Peritoneal Carcinosis and HIPEC: A second chance for patients, thanks to animal research

When we hear the phrase ‘animal research’ we tend to think about the development of new drugs for the clinical practice, or studying molecular pathways involved in the progression of disease; but we must also remember that the techniques used in the operation room are a consequence of biomedical research, including the use of animals. It is not just the creation of these techniques but also for the prior steps necessary for us to consider a surgical technique as an option when faced with a disease. An example of this is research into a type of cancer known as Peritoneal Carcinosis (PC) and the development of a technique, known as HIPEC, that may dramatically improve the prognosis for patients with this type of cancer.

What is the definition of Peritoneal Carcinosis? We describe this medical condition as the presence of neoplastic nodules caused by the spreading of a primary or secondary tumor in the peritoneal cavity. The peritoneal cavity, also called the abdominal cavity, is the largest body cavity and contains many of the major organs – such as the liver, kidneys, stomach and intestines – surrounded by a protective membrane known as the peritoneum.

Although PC is sometimes seen in primary tumours, such as peritoneal mesothelioma or Pseudomyxoma peritoneii, it is more frequently observed as a metastatic diffusion of gastroenteric (stomach and colon, primary) or gynaecologic (ovarian) tumors. In the second situation, we could see it as an advanced manifestation present at the same time as the primary neoplastic disease or appearing in the years following treatment of the tumour. This condition is often associated with a poor prognosis (about 6 months), depending on the site to which it spreads, the involvement of abdominal organs (like colon or liver) and how aggressive is the tumor at the moment of diagnose.

Peritoneal Carcinosis viewed by laparoscopy. Image: www.cancersurgery.us

Peritoneal Carcinosis viewed by laparoscopy. Image: http://www.cancersurgery.us

In the past, physicians have had only two options when combating the disease: systemic chemotherapy or palliative surgical therapy to debulk the tumor masses- removing as much as possible of tumors which cannot be entirely removed –  and prevent severe conditions such as bowel obstruction. Recently, surgical research developed another therapeutic approach, known as Cytoreduction (CR) associated with Hyperthermic intraperitoneal Chemotherapy (HIPEC). This technique consists of a two-part operation: during the first part, the surgeon debulks as much of the neoplastic nodules in the peritoneal cavity as possible, and in the second stage the peritoneal cavity is washed with a hyperthermic chemotherapy solution, where a solution containing a high concentration of chemotherapy drugs is heated to above body temperature (usually 41.5°-42.5°C) which increases absorption of the drugs by the target tumor and therefor their effectiveness.

The role of the hyperthermic solution and the possibility of using a high-dose of chemotherapic agent was developed through research in rodents and dogs: these studies demostrated that the peritoneal barrier itself is not a barrier that prevents substances from pass through it. This is in agreement with observations made during surgery in human patients, when we remove the peritoneum (for example, when we debulk a neoplastic nodule on a peritoneal surface with a technique known as peritonectomy) the rate at which drugs are cleared from peritoneal cavity is not significantly affected. [1]

Studies in dogs and subsequently in human volunteers demonstrated that the high concentration of chemotherapeutic drugs in the peritoneal cavity is not related to a high concentration of these in the blood stream [2]. In particular a key study undertaken in dogs by Rubin et al. [3], consisted of studying the effects of removing portions of the perotineum such as the the omentum, the mesentery or the small bowel on the clearance of substances like glucose, urea and insulin from the peritoneal cavity. Surprisingly, this experiment indicated that these operations do not influence the clearance of these substances. On the base of these observation, clinical studies were started on clearance of drugs from the peritoneal compartment:. These clinical studies demonstrated that the process observed in dog with other substances occured also with drugs and that, in some cases, the concentration of a drug within the peritoneal cavity could be extremely high without having effects on the concentration in the bloodstream.

A natural consequence of this evidence is that we can use a high-dose chemotherapy drug against these nodules without having systemic adverse effects on the patient, a problem frequently observed in conventional systemic chemotherapy. These studies also led researchers to reconsider the spreading of a tumour in the peritoneal cavity not as a systemic dissemination but as a local disease, and that treatment might be able to cure it rather than just have a palliative impact. If the peritoneal barrier can selectively allow only some molecules to pass through, it could have also an active role on slowing the diffusion of metastatic cancer cells.

This evidence, together with the property of hyperthermia in helping drugs to penetrate cancer cells [4], and avoid the normal defences that a tumor cell has, led to development of this ambitious surgical technique.

The results of this combined technique is clear. Against primary tumors this technique shows a high survival-rate after 5 years (reaching 96% in some studies [5]). Against secondary spreading of gastroenteric or gynaecological tumours it shows a lower efficacy that may be related to the more diverse biological characteristics of the tumor cells, to the physiopathological features (diffusion, tumor already treated with chemotherapy etc.) and also to the characteristics of the patient (such as clinical status, age, concomitant diseases) [6],[7],[8],[9]. The 5-years survival rate for PC from colorectal cancer, for example, according to studies conducted by Dr. Paul Sugarbaker of the Washington Cancer Institute, one of the most important researcher on this field, is around 40%, when the cytoreduction is complete and the disease is not so diffuse in the peritoneal cavity. [7] Also, this surgical approach can be uses a second time, in case of a recurrence of PC, and, ultimately, as a palliative treatment to delay complications and reduce suffering of the cancer patients.

These numbers could seem low but we have to consider that we’re facing a disease that is often fatal within six months if left untreated. This technique gives patients another chance until very recently, they did not have. Why? Because of research that was built up, in part, thanks to animal research

These results are a direct effect of research in the fields of surgery and oncology, from the including the development of more effective chemotherapic agents, research that, as we have said many times, requires the study of animals for everything from the basic understanding of the processes involved to the preclinical testing a new therapy’s effectiveness and safety profile.

Marco Delli Zotti

[1] Michael F. Flessner “The transport barrier in intraperitoneal therapy” Am J Physiol Renal Physiol 288:F433-F442, 2005. http://www.ncbi.nlm.nih.gov/pubmed/15692055

[2] Pierre Jacquet, Andrew Averbach, Arvil D. Stephens, O. Anthony Stuart, David Chang, Paul H. Sugarbaker “Heated Intraoperative Intraperitoneal Mitomycin C and Early Postoperative Intraperitoneal 5-Fluorouracil: Pharmacokinetic Studies” Oncology 1998;55:130–138 http://www.ncbi.nlm.nih.gov/pubmed/9499187

[3] Rubin J, Jones Q, Planch A, Rushton F, Bower J. “The importance of the abdominal viscera to pertioneal transport during peritoneal dialysis in the dog.” Am J Med Sciences 1986;292:203– 208. http://www.ncbi.nlm.nih.gov/pubmed/3752166

[4] Elwood P. Armour, Donna McEachern, Zhenhua Wang, et al. “Sensitivity of Human Cells to Mild Hyperthermia” Cancer Res 1993;53:2740-2744. http://www.ncbi.nlm.nih.gov/pubmed/8504414

[5] Yan TD, Black D, Savady R et al. “Systematic review on the efficacy of cytoreductive surgery and perioperative intraperitoneal chemotherapy for pseudomyxoma peritonei.” Ann Surg Oncol 2007;14:484-92 http://www.ncbi.nlm.nih.gov/pubmed/17054002

[6] Franco Roviello, Daniele Marrelli, Alessandro Neri, Daniela Cerretani, Giovanni de Manzoni, Corrado Pedrazzani, MD, Tommaso Cioppa, MD, Giacomo Nastri, MD, Giorgio Giorgi, Enrico Pinto
“Treatment of Peritoneal Carcinomatosis by Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemoperfusion (IHCP): Postoperative Outcome and Risk Factors for Morbidity” World J Surg (2006) 30: 2033–2040 http://www.ncbi.nlm.nih.gov/pubmed/17006608

[7] Paul H. Sugarbaker “Review of a personal experience in the Management of Carcinomatosis and Sarcomatosis” Jpn J Clin Oncol 2001; 31(12)573-583 http://www.ncbi.nlm.nih.gov/pubmed/11902487

[8] Zanon C, Bortolini M, Chiappino I et al. “Cytoreductive surgery combined with intraperitoneal chemohyperthermia for the treatment of advanced colon cancer.” World J Surg. 2006 Nov;30(11):2025-32. http://www.ncbi.nlm.nih.gov/pubmed/17058031

[9] Bijelic L, Jonson A, Sugarbaker PH “Systematic review of cytoreductive surgery and heated intraoperative intraperitoneal chemotherapy for treatment of peritoneal carcinomatosis in primary and recurrent ovarian cancer.” Ann Oncol 2007;18:1943-50 http://www.ncbi.nlm.nih.gov/pubmed/17496308

To learn more about the role of animal research in advancing human and veterinary medicine, and the threat posed to this progress by the animal rights lobby, follow us on Facebook or Twitter.

 

Thank You Doctor Salk! (and Drs Enders, Bodian, Landsteiner, Sabin…)

Today’s Google Doodle honours Dr Jonas Salk, who in 1954 created the world’s first effective polio vaccine, which was responsible for launching a campaign that has seen this terrible disease become an increasingly distant memory in most  – though sadly not all – parts of the world.

jonas-salks-100th-birthday-5130655667060736-hp

It’s an opportunity to reflect on the pioneering work of Dr Salk, who was born 100 years today, but we should also remember all the other great scientists whose work made crucial contributions to the development of the inactivated and live polio vaccines.

Salk’s 100yr anniversary: say thank you to those who helped develop the Salk vaccine against polio Tweet this!

Today, in honor of Jonas Salk and all the other polio vaccine pioneers, we are reposting this article, which we first published in 2011.

Albert Sabin and the monkeys who gave summer back to the children.

Albert Sabin has been called “the doctor who gave summer back to the children.”*

Because of his decades of research to develop the oral polio vaccine, children today know nothing of the fear that polio brought to the United States every summer well into the 20th century.  Swimming pools and movie theaters were closed and children were kept inside their homes by frightened parents.  Worldwide, the disease killed millions of people and left legions of others permanently disabled.

Albert Sabin administering the vaccine that saved millions from polio.

Albert Sabin administering the vaccine that saved millions from polio.

We’ve just celebrated the 50th anniversary of the introduction of Dr. Sabin’s vaccine. Estimates suggest that in just its first two years of worldwide use, the vaccine prevented nearly 500,000 deaths and five million cases of polio.  Today, the world is on the brink of realizing Dr. Sabin’s lifetime dream: the eradication of polio from the planet.

The development of the oral polio vaccine required years of extensive research with rabbits, monkeys and rodents.

Animal rights activists long ago seized on a single phrase by Dr. Albert Sabin, and have been using it ever since to try to support their outrageous claim that the developer of the oral polio vaccine(OPV) opposed the use of animals in research.

That phrase, “The work on prevention (of polio) was long delayed by an erroneous conception of the nature of the human disease based on misleading experimental models of disease in monkeys” spoken by Dr. Sabin during a congressional hearing in 1984, has been used in animal rights publications and comments for over two decades.

Dr. Sabin, a member of the Board of Directors of the pro-research Americans for Medical Progress until his death in 1993, spent years working to correct the record.  Here is a letter he wrote to the editor of the Winston Salem Journal, published in 1992.

Winston-Salem Journal

March 20, 1992

The Correct Conclusion

In a recent letter to the Journal (“Misrepresenting Research,” Feb. 20), Dr. Stephen R. Kaufman, the chairman of the Medical Research Modernization Committee, correctly quoted my 1984 testimony before Congress but he drew wrong conclusions from it.  Dr. Kaufman was also wrong when the said “the polio vaccine was based on a tissue culture preparation … not animal experimentation.”

On the contrary, my own experience of more than 60 years in biomedical research amply demonstrated that without the use of animals and of human beings, it would have been impossible to acquire the important knowledge needed to prevent much suffering and premature death not only among humans but also among animals.

In my 1956 paper in the Journal of the American Medical Association (Vol. 162, p. 1589), I stated that during the preceding four years “approximately 9,000 monkeys, 150 chimpanzees and 133 human volunteers were used thus far in studies of various characteristics of different poliovirus strains.”  These studies were necessary to solve many problems before an oral polio-virus vaccine could become a reality.

Albert B. Sabin, M.D.

Washington

It is true that in the early years of polio research some lines of inquiry eventually proved unsuccessful. An overreliance on a strain of the virus known as the MV strain that had become adapted to survive only in nervous tissue, and the fact that the Rhesus macaque, while a good model for many aspects of polio, cannot be infected through ingestion via the mouth, led to the incorrect assumption that polio could only infect nerve cells (despite evidence to the contrary from both clinical studies and laboratory studies with other polio strains and monkey species).   These mistakes were unfortunate, though understandable given the fact that virology as a science was in its infancy.

However, these failed attempts do not cancel out the fact that animal research, and research using monkeys in particular, was absolutely crucial to the development of vaccines for polio.  Without it the polio vaccine would certainly not have been developed by the end of the 1950’s, and we might even still be waiting for it.

These vital contributions made by animal research to the development of polio vaccines were not limited to the work of Albert Sabin, and include:

  • The discovery by Karl Landsteiner and Erwin Popper in 1908 that polio was caused by a virus, a discovery made by inoculating macaque monkeys with an extract of nervous tissue from polio victims that was shown to be free of other infectious agents.
  • The subsequent discovery by Simon Flexner  that blood serum from infected macaque monkeys could protect against polio infection.
  • The discovery by Carl Kling and colleagues in 1911, following an earlier discovery that polio virus could be isolated from the lymph nodes of the small intestine of monkeys, that polio virus was present in the throat and intestinal tissues of people who dies from polio. Soon afterwards they isolated virus from the intestines of patients suffering from acute polio, and importantly from family members who did not display the symptoms of polio, establishing that healthy carriers played an important role in spreading the disease. In these studies the presence of polio was demonstrated by injecting filtered fluid from the patients into monkeys, the only method then available to confirm the presence of polio (Introduction to Epidemiology, fifth edition, by Ray M, Merill, Jones and Bartlett Learning).
  • The discovery in the early 1930’s by the Australian scientists Macfarlane Burnet and Jean Macnamara that antibodies against one strain of polio did not always protect macaque monkeys against infection with another strain.
  • The discovery by John Enders, Thomas Weller and Frederick Robbins that the polio virus could be grown in a number of tissue types, not just nerve tissue as previously assumed, a discovery that required the use of mice and monkeys to prove that the cultured virus was indeed polio and still capable of causing paralysis.
  • The determination in 1949 by David Bodian and colleagues at Johns Hopkins University that there were three major families of polio virus, referred to as types 1, 2, and 3, and that a separate vaccine would be necessary for each to give broad protection against polio.
  • The discovery by David Bodian and colleagues in the late 1940’s and early 1950’s that the polio virus entered the body through the mouth, and then needed to pass into the blood stream before it could infect nervous tissue, and that if you could block the infection in the blood you could prevent the virus from entering nerve tissue and causing paralysis. The work of Enders and Bodian paved the way for the development of vaccines by Salk and Sabin.
  • The evaluation by Jonas Salk and his colleagues at the University of Pittsburgh  of vaccine candidates produced by inactivating the virus with formalin under a range of conditions, until a vaccine was identified that was effective and safe enough for human trials.
  • The evaluation by Albert Sabin of hundreds of polio virus strains in hundreds of monkeys and scores of chimps before identifying attenuated strains that were capable of efficiently entering the body through the digestive system and provoking an adequate immune response to protect against the different pathogenic strains of polio while not causing the disease themselves.

It is hardly surprising that those close to Albert Sabin are disgusted with the way in which his views are misrepresented by animal rights activists. Writing for the Wall Street Journal two years after his death Albert Sabin’s widow, Heloisa Sabin, discussed the value of animals to his research.

ANIMAL RESEARCH SAVES HUMAN LIVES

The Wall Street Journal, October 18, 1995

by Heloisa Sabin

Mrs. Sabin is honorary director of Americans for Medical Progress.

That scene in “Forrest Gump,” in which young Forrest runs from his schoolmate tormentors so fast that his leg braces fly apart and his strong legs carry him to safety may be the only image of the polio epidemic of the 1950s etched in the minds of those too young to remember the actual devastation the disease caused. Hollywood created a scene of triumph far removed from the reality of the disease.

Some who have benefited directly from polio research, including the work of my late husband, Albert Sabin, think winning the real war against polio was just as simple. They have embraced a movement that denounces the very process that enables them to look forward to continued good health and promising futures. This “animal rights” ideology — espoused by groups such as People for the Ethical Treatment of Animals, the Humane Society of the U.S. and the Fund for Animals — rejects the use of laboratory animals in medical research and denies the role such research played in the victory over polio.

The leaders of this movement seem to have forgotten that year after year in the early ’50s, the very words “infantile paralysis” and “poliomyelitis” struck great fear among young parents that the disease would snatch their children as they slept. Each summer public beaches, playgrounds and movie theaters were places to be avoided. Polio epidemics condemned millions of children and young adults to lives in which debilitated lungs could no longer breathe on their own and young limbs were left forever wilted and frail. The disease drafted tiny armies of children on crutches and in wheelchairs who were unable to walk, run or jump. In the U.S., polio struck down nearly 58,000 children in 1952 alone.

Unlike the braces on Forrest Gump’s legs, real ones would be replaced only as the children’s misshapened legs grew. Other children and young adults were entombed in iron lungs. The only view of the world these patients had was through mirrors over their heads. These, however, are no longer part of our collective cultural memory.

Albert was on the front line of polio research. In 1961, thirty years after he began studying polio, his oral vaccine was introduced in the U.S. and distributed widely. In the nearly 40 years since, polio has been eradicated in the Western hemisphere, the World Health Organization reports, adding that with a full-scale effort, polio could be eliminated from the rest of the world by the year 2000.

Without animal research, polio would still be claiming thousands of lives each year. “There could have been no oral polio vaccine without the use of innumerable animals, a very large number of animals,” Albert told a reporter shortly before his death in 1993. Animals are still needed to test every new batch of vaccine that is produced for today’s children.

Animal activists claim that vaccines really didn’t end the epidemics — that, with improvements in social hygiene, polio was dying out anyway, before the vaccines were developed. This is untrue. In fact, advanced sanitation was responsible in part for the dramatic rise in the number of paralytic polio cases in the ’50s. Improvements in sanitation practices reduced the rate of infection, so that the average age of those infected by the polio virus went up. Older children and young adults were more likely than infants to develop paralysis from their exposure to the polio virus.

Every child who has tasted the sweet sugar cube or received the drops containing the Sabin Vaccine over the past four decades knows polio only as a word, or an obscure reference in a popular film. Thank heavens it’s not part of their reality.

These polio-free generations have grown up to be doctors, teachers, business leaders, government officials, and parents. They have their own concerns and struggles. Cancer, heart disease, strokes and AIDS are far more lethal realities to them now than polio. Yet, those who support an “animal rights” agenda that would cripple research and halt medical science in its tracks are slamming the door on the possibilities of new treatments and cures.

My husband was a kind man, but he was impatient with those who refused to acknowledge reality or to seek reasoned answers to the questions of life.

The pioneers of polio research included not only the scientists but also the laboratory animals that played a critical role in bringing about the end of polio and a host of other diseases for which we now have vaccines and cures. Animals will continue to be as vital as the scientists who study them in the battle to eliminate pain, suffering and disease from our lives.

That is the reality of medical progress.

 

Animal rights activists are free to express their opposition to the use of animals in research, but they cannot do so by blatantly robbing society of scientific achievements.  This one fact is clear — if our critics had their way, today millions of children would be dead or disabled from polio and other infectious diseases.

* Of course Jonas Salk is equally, if not more, deserving of this accolade.

A Philosopher’s Dream

A moral philosopher had the following dream:

First Darwin appeared, and the philosopher said to him, “Could you give me a fifteen-minute capsule sketch for your support of medical research using animals?”

To the philosopher’s surprise, Darwin gave him an excellent exposition in which he compressed an enormous amount of material into a mere fifteen minutes,  ending with a warning to the philosopher that “I know that physiology cannot possibly progress except by means of experiments on living animals, and I feel the deepest conviction that he who retards the progress of physiology commits a crime against mankind. “ But then the philosopher raised a certain objection which Darwin couldn’t answer. Confused, Darwin scratched his head and disappeared.

Then Albert Sabin appeared.  He gave another detailed account of the importance of the work to the development of the Polio vaccine and concluded that “without the use of animals and of human beings, it would have been impossible to acquire the important knowledge needed to prevent much suffering and premature death not only among humans but also among animals.”  The same thing happened again, and the philosophers’ objection to Sabin was the same as his objection to Darwin. Sabin also couldn’t answer it at all, scratched his head and disappeared.

head-scratching

Then all the famous medical heroes of the past century paraded one-by-one to defend the work, and our philosopher refuted every single one with the same, singular objection.

After the last scientist vanished, our philosopher said to himself, “I know I’m asleep and dreaming all this. Yet I’ve found a universal refutation for all justifications of animal  research! Tomorrow when I wake up, I will probably have forgotten it, and the world will really miss something!”

With an iron effort, the philosopher forced himself to wake up, rush over to his desk, and write down his refutation. Then he jumped back into bed with a sigh of relief.

The next morning when he awoke, he went over to the desk to see what he had written.

It was,

“That’s what you say, but I am deeply skeptical.”

 

Jeffrey Kahn’s Odd Views on Animal Research

Professor Jeffrey Kahn visited UW Madison to discuss the use of monkeys in medical research.

He is the Robert Henry Levi and Ryda Hecht Levi Professor of Bioethics and Public Policy and the Deputy Director for Policy and Administration at the Johns Hopkins Berman Institute of Bioethics.

Professor Kahn has participated in numerous federal panels and chaired the influential Institute of Medicine (IoM) committee on the Use of Chimpanzees in Biomedical and Behavioral Research, which recommended that the NIH phase out most biomedical research on chimpanzees.

Because he is respected and listened to by those in charge of making policy decisions on matters of important medical research and public health issues, his talk at UW Madison drew much attention.

During his comments Prof. Kahn raised several objections about how animal research is regulated in the United States that deserve closer scrutiny.

Unfair application of the principles of utilitarian philosophy

Professor Kahn objected to justifying research based on utilitarianism on the grounds that it is unfair to consistently harm one group (non-human animals) for the benefit of another (humans).

However, the notion that pure utilitarianism forms the basis for an ethical defense of biomedical research is incorrect.

For example, a pure utilitarian view would also call for doing invasive experiments in mentally disabled human beings whose cognitive capabilities are comparable to those of animals used in research, or demand we forcefully harvest the organs of a potential human donor to save the lives of several others.

Of course, we don’t do any of these things. So it was perplexing to hear him state that utilitarianism is “how the system is set up.” 

No, it is definitely not.

Medical research with human and non-human animals is not based on a pure, utilitarian view.  Instead, it is partly based on a graded moral status perspective that posits we owe moral consideration to all living beings, but not to the same degree that we owe consideration to the lives of fellow humans. It is also partly based in our mutual recognition of equal, basic rights for all members of the human family.

These ethical considerations are embedded in federal regulations and NIH guidelines that call for minimizing the number of animal subjects used in any one study, the amount of suffering involved, and require the use the “lowest” species that can be expected to yield meaningful scientific answers.  It is also reflected in specific federal programs aimed at developing alternatives to animal use and, of course, in protections for human subjects.

It is true that NIH has never made explicit the ethical and philosophical principles underlying its research.  Nevertheless, the ethical principles etched in these regulations should be clear to anyone who spend the time to become familiar with them.

A misguided notion of scientific necessity

Professor Kahn views the “scientific necessity” of the work as inextricably linked to the ethics. His views are aligned with the conclusions of the panel that he chaired on chimpanzee research.  Within this framework a project would be morally justified only if all the following three conditions were met:

  1. No suitable alternative is available
  2. The work cannot be performed ethically on human subjects
  3. The work is required in order to accelerate the prevention, control and treatment of life-threatening or debilitating diseases

A large class of studies readily meet the first two requirements. When we seek information about the cellular and molecular mechanisms in a living organism, the technologies available to us at the present are invasive, and the work cannot be performed ethically in human subjects. If we could observe and manipulate molecular pathways and cells in living humans without jeopardizing their well being, then the work would be done in humans. But we don’t yet have such tools. No computer simulation, no in-vitro system, no MRI, no organs-on-a-chip currently available, provide an adequate alternative to animal studies.

The crux of the matter then boils down to the third condition, and therein lies the rub. When you are talking about the process of scientific discovery, this third condition is meaningless when applied to individual scientific projects. Science, as Professor Kahn himself points out, is not necessarily a predictable linear path from point A to point B, because it involves the exploration of the unknown. Science cannot promise that any one experiment can lead to a cure, nor can researchers know ahead of time which specific experiment or line of research will lead to a breakthrough. In Professor Kahn’s own words, “we call it research because we don’t know what the answer is.”  Why does he not realize that demanding a specific outcome in advance is out of the question?  One can only evaluate outcomes in retrospect, as Peter Singer has done offering in his approval for monkey studies in Parkinson’s research. Unfortunately, scientists on NIH study sections do not have the luxury of an oracle that can guide their decisions.

Instead, researchers understand that without animal studies we will not be able to develop new therapies and cures. Our expert scientific opinion is that were we to suspend animal research, most fields of biomedical research would come to a full stop. Meanwhile, patients and their families would pay the price of more human suffering.

Thus, the ethical question should be reframed as not whether one individual study is required but, in the case at the heart of this debate, whether the use of animal models is required to understand the molecular pathways underlying mental disorders so that we can  develop new treatments and cures for them.  Or more generally, if animals are required at all to advance medical knowledge and human health.  The scientific consensus in this matter, as indicated by a recent Nature magazine poll,  is overwhelming:

 

Bonus points should go to UW Professor Eric Sandgren who was nevertheless able to use Professor Kahn’s framework to explain, point by point, why he feels the studies under discussion can be justified. You may agree or disagree with his justification, but you cannot say he did not offer one. In contrast, Professor Kahn simply stated that he was “deeply skeptical” of the necessity of the work, despite acknowledging a lack of familiarity with the details of the study, nor bothering to explain the rationale for this view.

Given that the research at the center of this debate is aimed directly at anxiety disorders, a specific neurological condition that affects millions of humans, one might safely assume that Professor Kahn would express even graver doubts about basic research in animal subjects. He would have likely have rejected outright the research on olfactory cells that eventually allowed paralyzed people (and dogs) to walk again, among numerous advances in knowledge that have led to medical breakthroughs.

Professor Kahn ought to be reminded that the mission of the NIH is “to seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability,” and try to understand better the inherent uncertainty and necessity of scientific research.

Do IACUCs and NIH study sections fail to evaluate scientific necessity?

Given his misguided view of necessity, it should not be surprising Professor Kahn believes that neither IACUCs nor NIH study sections are able to assess the scientific need for specific studies. He harshly criticized such committees for taking the claims of any one proposal at “face value.

That is a very strong statement… and a decidedly incorrect one, too.

First, the overall scientific direction of medical research in the country is established by our medical and scientific leadership. In the neurosciences, scientists are guided in their research by NIH’s Neuroscience Blueprint. Among the important scientific directions relevant to this particular discussion—ones that Professor Kahn should have known about—were the Blueprint Neurotherapeutics Network (to advance the development of new drugs for nervous system disorders) and the Blueprint Non-Human Primate Brain Atlas (to provide comprehensive data on gene expression in the rhesus macaque brain , from birth to four years old). Such work is expected to aid research on human brain development and its disorders.

Second, NIH study sections diligently assess proposals with an eye to which studies stand a better chance of advancing our knowledge of function and disease and therefore may have the greatest potential to lead to new cures or fundamentally advancing a field of study. In making their assessments, scientists who participate in study sections use their expertise to assess which research directions and pilot data look most promising. There is never a guarantee that any one study will produce a breakthrough. If there is any one premise it is that animal research has led to numerous advancements in knowledge and medicine that has benefited human and non-human animals alike. This is not taken at face value, rather, it is an indisputable fact of medical history.

Third, once the scientific merit of a proposal has been established, IACUCs provide an additional layer of local scrutiny and compliance oversight. It is perfectly reasonable for IACUCs to ensure the work at the institution maximizes the welfare of the animal subjects in each study, and NIH requires such an assurance for institutions that receive federal funding. (For the small minority of projects that have not yet received NIH review, the IACUCs seek local expertise to evaluate the scientific merit of the study.)

Is funding “unnecessary” research a waste of resources?

Another miscalculation derived from Professor Kahn’s flawed view of “necessity” is the claim that if research is “unnecessary” according to his definition, then it is also unethical, especially considering the limited funding resources we have available at the moment.

It is perfectly legitimate for a society to assess how it distributes its resources, but in doing so the entire budget ought to be considered.

One may ask, for example, how Professor Kahn feels about resources spent on drones for the military, the Hubble telescope, unmanned trips to Mars, funding for theoretical physics, game theory, or the Arts.

Or, more to the point, one could ask for a more detailed justification of why society should spend its resources on philosophers and bioethicists?

Should society prioritize the support of bioethics over the development of a vaccine for Ebola or a cure for cancer, Alzheimer’s or Parkinson’s?

Which is one more crucial to our social welfare and which is more “unnecessary”?

Who will direct medical research?

Scientists must participate more in public life because social policies need to be decided on the basis of rational grounds and facts. These include important issues ranging from climate change, to the goals of the space program, to the protection of endangered species, to the use of embryonic stem cells or animals in biomedical research.

When scientifically inaccurate statements emanate from someone who has demonstrable influence on public policy decisions, scientists have a duty to speak up and correct the mistakes.

Animal research poses a legitimate moral dilemma. Decisions to pursue different lines of research that are perceived as controversial — be it research involving animals subjects or embryonic stem cells — cannot be assessed fairly without the active participation of scientists, physicians, patients and their families, because all are stakeholders in the work.

Unless these stakeholders get involved in such debates, we may find that their interests are not taken into account when the future direction of medical research is determined.

Dario Ringach

 

Paralyzed man walks again after olfactory cell transplant, thanks to animal research

Today, almost 30 years after Prof. Geoffrey Raisman first identified their potential to repair nerve damage in mice, the BBC reports that olfactory ensheathing cell transplantation has been successfully used to enable Darek Fidyka, who was paralyzed from the chest down in a knife attack in 2010, to walk again.

The paper reporting the transplant, which was carried out by surgeons in Poland and  led by Geoffrey Raisman of the UCL Institute of Neurology, is published today in the journal Cell Transplantation (5). The technique involves taking specialized cells known as olfactory ensheathing cells (OECs) from the patient’s own patient’s olfactory bulbs, and then grafting these cells at the site of injury, where they promote nerve cell growth to bridge the gap and restore function. An added advantage in using the patient’s own cells is that it avoids the problem of rejection by their immune system.

Speaking earlier today Geoffrey Raisman described the results as “more impressive than man walking on the moon”. He’s not to far wrong, this achievement shows what is possible for regenerative medicine, and is the result of decades of basic and translational research. Indeed, whereas only 12 people have  walked on the moon, this new technique has the potential to help many thousands of people to walk again here on earth.

2014 has been an extraordinary year of progress restoring function after spinal injury, in May we saw how epidural stimulation allowed 4 paralyzed men in the US to move their legs again, while scientists at Newcastle University in the UK used closed loop electrostimulation to restore voluntary movement in temporarily paralyzed monkey arms. These techniques, and now OEC transplantation, show that many cases of paralysis are potentially reversible. Not every technique will be appropriate for every patient, and it will take much additional research before they are widely available, but together they represent a huge advance.

Darek Fidyka learns to walk again following OEC transplantation. Image BBC News.

Darek Fidyka learns to walk again following OEC transplantation. Image BBC News.

In each case it is an advance that rests on many decades of careful research in both animals and in human subjects, in particular basic research that uncovered the role of specialized cells and provided scientists with the knowledge about organization and function of the brain and spinal cord that enabled these pioneering therapies to be developed.

In a post in 2012 I discussed how Geoffery Raisman’s research led to the successful testing of olfactory ensheathing cells in injured dogs, and I’m reposting that article here:

Paralysed dogs walk again thanks to nasal cell transplants…and Professor Raisman’s rats. (published 19 November 2012)

This morning the BBC News carried a report on a medical breakthrough – and it is not a term I use lightly – that has enormous implications for people who have been paralyzed following spinal cord injuries. A team at the University of Cambridge led by Professor Robin Franklin Department of Veterinary Medicine, along with colleagues at the MRC Centre for Regenerative Medicine in Edinburgh succeeded in restoring the ability to walk with their hind legs to dogs which had been paralyzed by spinal injury. To do this they removed a special type of cell called the olfactory ensheathing cell (OEC) from the nasal passageways of the dogs, grown them in culture until a sufficient number had been produced, and then transplanted them at the site of injury. Many of the dogs which received the transplant were subsequently able to walk with their hind legs if supported by a harness, and some even able to walk without being supported by a harness, whereas dogs which received a control injection did not recover the ability to move their hind legs.

This is a major medical advance, and the first time that cell transplantation has been demonstrated to reverse paralysis in a real-life situation where the injury involves a combination of damage to the nerve fibre and to surrounding tissues, and there is a significant delay between injury and treatment, and while the therapy did not completely restore function it marks a very significant step towards a therapy that can be evaluated in a human clinical trial. It also of course is a very promising therapy for dogs that have suffered spinal injuries, for example after being hit by a car, and as such is an excellent example of the One Health concept which seeks a closer integration of human and veterinary medicine.

As with many breakthroughs this one did not happen overnight, indeed it is the result of decades of research. The story really begins in 1985 when Professor Geoffrey Raisman at University College London (for a good overview of his work see the UCL spinal Repair Group homepage) was studying the unique ability of nerve fibres in the olfactory system to grow and make the connections with central nervous system – an ability that other adult nerve cells lack and which is probably retained in the olfactory system due to the importance of preserving the ability to smell despite exposure of nerve cells in the nasal passages to toxins in the environment (a good sense of smell being crucial to survival for many mammalian species). He found that in a part of the brain termed the olfactory bulb of mice and rats a specific type of glial cell, cells that act to support and regulate the activity of the nerve cells along which nerve impulses travel , were responsible for creating the pathway along which the olfactory nerve fibres could regenerate (1).

Studies in rats were key to unlocking the potential of olfactory ensheathing cells in repairing spinal injuries. Image courtesy of Understanding Animal Research

This discovery suggested that if these specialized olfactory ensheathing cells (OECs) were transplanted at the site of spinal cord injury they might promote the growth of a bridge of nerve cells that would reconnect the severed pathway and restore function. In a series of experiments in rats Professor Raisman and colleagues demonstrated that OEC transplantation could repair a variety of different types of spinal cord injury, in order to restore function, for example to improve the ability to breath and climb following spinal cord injury (2) and to restore the ability of rat paws to grasp in order to climb following lesion of the spinal nerve that runs from the spinal cord down through the arm (3). Other scientists provided additional key information, for example scientists at the University of New South Wales in Australia demonstrated that OECs could be isolated from the nasal mucosa as well as from the olfactory bulb (4), and that these can also repair spinal cord injuries, an important step since obtaining OECs from the nasal mucosa is far more straightforward and safer than harvesting them from the brain. These discoveries, and the refinement of OEC transplant techniques over the past 2 decades by scientists such as Prof. Raisman, paved the way for the “real life” veterinary study reported today. A human clinical trial of this technique cannot be far off, though it is worth noting Prof. Raisman’s words of caution to the BBC concerning what has been achieved and what is still to be done:

“This is not a cure for spinal cord injury in humans – that could still be a long way off. But this is the most encouraging advance for some years and is a significant step on the road towards it…This procedure has enabled an injured dog to step with its hind legs, but the much harder range of higher functions lost in spinal cord injury – hand function, bladder function, temperature regulation, for example – are yet more complicated and still a long way away.”

In this respect it is worth noting the other approaches to repairing spinal cord injury, for example using other glial cell known as astrocytes and the use of electrical stimulation have produced promising outcomes in animal studies and early human clinical trials. Indeed, a clinical study of electrostimulation that we discussed last year reported “improved autonomic function in bladder, sexual and thermoregulatory activity that has been of substantial benefit to the patient”. In the future these different approaches may be combined to maximize the benefit to the patient, but it is still far too early to say which techniques will best complement each other. One thing we can be sure of is that turning these very promising technologies into effective treatments – perhaps even cures – for paralysis will require further research, both in the lab and in the clinic.

Paul Browne

1) Raisman G. “Specialized neuroglial arrangement may explain the capacity of vomeronasal axons to reinnervate central neurons.” Neuroscience. 1985 Jan;14(1):237-54. PubMed: 3974880

2) Li Y, Decherchi P, Raisman G. Transplantation of olfactory ensheathing cells into spinal cord lesions restores breathing and climbing.” J Neurosci. 2003 Feb 1;23(3):727-31. 12574399

3) Ibrahim AG, Kirkwood PA, Raisman G, Li Y. “Restoration of hand function in a rat model of repair of brachial plexus injury.” Brain. 2009 May;132(Pt 5):1268-76. Epub 2009 Mar 13. PMID: 19286693

4) Lu J, Féron F, Mackay-Sim A, Waite PM. “Olfactory ensheathing cells promote locomotor recovery after delayed transplantation into transected spinal cord.” Brain. 2002 Jan;125(Pt 1):14-21. PMID: 11834589

5) Tabakow P et al. “Functional regeneration of supraspinal connections in a patient with transected spinal cord following transplantation of bulbar olfactory ensheathing cells with peripheral nerve bridging” Cell Transplantation, published online 20 November 2014 http://www.ingentaconnect.com/content/cog/ct/pre-prints/content-CT-1239_Tabakow_et_al

University of Wisconsin responds to dishonest petition attacking psychiatric research

What do you do if your university is the target of an aggressive publicity campaign that distorts and misrepresents the work of one of your most highly respected scientists? What do you do if hundreds of thousands of people sign a petition calling for a research project to be cancelled, even though the petition contains numerous errors of fact? What do you do if a media campaign, backed by several of the world’s largest animal rights groups threatens to undermine academic freedom and the research evaluation process at your University?

Do you ignore it? Do you give in? What do you do?

Infant rhesus monkeys playing in nursery. Wisconsin National Primate Research Center. @2014 University of Wisconsin Board of Regents

Infant rhesus monkeys playing in nursery. Wisconsin National Primate Research Center. @2014 University of Wisconsin Board of Regents

These are questions that the University of Wisconsin -Madison has faced in recent weeks as a change.org petition that seeks to end a research project led by Professor Ned Kalin, chair of the University’s Department of Psychiatry. The petition, backed by many animal rights groups across the world, including PeTA and HSUS, has gathered more than 300,000 signatures

So did UW-Madison give in? Did they simply ignore the petition?

No, they did something much better.

UW-Madison issued the response below rejecting the erroneous claims made by the author of the petition, Dr Ruth Decker, and defending Professor Kalin’s right to undertake important research. Just as importantly they defend the right of the scientific and medical experts at UW-Madison and the NIH – and not the misinformed mob – to decide which projects should be approved and funded.

We commend UW-Madison on taking this strong position in support of science.

Responding to Ruth Decker’s change.org petition

Since September, many people have taken interest in a University of Wisconsin–Madison study on the impact of early life stress on young rhesus monkeys. Thousands have added their names to a petition on the website change.org, calling for an end to the work, and we appreciate and share their concern for animals.

But we don’t appreciate the way petition’s author, Dr. Ruth Decker, misrepresents the research. By piling up mistakes, myths and exaggerations, and omitting important information, she asks well-meaning people to speak out with little understanding of the real science and the long, deliberative process through which it was approved.

This isn’t fair to the people who signed the petition, or to UW–Madison psychiatry professor Ned Kalin and the scientists involved in the work, or to the millions of people who suffer from mental illness for whom available treatment methods offer little relief.

The truth is of little concern to activists who wish to end animal research, no matter the benefit to humans and animals. We don’t share that sentiment. We prefer people make their judgments on animal research with a fuller understanding of the research — of both its costs and potential benefits.

So, if you have read the change.org petition, please also consider these corrections and additional information:

  • This is not a repeat of experiments UW–Madison psychology professor Harry Harlow conducted as many as five decades ago, some of which subjected animals to extreme stress and isolation. The methods for the modern work were selected specifically because they can reliably create mild to moderate symptoms of anxiety in the monkeys. They were chosen to minimize discomfort for the animals, and to minimize the number of animals required to provide researchers with answers to their questions.
  • There is no “solitary confinement.” The animals live in cages with other monkeys of their own age, a method of care called peer rearing. This method is often used when mothers reject their infant monkeys, which happens regularly in situations from nature to zoos to clinical nurseries with first-time mothers or following caesarean-section births. In a group setting, even veterinarians would have difficulty distinguishing the peer-reared animals from those that that were maternally reared.

The purpose of peer rearing is not to demonstrate that removing a monkey from its mother causes anxiety, a common misconception we have heard from people who have signed the petition.

Again: peer rearing was chosen because it is known to produce mild to moderate anxiety symptoms. With a group of animals predisposed to anxiety raised in a controlled setting, researchers can use state-of-the-art techniques to observe and measure even very subtle differences in brain chemistry and structure. Those chemical and anatomical differences may suggest new treatments — via nutrition, exercise, meditation, drugs or another approach — for people suffering from mental illness.

  • The animals in the study are not “terrorized,” and do not experience “relentless torture.” Most of their time is spent as a house pet would spend its days — grooming, sleeping, eating and playing with toys, puzzles and other animals.

On occasion, to assess the monkeys’ level of anxious temperament, they are observed under two anxiety-provoking conditions. The first involves the presence of an unknown person who briefly enters the room, but does not make eye contact with the monkey. The second involves the monkey being able to see a snake, which is enclosed in a covered Plexiglas container in the same room, but outside the monkey’s cage.

After each event, the animal’s brain activity is monitored by a non-invasive functional magnetic resonance scan, and blood samples are taken. The stress the monkeys experience is comparable to what an anxious human might feel when encountering a stranger or a snake or a nurse with a needle.

  • No one was “left out” of the review by UW–Madison oversight committees. Several university committees spent a great deal of time assessing Dr. Kalin’s anxiety research, and each committee found it to be acceptable and ethical. These were groups of researchers, veterinarians and public representatives tasked with considering animal research on ethical grounds, and with ensuring potentially beneficial research will subject the fewest animals to the least invasive measures.

As the petition notes, an animal rights group took allegations about the committee process to the U.S. Department of Agriculture. What the petition does not mention is that USDA conducted an investigation in August in response to that complaint. Inspectors found the complaint lacking merit, and the process to be entirely within compliance with federal regulations.

And, as with all animal research on campus, specially trained veterinarians will care for the monkeys involved and ensure that all the work is done in accordance with federal regulations enforced by the National Institutes of Health and the USDA.

The decision to study animal models to understand human psychiatric disorders is not made lightly. Roughly a quarter of the people in the United States, including children, suffer from mental illness. Their conditions subject them to immeasurable disability and dysfunction. And the worst outcome, suicide, is increasing and already among the leading causes of death in adolescents. To develop effective treatments that may alleviate the suffering of millions, it is necessary to understand the root cause of psychiatric illnesses.

In this case, the human suffering is so great that Kalin, the National Institutes of Health and UW–Madison’s review committees believe the potential benefit of the knowledge gained from this research justifies the use of an animal model.

More information on the anxiety and depression research is available at animalresearch.wisc.edu.

Related posts:

Child health benefits from studies of infant monkeys – Part 1

Harlow Dead, Bioethicists Outraged

Speaking of Research

To learn more about the role of animal research in advancing human and veterinary medicine, and the threat posed to this progress by the animal rights lobby, follow us on Facebook or Twitter.

Five Star review for Speaking of Research website

A few months after the Speaking of Research website got full marks in a recent review we’ve done it again. In Lab Animal Europe‘s Website of the Month, Speaking of Research got an overall score of five out of five and was considered ‘Excellent’ for Ease of Use, Content and Visual Impact.

Click to Enlarge

Click to Enlarge

It concludes:

All, in all, this is an excellent and informative website. [...] We highly recommend it.

A big thanks to Lab Animal Europe for the review and we’ll keep trying to add “more information, more updated news, and, actually, more of everything we loved about this website“.

Speaking of Research