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Mark Wulfe:
From The Aasgaard Company studios in beautiful Wichita Falls, Texas... From the finest mind in the modern fitness industry... The One True Voice of the strength and conditioning profession... The most important podcast on the internet... Ladies and gentlemen! Starting Strength Radio.

Mark Rippetoe:
Welcome to Starting Strength Radio. We're here on Friday as we are on every Friday. And every once in a while we change things up. Sometimes I sit here and talk just to amuse myself and we record it and we call that a show. Today we actually have an actual show with an actual guest and an actual important topic.

Mark Rippetoe:
And we're here with John Horgan today. John is the author of an article about cancer treatment, funding, research []. And things that are actually kind of important things that you need to think about in our ongoing effort to get you to think instead of obey when doctors tell you things. We're going to talk to John about an extremely important topic here. And John, thank you for being with us today.

John Horgan:
It's my pleasure, Mark.

Mark Rippetoe:
We've got a thread up on the on my Q and A on the website that features this features your article and we've we we've gotten quite a few hits and it's got some real good discussion on this. But I thought it was an extremely valuable topic because of the fact that everybody... that somebody everybody knows has died of cancer. It's the second leading cause of death in the United States. And 1.7 million cancer diagnoses last year and six hundred thousand deaths. This is a third of them. A third of the people die with it.

Mark Rippetoe:
Now think about that. Four out of ten people will get cancer in their lifetime at some point. Cancer treatment is horrible. Everybody knows someone who's gone through cancer treatment and it's been horrible. It's terribly invasive. It it makes your life a living hell for the period of time that you're engaged in the treatment. Sometimes it's successful, sometimes it's not. Whole bunch of money's been spent on this and things aren't as they seem as it turns out and we're to talk to John about this.

Mark Rippetoe:
Again. Thanks, John, for being on. Talk to us about the situation because this is this is a serious deal.

John Horgan:
Well, first of all, as you say, everybody has been affected by cancer, whether or not you're the person who gets it. My mother died - I'm 66 - my mother was younger than I am now when she died of breast cancer that metastasized to her brain. My brother-in-law died of cancer very young. One of my best friends from high school died of cancer when he was in his late 40s.

John Horgan:
And I'm a science journalist and so when cancer disrupts people's lives, often they they get in touch with me and and they're looking for answers. What's the latest treatment? How can my my my husband or my wife or my parents be cured of cancer? And so for decades, I've been tracking progress in cancer or the lack of progress.

John Horgan:
And the news that I have for people, unfortunately, is not that good. We've been officially waging the war on cancer since the early 1970s. And the struggle goes back much further than that. People have probably heard that over the last 30 years there has been a pretty steep decline in cancer mortality rates, but this comes after at least 60 years of increased cancer mortality rates. And if you look at the big picture, there's been really very little progress against cancer.

John Horgan:
Almost all the success that we've had against cancer that accounts for the drop in mortality over the last few decades comes from people stopping smoking. There there has been a huge decrease in the number of Americans who smoke now compared to the 60s and 70s.

Mark Rippetoe:
Smoking rates have changed quite a bit and I think most of us have noticed this. When I was a kid, oh my God, everybody smoked. Probably probably smoking rates at one time in this country were 50 percent. I'll bet they were as high as 50 percent, I don't know that, but that's that's my feeling about it. It was tolerated everywhere.

Mark Rippetoe:
When I was in high school they actually had a hall in the school building dedicated to where the faculty and the kids could go smoke between classes.

Mark Rippetoe:
And my parents smoked. I've hated it since I was old enough to be aware of myself. It stunk. They smoked in a car while we were in the backseat. I've hated it all my life. I've never smoked.

Mark Rippetoe:
I hate the habit. I hate people that smoke. But just it's it's been something this disgusted me my whole entire existence. And I have noticed that over the past several decades a lot fewer people are smoking now than they were back then. I think that the current rate is something like 13 percent. Is that right?

John Horgan:
It's gone away, down. It depends on how you measure it, but unfortunately, though, vaping is becoming much more popular among young people. In fact, I have a son and daughter in their mid 20s and I was just with them last night and they confessed that they both they both vape.

John Horgan:
It's not clear that vaping is as dangerous as regular cigarette smoking, but it's certainly not good for you. And it it it keeps you addicted to nicotine.

Mark Rippetoe:
Right. It's just a way to not have to quit. And I think we'll talk about that later, because that that's an interesting phenomenon. What's interesting to me is that it gets thrown into the same legal constraint situation as actually smoking tobacco. You go into a bar and the bar doesn't let you either smoke tobacco or vape, and I don't I'm not sure why that is.

Mark Rippetoe:
I think the... One of the ways we may have dealt with this is by making just the activity associated with smoking socially... how we say - unacceptable - and that vaping looks enough like smoking to where we have to prevent that, too. And I'm not sure that makes a lot of sense, but nonetheless, that's what's being done.

Mark Rippetoe:
So if the decrease in cancer mortality rates are due to... due to the cessation of smoking...

John Horgan:
Primarily, not entirely.

Mark Rippetoe:
...Primarily, I guess it would be true that as the population has grown, more people are not dying of cancer because fewer people are smoking, and that is primarily responsible for that statistic. Is that a correct interpretation?

John Horgan:
The absolute number of people who get cancer and die of cancer is still going up for two reasons. The population is just increasing all the time. Also, we're getting older as a population and cancer is a disease of old age that, you know, the odds that you're gonna get cancer just go up pretty steadily as you get older.

John Horgan:
So as people are dying less often because of other health problems like heart disease, respiratory disorders, things like that, infectious diseases, the number of people who get cancer rises. So what scholars who are trying to track progress in cancer do is they adjust for the aging of of the population and that actually presents the statistics in a better light.

Mark Rippetoe:
Well, I think probably it's true that - and you tell me whether you agree with this or not - if you get cancer in your 30s and 40s, there's probably some kind of genetic predisposition involved in that. If you get cancer in your 50s and 60s, you probably are seeing the effects of environmental causes - smoking that sort of thing. And if you get cancer in your 70s and 80s... Well, you got to die of something, right?

John Horgan:
The... Smoking is by far the biggest risk factor for cancer that nothing else remotely close to that has been discovered in terms of environmental factors. Genetics is a big part of the picture as well. Some people do have a genetic inherited disposition to cancer, but the biggest cause of cancer is just random mutation errors that creep into the body as a result of all the cells replicating over and over again.

John Horgan:
The chances that you're going to have a rare mutation that causes a lethal cancer just go up as a function of age. And unfortunately, there's not a lot that we can do about that. Diet is important. Obesity is linked to cancer, although not as tightly as as smoking is. But a lot of the... People get cancer is just it's just plain bad luck. And in fact, there is a theory called the bad luck theory of cancer that has pretty much established that.

Mark Rippetoe:
Now smoking causes, obviously lung cancer, but I am under the impression also that smoking causes lots and lots of other cancers as well.

John Horgan:
It does, yeah.

Mark Rippetoe:
And because you swallow the saliva in your mouth that's been exposed to smoke. You see cancers of the digestive tract with respect to smoking as well. Cigars, dip, cause cancers of the mouth, all of these kinds of things. As it turns out, the smoke of burning plants is not good for your mucosa. Who would have guessed that? Isn't that crazy?

Mark Rippetoe:
Have you run on to any data that suggest that marijuana is less likely to cause cancer with similar levels of exposure than tobacco is?

John Horgan:
I haven't. I haven't. I don't really know the literature on marijuana. I would assume that that it it is associated with some elevated risk. Of course, I don't know many marijuana smokers who smoke as often over the course of a day as tobacco smokers.

Mark Rippetoe:
Well, yeah because you cause you fucking can't...and still have what you call a day.

John Horgan:
Yeah.

Mark Rippetoe:
Right. I don't know. A lot of marijuana smokers that get in fights either.

Mark Rippetoe:
"Hey let's let's let's let's get a joint and go out and smoke a bunch of dope and then go out and get in a fight. You want to?" They don't do that.

John Horgan:
You know, apparently alcohol is also associated with a slightly elevated risk of cancer. So it's bad if you if you drink and you also smoke your chances of getting cancer of the throat and the larynx and all this kind of stuff up here. They really, they really go up. But researchers...

Mark Rippetoe:
But I don't smoke so it's okay if I drink, right?

John Horgan:
Yeah. Yeah. I'm not a drinker. I quit drinking 10, 10 years ago as as well. I haven't... I smoked a little bit when I was young, primarily when I was drinking. But then my mother in law died of cancer when she was very young and that pretty much cured me of any desire to have cigarettes after that.

John Horgan:
And I kept drinking for another 20 years or so and I finally gave that up as well. So, I don't really have anything else to give up at this point in my life.

Mark Rippetoe:
Hell, John, you'll never die. You're going to be immortal.

John Horgan:
I play hockey, so I might.

Mark Rippetoe:
Well, you're going to lose all your teeth at some point. Teeth are vulnerable to hockey aren't they? Yeah.

Mark Rippetoe:
So it... Cancer, though, is a big industry, isn't it? A lot of money is spent on convincing people on - hell on ads on television - that cancer treatment centers of America or whatever these chains are that advertise, can just fix you right up. And boy a rosy scenario is painted by these people, isn't it?

John Horgan:
Yes. So there have been some studies of the advertising promoted by these cancer centers. There are about twelve hundred of them in the country. And a couple of years ago, they spent more than one hundred and seventy million dollars on cancer ads.

John Horgan:
In these ads - I'm sure you've seen them. I've seen lots of them - they tend to talk about an individual person. They show this person having a wonderful time, kayaking and or sky diving, enjoying their life with their family after they've been cured by...of cancer by the, by this cancer center. And the problem is that's not really the way that you can judge progress in cancer.

John Horgan:
As I said, there has been very little progress. If you take away all the benefits of the decline in smoking, there's been very little progress when it comes to treatments for the big killers, which are lung cancer, colon cancer, breast cancer, prostate cancer, those sorts of things.

John Horgan:
A couple of success stories that I want to mention. Childhood cancer is much more treatable than it used to be and that's a wonderful thing.

Mark Rippetoe:
Yes, it is.

John Horgan:
Childhood cancer is very rare. It's it's like point three percent [0.3%] of all cancer deaths. It's just a tiny fraction.

John Horgan:
And there are some cancers of the blood and the lymph system also are more treatable than than they used to be. There are a couple of drugs that are good for breast cancer. Herceptin is is one.

John Horgan:
But we're still treating cancer in the same way basically today that we have been for the last 50 years or so. And that's trying to cut it out...

Mark Rippetoe:
Remove the lesion and then chemo and radiation.

John Horgan:
That's it.

Mark Rippetoe:
What about childhood cancers and circulatory cancers makes them more receptive to treatment these days? Is it the the medications or we got different physical approaches to these or how does it work?

John Horgan:
The thing to keep in mind about cancer is that it's it's this kind of umbrella term for all these different diseases. And cancer it is comes in all these different varieties that attack attack different organs and organs in the body and even in the same person, cancer keeps mutating. So for researchers, they're chasing this constantly moving target and there are lots of different targets.

John Horgan:
And so every now and then, they will find a drug or a treatment that works for a very specific kind of cancer. And that has been the case with with childhood cancer. And as I said, some of some of these other relatively uncommon cancers.

John Horgan:
But but for the big killers, like lung cancer, which is by far the most lethal of all cancers, the prognosis is still about the same today as it was going decades back. So that's sort of that I'm trying to get across to people. If they just were listening to all the positive ads coming out from the the cancer industry, they would think that we're making tremendous progress. But in fact, we're not.

Mark Rippetoe:
Well, the trick, I guess, is to not do something that we know produces lung cancer and that way you're less likely to get lung cancer. Now, I have a good friend whose mother died of lung cancer about 20 years ago. And she was never a smoker. Somethings just, you know... Sometimes shit happens, you know, and it's just a it's a tragic deal when it does.

Mark Rippetoe:
But if you are actively tipping the scales in the direction of cancer by doing what, oh you think looks cool in a movie or something like that. I wish people could think more clearly. People do not think about the long term ramifications of their actions. Very seldom do human beings do that, right?

Mark Rippetoe:
I don't have a tattoo, John. And the reason I don't have a tattoo is because I learned a long time ago that I didn't like the same things five years later that I used to like. And and you can't get the goddamn things off. So, So I decided to not do that.

Mark Rippetoe:
And smoking is kind of the same thing. You know, smoking has been. You see, if you watch a Tarantino movie. I don't know what the deal is with Tarantino, but Tarantino likes all his character to smoke.

Mark Rippetoe:
I just got through watching Once Upon a Time in Hollywood. That's a damn good movie, you know. Everybody smoked in this thing. I guess it was the time. It was it was perfectly in character for everybody to smoke back then. But, you know, Pulp Fiction, all those movies, everybody smokes. You've seen all those, John?

John Horgan:
Yeah. Yeah.

Mark Rippetoe:
Have you seen Atomic Blond?

John Horgan:
Is that the one with Charlize Theron?

Mark Rippetoe:
Yes, it is. And with James McAvoy. That's a damn good movie, it really is, but everybody's smoking in the damn thing. Course it was nineteen eighty nine and you know, it's I guess makes sense for the period, but they're... Everybody's smoking in the things and, you know, we see these movies and I guess, you know, people that are young and are still formative, you know, are making decisions about what the hell to do.

Mark Rippetoe:
Kill Bill didn't have...no, that that's true. I wonder what the deal was about Kill Bill. You saw kill Bill?

John Horgan:
I did.

Mark Rippetoe:
And you know, both parts there wasn't a lot of smoking in that. And I think it was set in current times, maybe that's. I don't know. Maybe he's sensitive to that.

John Horgan:
Well, you go back to the 1950s and all the heroes and heroines are smoking. And a lot of those actors ended up dying of lung cancer.

Mark Rippetoe:
They did. They did, in fact. And hell, I I remember even back then, I remember on YouTube...ack, what am I saying...on TV doctors were advertising cigarettes. It was just fascinating.

John Horgan:
You know that doctors who did the first big study in the 1950s that established how bad smoking is for you, they all smoked. There was this guy named Richard Doll, a British lord who was the leader of this study. He smoked. The other guys who were doing this study, they smoked. They sent out this survey to about 40000 British doctors, almost all of whom smoked. The people who did this study back in the 50s didn't think that smoking was bad for your health. They they set out to do this research basically to disprove that hypothesis which they thought was almost certainly wrong. And then the data just jumped out at them.

John Horgan:
Your chances of dying of lung cancer are about 25 times greater if you have if you're a serious smoker than if you're not a smoker.

Mark Rippetoe:
Well, and that's intuitively obvious to anyone thinking clearly about the function of your goddamn lungs. I mean, isn't it? Isn't that intuitively obvious that you want air to be in your lungs?

John Horgan:
It seems so now, but back then... So these guys thought that maybe it was coal pollution. They thought it was the tar being used to surface roads. They had all these other theories for why there was this lung cancer.

Mark Rippetoe:
Except the thing that is right in front of their face.

John Horgan:
Exactly. Because they were smokers.

Mark Rippetoe:
What a bunch of weird shit that is. I just... I don't understand it. I mean, I never have understood it.

Mark Rippetoe:
So, John, everybody not only is of the opinion that cancer is easily cured now because the advertising that we are always seem to be engaged in for the cancer industry, everybody is always encouraged on the same basic media platform to get screened, screened for cancer. There are total body screening centers, screening products.

Mark Rippetoe:
Prostate cancer has got a test. Colon cancer's got a test. Colonoscopies are encouraged. There's a there's a less invasive version of that that doesn't involve anaesthesia or or going up inside your butthole that still costs five hundred dollars. Well, I can't remember the name of it. I was encouraged to get this done a couple of weeks ago myself.

Mark Rippetoe:
Cancer screening, cancer testing isn't is a terribly big part of the cancer industry, isn't it? And tell us about that.

John Horgan:
It's huge. The basic idea behind cancer screening seems really sensible. The earlier you detect cancer, the better the chance of getting rid of it, of curing it. Right. That that's the idea behind...

Mark Rippetoe:
Seems logical.

John Horgan:
...All these intensive screening programs. So that's why you have mammograms that have gotten higher and higher resolution over the decades. More and more women are being urged to get to get mammograms at younger and younger ages. Same with men for prostate cancer. Same with just having your doctor check you for moles or funny looking things on your skin that could be melanoma. Same with colonoscopies.

John Horgan:
What has only emerged over the last 10 years or so is that a lot of these tests are detecting - they're not false positives, exactly. They're actually detecting anomalous cells in people. Cancerous cells in some cases. But these cells never would have compromised your health. They never would have killed you. They never would have even made you sick in any way.

John Horgan:
A lot of people now who are being autopsied, they're dying of causes other than cancer. And it turns out that they have cancer in their bodies that never affected their health in any way.

John Horgan:
So what this means - and again, this is this has just emerged quite recently - what this means is that a majority of people who are being treated for breast cancer and prostate cancer, these are the two biggest problems in screening, are being treated unnecessarily. That means they're getting surgery, chemo and radiation. And all the psychological trauma of being diagnosed with cancer.

Mark Rippetoe:
That can't be understated too.

John Horgan:
For no reason. Right. Oh, this is millions of people in the United States now who have been treated for no good reason.

John Horgan:
The problem is, the reason why this is a difficult problem to solve, is that some of those people in whom cancer is detected early on actually would go on to be harmed by that cancer and killed. But there's no way to determine in these very early stages who's going to be fine and who's going to be killed by the cancer.

John Horgan:
But the odds when it comes to breast cancer or are - depending on how you calculate it - 10 to 30 times greater that you never would have been harmed by that breast cancer than if that test is actually saved your life. With prostate cancer, it's 100 or more times more likely that you're getting unnecessary treatment as as a result of a positive test.

Mark Rippetoe:
Now, let's say that again, shall we? Let's say that again, boys and girls. You're one hundred times more likely to be treated unnecessarily for prostate cancer if you're being treated on the basis of an elevated PSA, then you are to have your life saved by it.

John Horgan:
Right.

Mark Rippetoe:
One hundred times.

Mark Rippetoe:
OK. I know people who have been told by their doctor that an elevated PSA is a direct proxy for an enlarged prostate. That, yes, they will tell you this. I have no BPH at all and I have an elevated prostate on my last exam and I am aware of what PSA actually is, what the protein is and what it does. You people that don't know look it up.

Mark Rippetoe:
I asked a urologist about this a long time ago when I was young and naive because I was just a science kid and I just wanted to know.

Mark Rippetoe:
I asked him, "What is PSA?" And his response was, "PSA is an indicator of prostate cancer." And I said, "No, you don't understand my question. I want to know chemically, biochemically, what is the substance PSA." And he patiently explained again, "Well, it is a it's a marker for prostate cancer. It's the thing that prostate cancer secretes." And I said, "Because prostate cancer wants me to know it's here? And that's why it does that?" And he he just, you know, patted me on the head. "There, there, young man. I'm the doctor." And didn't have any idea what I was even asking.

Mark Rippetoe:
And. And. I am so disappointed with doctors so many times. This is one of them. This is... This thing is has been a scam. A good friend of mine, my professor from my undergraduate degree, one of my professors trained with me at the gym. And I'm firmly convinced that he died as a result of prostate cancer treatment, treatment. I'm firmly convinced that that's what happened to him.

Mark Rippetoe:
And a lot of this is unnecessary. These idiots don't know how to perform the surgery. They go in and do it anyway. They biopsy people. Punch holes in a encapsulated gland and, you know, thinking that if you get cancer in any one of these biopsies we have to chop your prostate out and never mind the fact that you can't pee correctly from then on, never mind the fact that you'll never come again. Never mind any of that shit that has to do with quality of life. But by God, we got to get this out of here or you're gonna die.

Mark Rippetoe:
You know what? Death isn't the worst thing that can happen to you. I hate to be all existential about it, but I don't want to wear a diaper for 30 years, because you thankfully saved my life, I wear a diaper

Mark Rippetoe:
So these are secondary considerations, of course. But then I've been... I'm actually not being flippant. I'm really not. I've thought about this quite a bit.

John Horgan:
Listen, Mark, I have as as I'm sure you do... I know a bunch of men who have had prostate surgery or that you know, that the radiation seed put down there and I know that overwhelmingly the odds are that they didn't need to get that treatment. It's caused incontinence and impotence. And, you know, these these other health problems.

John Horgan:
The person who had who came up with the scientific discovery on which the PSA test is based years ago wrote an op-ed for The New York Times about the test and said it was a great regret of his that he had made this discovery that led to this test, which on balance has harmed more people than it's helped.

Mark Rippetoe:
A very harmed balance. An overwhelmingly harmed.

John Horgan:
Yes. Mammograms, the odds aren't quite as bad. But all these tests, if you measure not just the number of people whose life is saved from that specific cancer, but if you look at all causes of death, none of the tests work.

John Horgan:
And this is significant because sometimes people the diagnosis of death might be from a different kind of cancer or from heart disease or a respiratory disorder or an opportunistic infection that's not counted as a death from that kind of cancer. When actually these are problems that were created by the treatment, by the unnecessary treatment for that cancer.

John Horgan:
So there are some lives being saved by early detection, but they're balanced out by people who are dying prematurely because of this unnecessary treatment. That's the problem.

Mark Rippetoe:
Our friend here and in the gym, John Wilson, was diagnosed with stage four renal carcinoma about... What was it, Nick? Four years ago? It's been about four years. And they've had him on chemo and tirst one thing and another. He's always on some kind of therapy. But but, John, he hasn't even lost any weight. He weighed two hundred and seventy pounds. You know.

Mark Rippetoe:
And we've always encouraged and keep training and because... And I told him this a long time when he first came into office and said that they had diagnosed him with... He was all panic stricken and everything. And as you know, it's understandable. You receive a cancer diagnosis, you start thinking, you know, what it's going to be like to have worms crawling through you and, you know, looking up at the top lid of the coffin from now on and all this other shit. So it's a you know, it's a it's a it's a terrible situation to be placed in.

Mark Rippetoe:
But I told him, I said, John, listen to me very, very carefully. If you're coming in the gym and you're getting stronger and you're not losing any weight, then you cannot be dying of cancer. Because cancer is most often a wasting disease. People receive a cancer diagnosis and they sit down because they're dying. They sit down and behave themselves and they waste away and they die.

Mark Rippetoe:
And there are things you can do to to help yourself. And these are just extensions of what we do with strength training anyway, strength training applied to a situation like this, it works the same way.

Mark Rippetoe:
If you are actively involved in making yourself stronger and actively involved in being as healthy and strong as you can possibly be, you certainly as hell have a better chance of getting through this than if you just listen to them and take it take it easy and just, you know, spend your last few months here on Earth, you know, talking to your mom and, you know, visiting with your kids and going to church and all this other shit.

Mark Rippetoe:
They gave him six months. And here he is four years later. He won't go away. He's a he's a giant pain in the ass. He won't go away.

John Horgan:
Good for him.

Mark Rippetoe:
And and, you know, so he just said, "Nah, I don't think I want to die of cancer." And so he's doing the things that he needs to do to not die of cancer. But how many other people just as a result of this horrible psychological blow...

Mark Rippetoe:
You have cancer. I'm sorry to tell you. But you're dying of cancer. You've got four weeks to live. I suggest that you get your affairs in order. How many people? Upon given a news like this say, "You know what, fuck this. I don't think I'm going to. I don't think I'm going to go out like that." And and actively attempt to do something positive about it. Change your diet, change their exercise habits, alter their environment to the extent that that is necessary to make this better.

Mark Rippetoe:
I think we have. We ignore cases like John's. And we we look back on our on our mom. And we watch her die of cancer and we look at these other people who were essentially murdered by the diagnosis, because that happens.

John Horgan:
Yeah, well, here's the here's the big irony that... What I was talking about before that this finding that a lot of people have cancer that never would have hurt them, the implication is that our immune systems actually defeat cancer quite often.

John Horgan:
We have this natural defense system that works really well. Of course, it's not infallible. Cancer overwhelms some people's defenses and it kills them. But the irony is that with some of these early interventions after that... You get a PSA test or a mammogram. You're getting the treatment then that is harming your own natural defenses against cancer, which might have been more effective than the surgery and the radiation and and the chemo.

Mark Rippetoe:
The premise of chemo, the previous radiation, of course, is to try to kill everything and just hope the cancer dies first. And, you know, that's a very interesting observation. I wonder if... Looking at this from an evolutionary biology perspective, as I mean, all mammals, all vertebrates probably have some rate of cancer, don't they?

Mark Rippetoe:
I mean, we all know dogs that have... We've had dogs that have died. Had a big tumor and they... we had to put the dog down. Horses, cattle, tumors are in everything. Had we not evolved some kind of a mechanism to deal with that, as you know, back long, long time ago in evolutionary history, we wouldn't be very successful as animals, now would we? So this has to be I don't think that's been studied enough. I don't think that's been looked at enough. But then again, I I'm not aware of the research. What is ongoing in terms of looking at the way we can help the body deal with cancer without exogenous means? Are you familiar with that?

John Horgan:
It's just... it's this stuff that it's the stuff that we all read about in the newspaper every day is basically... Well, quit, quit smoking. Diet, have a sensible diet, you know, fruit and vegetables. Exercise a lot. Exercise is just... has all sorts of benefits. But there isn't any magic formula that the connection between smoking and cancer is unique in being really powerful. All these other things are kind of playing at the margins.

John Horgan:
I think that the best thing people can do collectively to improve cancer care in this country, it's going to be really difficult. That requires a cultural change. It means that not only doctors have to change, doctors have to prescribe tests less and treat cancer less aggressively because the data just are showing that those things don't work.

John Horgan:
Consumers also have to be less afraid of cancer and they have to realize that a lot of these tests that are getting that are leading to diagnoses are not good for them. They're not saving lives. In fact, they're they're cutting some lives short prematurely.

John Horgan:
So there's this movement in health care now among physicians called sometimes called gentle, gentle medicine or conservative medicine. It means just recognizing the limits of what medicine can do and recognizing that our bodies have these natural healing properties. And it just means less medicine.

Mark Rippetoe:
First, do no harm.

John Horgan:
First, do no harm. It's the it's the oldest precept in medicine. It goes back to Hippocrates. And cancer care, the way it's being practiced, especially in the United States today, just grossly violates that that slogan first, do no harm. Lots of people are being harmed unnecessarily and it will be really difficult.

John Horgan:
Whenever I write about cancer and especially about the tests, people tell me I'm crazy. And that they you know, the tests are saving lives and that I'm a fool if I don't get tested, which I don't. But in fact, the data overwhelmingly show that these tests are not are not doing doing a good job.

John Horgan:
So I this is why I write about this issue constantly. I'm glad you're talking about it on your show, because it's the only way people are going to realize what's going on and try to change their behavior. And if we can change our behavior and get less tests, less treatments, we'll also save a lot of money. Cancer costs are just skyrocketing in this country as part of our...

Mark Rippetoe:
What is the figure I saw in your article? Hundred and twenty five billion dollars spent in 2010 and we're on track to spend one hundred and seventy five billion dollars in 2020. So that's what? A 40 percent increase in ten years? And that can't all be attributed to population growth. So some of it can, but certainly not all of it.

John Horgan:
Well, a lot of the latest treatments are extremely expensive. Some of your listeners might have heard of immunotherapy, which is generating a lot of excitement recently and for good reason. There have been some real successes with immunotherapy for very specific kinds of cancer.

John Horgan:
But first of all, immunotherapy only works for a very small percentage of people, well under 10 percent. And as it's being used right now, it's extremely expensive. It can cost over one million dollar, one million dollars per patient to get immune therapy. It requires a lot of customized care and follow up care. Terrible side effects for some patients.

John Horgan:
There is an analysis by a famous cancer physician at Columbia University, Siddartha Mukherjee. Just last year, he said that if immune therapy is used more widely, it will bankrupt the American health care system, which is already near bankruptcy.

Mark Rippetoe:
Well, yes. And it's a it's a shame is, is this these types of hideously expensive treatment are being held out as well as hopes to people for whom they will have no benefit.

John Horgan:
That's right.

Mark Rippetoe:
People whose families will be gutted financially as a result of trying to provide this for them. And yeah it's a.. that's that's an interesting deal.

Mark Rippetoe:
Another interesting deal to me is the is the research aspects of this. You talked in your article about John Ioannidis. I'm a big fan of his work. He he's done a lot of stuff that makes us take a step back when we start worshipping peer reviewed research. He and Bruce Charlton.

Mark Rippetoe:
If you're familiar with Dr. Charlton, he's a British guy that has done the same kind of thing, calling into question the actual studies themselves, because they're so much of this stuff is just not reproducible. They'll... Anything can be published and I would imagine that a lot of the false hope that's being promulgated by cancer treatment, the cancer treatment industry, is the result of some research that may or may not be any good.

John Horgan:
Yeah, and you know that that Ioannidis is this guy who for about 15 years has been pointed out that that the scientific literature, the peer reviewed literature, which is sort of the gold standard of human knowledge, is riddled with inaccuracies.

Mark Rippetoe:
It's "the evidence." If you're not operating on the evidence, then you're not engaged in an evidence based practice.

Mark Rippetoe:
Right now in my field, exercise, science and strength training the literature. Is shit. It's absolute shit. None of it is of any use. Literally none of it. Just to quote a famous example of this is in the literature, John. There was it was a paper published 11, 12 years ago by some guys down in Australia that were they were they took a cohort of eleven people and they determined that there was no difference in the amount of weight these people could bench press if they were laying on a bench or laying on a balance ball.

Mark Rippetoe:
This is this is insane. This is absolutely insane. The data set was shared, the heaviest bench press in the whole thing was 250 pounds or something like that. You know, eleven people, six women, five men, this sort of thing.

Mark Rippetoe:
So essentially what happened was- and this happens all the time - is this guy published one of his students masters thesis. And its...The literature in the exercise sciences is composed of trash like this.

Mark Rippetoe:
I hope - and I may be wrong in hoping this - but that the more rigorous sciences - chemistry, physics, these sorts of things - have better quality publication than than what we have over here. But Ioannidis, is that the way you pronounce his name?

John Horgan:
I call him Ioannidis.

Mark Rippetoe:
Ioannidis.

John Horgan:
Just guessing.

Mark Rippetoe:
Ioannidis. I don't know. Let's have him on the show. First thing we'll do, straighten out that pronunciation.

Mark Rippetoe:
He's... I can't I can't thank him enough for pointing out how bad most of the literature is and that you worship it at your peril.

John Horgan:
Well, and he's also pointed it out - and this this makes sense - that the problems with the literature go up as the financial stakes go up. So that's why, you know, if you're talking about, I don't know, some esoteric part of physics, there can be problems in that literature, too, because there's competition among the researchers. But if you're talking about a possible new drug for cancer that can have a... generate a revenue stream of millions or billions of dollars of dollars, the incentives for that to come out in a certain way are enormous.

Mark Rippetoe:
And that that can't be circumvented, can it? You can't take away financial incentives for research that potentially affects revenue streams that are in the ten figures.

John Horgan:
The problem is...

Mark Rippetoe:
They won't leave it alone. They can't leave it alone.

John Horgan:
You could have... There are some groups. There is a group called the Cochrane Collaboration. It's an international network of physicians. It's nonprofit. It accepts no money from the biomedical industry, from pharmaceutical companies. And they evaluate studies of different treatments and try to provide a really objective assessment of of lots of different studies put together. They do these these big meta analysis.

John Horgan:
There are people - as a result of some of the problems that Ioannidis and others have drawn attention to - there are people in medicine and other fields who are trying to provide more objective, reliable data on different scientific claims. And I think things in principle can improve. But right now, it's still pretty bad. And in medicine, most of the big trials are still funded by the companies that stand to benefit if those trials come out in a positive way.

Mark Rippetoe:
It's standard for the manufacturer of the product are doing a trial on it, sure. And I understand that there's no other source for the money. I understand that. It makes logical sense to me that people who did benefit from this would be invested in it upfront. Duh, right?

Mark Rippetoe:
But the prescribers. The people who write this stuff are not doing their homework. Not doing their jobs. They're not... They've just abdicated their there thinking part of the responsibility for this stuff, because, you know, they have access to the same data you've got access to. And they're ignoring it. For whatever reason. And it's unfortunate.

John Horgan:
Another one another part of the problem here is, is that doctors are afraid that if they don't prescribe a test... So my my doctor is constantly telling me I need to get a PSA test and I say no. And but he wants to be on record telling me that he's recommended the tests because if I get prostate cancer, then he can say it wasn't his fault. It was my fault.

Mark Rippetoe:
He's covering his ass. And I understand why that is.

Mark Rippetoe:
And, you know, you can attribute a huge amount of this problem to the legal system. You certainly can. I mean, there are people trolling on the radio. There are law firms or referral services trolling on the radio for glyphosate poisoning. You know, that's caused apparently glyphosate, which is Roundup cause some cases of lymphoma.

Mark Rippetoe:
And all you got to convince is 12 people on a jury to award at 80 trillion dollar settlement based on Monsanto's manufacture of glyphosate under patent. And they'll get it done. They'll get it done. You know, damn good and well, they'll get it done, right.

Mark Rippetoe:
I mean, how many people in the United States have used glyphosate out in the front yard or in the pasture? You know probably twenty five percent of the entire population has used roundup at one time or another. And how many what percentage of those people have lymphoma? The same number that would have had lymphoma had they not used glyphosate. But you don't have to... That's not the burden that you bring to the jury. Is it?

Mark Rippetoe:
Here's this poor lady. And she's gotten lymphoma and she used glyphosate. And there's a study, hey, there's a two or three studies that show that Monsanto knew about this prior to the the sale of this product to this poor lady. And look at her. Look at her right now. She needs your help. Jury. She needs your money. And that's, you know. This is a... Yeah, I don't know, man.

John Horgan:
I don't know what we're going to do.

Mark Rippetoe:
I'm sympathetic to the... What I'm saying is that you have to have a certain amount of sympathy for the doctors because to be sued under these circumstances. And if all they have to do to you and me is say, "Man, I'm just telling you, you know, I've recommended you get a PSA test. You know, I don't want you to get you to get prostate cancer. And you to come back and blame me for not recommending you got prostate specific antigen test. And as a result, I want this in your record right now that I said you needed PSA and you refused it."

Mark Rippetoe:
I don't blame them. I don't blame them at all.

John Horgan:
Yeah. You know, I've I've been thinking about what we can do with our health care system, because the problems, of course, go way beyond just cancer. It's the system as a whole that's that's messed up.

John Horgan:
I am... I think that the market capitalism can do a lot of things for us. But when it comes to health care, I think free market forces have made a mess of things in this country. If you look at you compare American medicine to medicine and other advanced industrialized countries like Europe, where they have more socialized systems of medicine, they spend much less and they don't die as often. Their cancer mortality rates are lower than ours.

Mark Rippetoe:
Well, now that's I don't know... I know exactly what you're saying. And that's that's what the data show, but I don't know that that's capitalism's fault. Our medical system has not been a free market since 1966. And if if you have a doctor working for the government, that doctor is just as likely to be sued as somebody working for a private medical group over here.

Mark Rippetoe:
The British Public Health Service is more than happy to just let people die. Where over here, we want to we want to treat them. And it's the funding. The differences in the funding. Private insurance is going to pay more than British public health service. But I don't know a lot of people in Canada that are terribly... That are completely happy with the care they get up there because it's a socialized system and it's provided as a is a service like water, I guess. But somebody has to pay for it. Everybody pays for it. But I don't I don't think it's fair to lay the blame for the problems in our system entirely at the feet of the free market, because the free market has not operated in this system since the introduction of Medicare in 1966.

John Horgan:
So we have this we have this kind of weird hybrid system.

Mark Rippetoe:
Yeah, we do.

John Horgan:
I'm just I'm just looking at the I mean, you know, that the United States, if you and you have a chart per capita spending for health care of all you know, all the European countries and Japan and countries that are that are modern and have really good health care facilities, they are are like this. And then here's the United States way up here.

John Horgan:
We just spent a huge amount more than anybody else. And yet our our outcomes are really crappy both when it comes to cancer and longevity and child mortality. So I don't know what the answer is. It's a colossal problem.

Mark Rippetoe:
It is a problem. One of the problems, though. One of the reasons it's so goddamn expensive is because the FDA makes it that way. Now, that's the government. Yeah, it's the government. And everybody says, well, we've got to... We've got to prevent another tragedy that occurred with what was the name of the pain killer that they used inappropriately all those years ago that caused all the massive birth defects?

John Horgan:
Thalidomide.

Mark Rippetoe:
Thalidomide babies, that sort of thing. In an attempt to prevent something like that from happening, we have rather heavy handedly applied a blanket system of approval protocols for everything that run. I mean, what you what is the number what does it cost to get a new drug through FDA trials? And how long does it take?

John Horgan:
I can tell. It can be more than 100 million dollars.

Mark Rippetoe:
More than 100 million dollars just with the FDA. In order to satisfy all that. And what if the drug that the FDA trial is finally determined the thing was good for is only useful in about ten thousand total patients? It's gonna be real goddamn expensive, isn't it?

John Horgan:
Yeah.

Mark Rippetoe:
And if everybody is going to be treated with that, then Medicare's gonna step in and mandate that everybody be treated for it. Yeah, shit's gonna get expensive. OK. Shit's going to get expensees. All I'm saying is that there are other factors besides free market capitalism that have made things real expensive and it's best to keep that in mind.

John Horgan:
That's true. Lots of regulation. I just want to point out though... I mentioned this in my piece that the FDA that, you know, the rate of failure for new trials of cancer drugs is higher than any part of any other part of medicine. And the drugs that have been approved - this was a study of drugs approved by the FDA between, I don't know, 2007 and 2014, some period like that - and they extended life of cancer patients on average by about 2 months. A majority of the drugs actually didn't extend life at all and harmed quality of life. So they had actually no value at all. And these are the drugs that have been approved by the FDA.

Mark Rippetoe:
Let me also take this opportunity to point out that North Korea, it's been a very long time since North Korea has developed a life-saving drug. Right. It's been very damn long time since the Russians or the the Chinese have developed a life-saving drug. Most of that occurs here in the United States, because at least here, the drug companies understand that they at least can get part, if not all of their hundred million dollar investment in that drug recoup through sales, which they can't do over there.

Mark Rippetoe:
I mean, you know, if you've got one hundred million dollar barrier to a new drug coming on the market. You know, you've got to be able to to. I mean, that's a lot of skin in the game, right? Yeah. And not everybody is gonna be capable of participating in this deal.

Mark Rippetoe:
And it just, you know, if you have a chance to get paid for it, you might be more likely to to try to develop something new. But your point is certainly not lost.

Mark Rippetoe:
We spent all of his money on this shit and it's not making things much better. And the reason it's not making things much better appears to be that there actually is a bottleneck here. Cancer kills people. It's a horrible disease. It kills people if it gets out of hand, if it becomes an actual death sentence. It's it's not something that can be fixed, but things that can't be fixed are being treated anyway. But things that that can get fixed by themselves are being treated unnecessarily.

Mark Rippetoe:
So we've got a we've got a situation where the best way to not die of0 cancer is to: don't smoke. You fucking idiots, don't smoke. That's... It stinks. Everybody hates it. Nobody wants to be around you. You don't care. Go ahead. Smoke. But do it over there. Go outside. But why just don't you just quit?

Mark Rippetoe:
And if you do get cancer when you smoke, good. Get out of here. You knew better than that. Now, didn't you? You knew better than that. As we've all known for a very long time, that it can kill you. It can make you have cancer. All right. I'm sorry you're dying. But you know what? It's not like you weren't told. OK.

John Horgan:
That's some tough love there, Mark.

Mark Rippetoe:
Well, you know, John, is it... but you know what my fallback position is, it's true.

John Horgan:
Yeah.

Mark Rippetoe:
Now isn't it? This isn't news. This isn't news. Just don't smoke. You know, you may die of cancer anyway. Absolutely true. I mean, his mom died of cancer. She didn't smoke. Might die of cancer anyway. But why would you do something that increases your likelihood of dying from cancer by twenty five times? If you could just not do that. Yeah, I mean, I understand you. You have to eat, right? Yeah. Drink water. But you don't have to smoke. And here's your takeaway, boys and girls, you don't have to smoke. Don't smoke.

Mark Rippetoe:
John, I think we kicked this around pretty thoroughly.

John Horgan:
Yeah, I enjoyed it.

Mark Rippetoe:
Enjoyed the conversation. If you think of some clever to talk to us about, let me know, we'll get you back on.

John Horgan:
I appreciate it, Mark.

Mark Rippetoe:
John Horgan has been our guest today on Starting Strength radio. We hope we've turned on some lights for you, and would appreciate it if you'd pass this around.

Mark Rippetoe:
And I guess the best thing to do is hide and wait for next Friday and see what we come up with then. Thanks for being here. Talk to you next time.

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