗法处于初期阶段，但在一小部分患者中，这种机制使患者得到长期缓解，相当于治愈。目前正在进行超过1000项临床试验，针对各种不同的癌症。现在甚至可通过编辑基因组来重编免疫细胞的程序，以增强抗癌效果；上个月，美国批准了第一种这样的基因疗法。

Yet cancer sufferers need not wait for the therapies of tomorrow to have a better chance of survival today. Across rich and poor countries, the survivability of cancer varies enormously. Men die at far higher rates than women in some countries; in other countries, at similar levels of development, they do comparably well. The five-year survival rate for a set of three common cancers in America and Canada is above 70%; Germany achieves 64%, whereas Britain manages a mere 52%. Disparities exist within countries, too. America does well in its treatment of cancer overall, but suffers extraordinary inequalities in outcomes. The death rate of black American men from all cancers is 24% higher than it is for white males; breast-cancer death rates among blacks are 42% higher than for whites. A diagnosis in rural America is deadlier than one in its cities.

然而，目前的癌症患者无需等待未来的治疗去提高生存率。在富国和穷国，癌症生存率差异极大。有些国家的男性死亡率远高于女性；在一些发展水平类似的国家，患者生存率相对较高。美国和加拿大三种常见癌症的五年生存率超过70%；德国达到64%；英国只有52%。同一国家也存在差异，美国癌症治疗的整体水平不错，但结果极不平衡。在所有癌症中，黑人男性的死亡率比白人男性高24%；黑人乳腺癌的死亡率比白人高42%。美国农村的诊断比城市的诊断更为危险。

Practical as well as pioneering

务实与开创并举

Variations between countries are partly a reflection of health-care spending: more than half of patients requiring radiotherapy in low- and middle-income countries do not have access to treatment. But big budgets do not guarantee good outcomes. Iceland and Portugal do not outspend England and Denmark on health care as a proportion of GDP, but past studies show wide variation in survivability in all cancers.

在一定程度上，国家之间的差异反映出医疗保健支出情况：在中低收入国家，半数以上需要放疗的患者得不到治疗。但充沛的资金无法保证好的结果，冰岛和葡萄牙的医疗健康支出占GDP比例并不高于英国和丹麦，但研究显示所有癌症的生存率有很大差异。

Instead, the problem is often how money is spent, not how much of it there is. To take one example, a vaccine exists against the human papillomavirus (HPV), which causes cancers of the cervix in women, as well as cancers of the head and neck. Rwanda started a programme of routine vaccination in 2011, and aims to eradicate cervical cancer by 2020. Other countries are far less systematic. Vaccinations could help prevent cervical cancer in 120,000 Indian women each year.

问题往往是怎样花钱，而不是有多少钱。例如：目前存在抗击人乳头状瘤病毒的疫苗，该病毒可导致宫颈癌、脑癌、颈癌。2011年，卢旺达启动例行性疫苗接种计划，目标是2020年消灭宫颈癌。其他国家远远缺乏计划性，每年疫苗能帮助12万印度女性预防宫颈癌。

Policymakers are not powerless. More can be done to verify which treatments (and combinations thereof) work best. A ￡1.3bn ($2bn) cancer-drug fund in England, which made expensive new medicines easier to obtain, did not assess the efficacy of the drugs it provided—a huge missed opportunity. Measuring the incidence and survival of cancer, through cancer registries, spotlights where patients are being failed. Access to health care matters, too: the number of Americans whose cancers were diagnosed at the earliest possible opportunity went up after Obamacare was enacted. And prevention remains the best cure of all. Efforts to rein in tobacco use averted 22m deaths (many of them to cancer) between 2008 and 2014. Yet only a tenth of the world’s population lives in countries where taxes make up at least three-quarters of the price of cigarettes, as recommended by the World Health Organisation.

决策者并非无能为力，他们可以做更多工作，验证哪些治疗（及联合治疗）最为有效。英国13亿英镑（20亿美元）的抗癌药物基金使患者更易获取昂贵的新药，但该基金不去评估药效，这是错失良机。在凸显患者失望的癌症登记处，可以评估癌症的发病率和生存率。医疗保健的获取也很重要：美国实行奥巴马医改后，尽早被诊断出来的美国癌症患者数量增加。预防仍是最佳治疗手段，2008-2014年控烟工作避免了2200万人死亡（许多患有癌症）。世界卫生组织建议烟草税至少占香烟价格的75%，但世界人口仅有20%生活在这些国家。

Taxes and budgeting are a lot less exciting than tumour-zapping proton beams and antibodies with superpowers. But the decisions of technocrats are as important as the work of technicians. Cancer kills millions of people not simply for want of scientific advance, but also because of bad policy.

相比消灭肿瘤的质子束和强大的抗体，税收和财政不容乐观。但是，技术官僚的决策和工作同样重要。数百万人死于癌症，不仅仅因为科学不够发达，而且还因为糟糕的政策。