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IDENTIFICATION AND QUANTIFICATION
OF DRUGS, METABOLITES,
DRUG METABOLIZING ENZYMES,
AND TRANSPORTERS
Concepts, Methods, and Translational Sciences
IDENTIFICATION AND
QUANTIFICATION
OF DRUGS,
METABOLITES, DRUG
METABOLIZING
ENZYMES, AND
TRANSPORTERS
Concepts, Methods, and
Translational Sciences

Edited by

SHUGUANG MA
SWAPAN K. CHOWDHURY
Elsevier
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 Contributors
Farah Al Qaraghuli Department of Pharma-
ceutical Sciences, School of Pharmacy and
Pharmaceutical Sciences, The State University
of New York at Buffalo, Buffalo, NY, United
States
Ravindra Varma Alluri Clinical Pharmacology
and Safety Sciences, R&D BioPharmaceuticals,
AstraZeneca, Cambridge, United Kingdom
Sophie M.A. Argon Department of Pharma-
ceutics, School of Pharmacy, University of
Washington, Seattle, WA, United States
Piyush Bajaj Drug Safety Research and Evalua-
tion, Takeda Pharmaceutical International Co.,
Cambridge, MA, United States
Tashinga E. Bapiro DMPK, Research and Early
Development, Oncology R&D, AstraZeneca,
Cambridge, United Kingdom
Abdul Basit Department of Pharmaceutics,
University of Washington, Seattle; Depart-
ment of Pharmaceutical Sciences, Washington
State University, Spokane, WA, United States
Andreas Brink Roche Pharma Research
and Early Development, Roche Innovation
Center Basel, F. Hoffmann-La Roche Ltd, Basel,
Switzerland
Tingting Cai Laboratory Testing Division,
WuXi AppTec, Nanjing, China
Jose Castro-Perez Agios Pharmaceuticals, Inc.,
Cambridge, MA, United States
Jae H. Chang Preclinical Development, ORIC
Pharmaceuticals, South San Francisco, CA,
United States
Eugene Chia-Te Chen Department of Drug
Metabolism and Pharmacokinetics, Genentech,
South San Francisco, CA, United States
Marie Croft Pharmaron ABS, Germantown,
MD, United States
xi
Liam Evans Hypha Discovery Ltd., Oxford-
shire, United Kingdom
Raymond Evers Department of Pharmacokinet-
ics, Pharmacodynamics and Drug Metabolism,
Merck & Co Inc., Kenilworth, NJ, United States
Robert S. Foti Pharmacokinetics, Pharmaco-
dynamics and Drug Metabolism, Merck
Research Laboratories, Boston, MA, United
States
Adrian J. Fretland DMPK, Research and Early
Development, Oncology R&D, AstraZeneca,
Waltham, MA, United States
Christopher Gemski Translational Research
Bioassay and Immunogenicity Group, Drug
Metabolism and Pharmacokinetic Department,
Takeda Pharmaceuticals International Co.,
Cambridge, MA, United States
Anima Ghosal Independent Consultant,
Piscataway, NJ, United States
Jia Hao Drug Metabolism, Gilead Sciences
Inc, Foster City, CA, United States
Satyajeet Haridas Translational Research Bio-
assay and Immunogenicity Group, Drug
Metabolism and Pharmacokinetic Department,
Takeda Pharmaceuticals International Co.,
Cambridge, MA, United States
Simon Hauri Roche Pharma Research and Early
Development, Roche Innovation Center Basel,
F. Hoffmann-La Roche Ltd, Basel, Switzerland
Nina Isoherranen Department of Pharma-
ceutics, University of Washington, Seattle,
WA, United States
Wenying Jian DMPK, Janssen R&D, Spring
House, PA, United States
Kevin Johnson Drug Metabolism and Pharma-
cokinetics, Genentech, South San Francisco,
CA, United States
xii Contributors
Barry Jones DMPK, Research and Early Devel-
opment, Oncology R&D, AstraZeneca, Cam-
bridge, United Kingdom
Robert S. Jones Drug Metabolism and Pharma-
cokinetics, Genentech, South San Francisco,
CA, United States
Jan Felix Joseph Freie Universitaet Berlin, Insti-
tute of Pharmacy—Pharmaceutical Analysis;
Freie Universitaet Berlin, Department of
Biology, Chemistry, Pharmacy, CoreFacility
BioSupraMol, Berlin, Germany
S. Cyrus Khojasteh Drug Metabolism and
Pharmacokinetics, Genentech, South San
Francisco, CA, United States
Yurong Lai Drug Metabolism, Gilead Sciences
Inc, Foster City, CA, United States
Hoa Le Drug Metabolism, Gilead Sciences,
Foster City, CA, United States
Xiaomin Liang Drug Metabolism, Gilead Sci-
ences Inc, Foster City, CA, United States
Liming Liu Product Development, Curon
Biopharmaceutical Ltd, Shanghai, People’s
Republic of China
Filipe Lopes Roche Pharma Research and
Early Development, Roche Innovation Center
Basel, F. Hoffmann-La Roche Ltd, Basel,
Switzerland
Justin Q. Ly Drug Metabolism and Pharmacok-
inetics, Genentech, South San Francisco, CA,
United States
Shuguang Ma Drug Metabolism and Pharma-
cokinetics, Genentech Inc., South San Francisco,
CA, United States
Roshini Markandu DMPK, Research and Early
Development, Oncology R&D, AstraZeneca,
Cambridge, United Kingdom
Rosalinde Masereeuw Division of Pharmacol-
ogy, Utrecht Institute for Pharmaceutical
Sciences, Utrecht, The Netherlands
J. Eric McDuffie Investigative & Mechanistic
Toxicology, Janssen Research & Development,
San Diego, CA, United States
Kaushik Mitra Department of Drug Metabo-
lism and Pharmacokinetics, Janssen Research
and Development, Springhouse, PA, United
States
Diana Montgomery Department of Pharma-
cokinetics, Pharmacodynamics and Drug
Metabolism, Merck & Co Inc., Kenilworth, NJ,
United States
Alexandra L. Orton DMPK, Research and Early
Development, Oncology R&D, AstraZeneca,
Cambridge, United Kingdom
Katie H. Owens Department of Pharmaceutics,
School of Pharmacy, University of Washing-
ton, Seattle, WA, United States
Axel P€ ahler Roche Pharma Research and
Early Development, Roche Innovation Center
Basel, F. Hoffmann-La Roche Ltd, Basel,
Switzerland
Maria Kristina Parr Freie Universitaet Berlin,
Institute of Pharmacy—Pharmaceutical Analy-
sis, Berlin, Germany
Shefali Patel DMPK, Janssen R&D, Spring
House, PA, United States
Ichiko D. Petrie Department of Pharma-
ceutics, School of Pharmacy, University of
Washington, Seattle, WA, United States
Richard Phipps Hypha Discovery Ltd., Oxford-
shire, United Kingdom
Chandra Prakash Agios Pharmaceuticals, Inc.,
Cambridge, MA, United States
Bhagwat Prasad Department of Pharmaceutics,
University of Washington, Seattle; Department
of Pharmaceutical Sciences, Washington State
University, Spokane, WA, United States
Isabelle Ragueneau-Majlessi Department of
Pharmaceutics, School of Pharmacy, Univer-
sity of Washington, Seattle, WA, United States
Venkatesh Pilla Reddy DMPK, Research and
Early Development, Oncology R&D; Depart-
ments of Modeling and Simulation, Early
Oncology Drug Metabolism and Pharma-
cokinetics, R&D Oncology, AstraZeneca,
Cambridge, United Kingdom

Ellen Riddle Drug Metabolism, Gilead Sciences
Inc, Foster City, CA, United States
Qian Ruan Pharmaceutical Candidate Charac-
terization, Bristol-Myers Squibb, Princeton,
NJ, United States
Simone Schadt Roche Pharma Research and
Early Development, Roche Innovation Center
Basel, F. Hoffmann-La Roche Ltd, Basel,
Switzerland
Dhaval K. Shah Department of Pharmaceutical
Sciences, School of Pharmacy and Pharma-
ceutical Sciences, The State University of New
York at Buffalo, Buffalo, NY, United States
Julia Shanu-Wilson Hypha Discovery Ltd.,
Oxfordshire, United Kingdom
Kelly MacLennan Staiger Drug Metabolism,
Gilead Sciences Inc, Foster City, CA, United States
Jonathan Steele Hypha Discovery Ltd., Oxford-
shire, United Kingdom
Manthena V.S. Varma Medicine Design,
Worldwide R&D, Pfizer Inc., Groton, CT,
United States
Matthew P. Wagoner Drug Safety Research
and Evaluation, Takeda Pharmaceutical Inter-
national Co., Cambridge, MA, United States
Naidong Weng DMPK, Janssen R&D, Spring
House, PA, United States
Stephen Wrigley Hypha Discovery
Oxfordshire, United Kingdom
Contributors xiii
Caisheng Wu School of Pharmaceutical Sci-
ences, Xiamen University, Xiamen, China
Graeme C. Young GlaxoSmithKline Research
and Development Ltd., David Jack Centre,
Ware, United Kingdom
Jingjing Yu Department of Pharmaceutics,
School of Pharmacy, University of Washing-
ton, Seattle, WA, United States
Lushan Yu Institute of Drug Metabolism and
Pharmaceutical Analysis, Zhejiang University,
Hangzhou, People’s Republic of China
Su Zeng Institute of Drug Metabolism and
Pharmaceutical Analysis, Zhejiang University,
Hangzhou, People’s Republic of China
Haeyoung Zhang Department of Pharma-
ceutics, University of Washington, Seattle,
WA, United States
Wanying Zhang Department of Pharma-
ceutical Sciences, School of Pharmacy and
Pharmaceutical Sciences, The State Univer-
sity of New York at Buffalo, Buffalo, NY,
United States
Andy Z.X. Zhu Department of Drug Metabo-
lism and Pharmacokinetics, Takeda Pharma-
ceuticals International Co., Cambridge, MA,
United States
Mingshe Zhu MassDefect Technologies, Prince-
ton, NJ, United States
Ltd.,
 Foreword
It is my great pleasure to write the fore-
word for this excellent book. The study of
drug metabolism and disposition is a mature
science, but still essential in drug discovery
and development. Indeed, a quick search of
PubMed, using “drug metabolism” as the
search term, came up with more than
18,000 hits. One of the earlier articles is by
Bernard Brodie, considered to be the founder
of modern pharmacology and a major con-
tributor to the study of drug metabolism.
His article—published in the Journal of Phar-
macy and Pharmacology in 1956—is titled
“Pathways of Drug Metabolism” and it is based
on a lecture at the University of London [1].
It describes his work over the decade and
some of it is based on collaborations with
other pioneers in the field such as Julius
Axelrod. One sentence still resonates very
much and it actually covers much of the ma-
terial described in this book:
Finally, it is thought that a detailed knowl-
edge of enzymes involved in drug “detoxifica-
tion” might help the medicinal chemist to
develop compounds of either high or low stabil-
ity in the body, whichever would be more de-
sirable in gaining a desired therapeutic result.
Drug metabolism sciences have advanced
tremendously since the publication of this ar-
ticle and this progress was to a large extent
enabled by advances in the availability of
biochemical reagents and bioanalytical tech-
niques, in particular mass spectrometry.
Both academic and industrial scientists have
xv
identified many breakthroughs that have
ultimately contributed to bringing drugs to
patients with an urgent need for better trea-
tments. It is very gratifying that the number
of drugs approved by the FDA is increasing
steadily with 38 NMEs (new molecular en-
tity) and 10 BLAs (biological license applica-
tion) approved by the US Food and Drug
Administration (FDA) in 2019 [2]. The level
of innovation is best illustrated by about half
of the approved drugs in 2019 having a
breakthrough designation. Drug metabolism
and pharmacokinetics (DMPK) scientists are
fully embedded in project teams in drug dis-
covery and work hand in hand with medici-
nal chemists on the identification of drugs
with superior properties. These scientists
have become very good at dialing out the
“known unknowns” such as metabolism by cy-
tochrome P450 enzymes. However, this has
actually resulted in having to deal with much
more complex drug disposition pathways in-
volving less well-studied drug metabolizing
enzymes and also more and more drug
transporters. This trend is also fueled by a
shift toward more and more drugs having
beyond the “rule of five” molecular proper-
ties [3]. Indeed, the average molecular
weight of drugs approved by the FDA in
2016 and 2017 was more than 500 Da and
the median clogP of drugs approved from
2008 to 2017 is now 3.3, in part driven by try-
ing, for example, to disrupt protein-protein
interactions. An additional consequence of
this shift in properties is that in vitro to
in vivo extrapolation of ADME properties
xvi
to predict the human pharmacokinetics has
become more complex and the same can be
said of predicting drug-drug interaction—
many of which now involve drug trans-
porters. If anything, the involvement of
DMPK scientists is now more important than
ever because of the pursuit of novel molecular
modalities in academia and in the pharma-
ceutical industry; a few that come to mind
are antibody-drug conjugates, protein de-
graders, and macrocyclic peptides. DMPK
scientists can help make drugs out of these
hard-to-drug modalities. Finally, the integra-
tion of this diverse array of in vitro and in vivo
data is enabled by computational modeling
and simulation. Physiologically based phar-
macokinetic (PBPK) modeling is a very pow-
erful tool to predict human pharmacokinetics
and study drug-drug interaction as well as
the pharmacokinetics in special populations
and infants. Pharmacokinetic/pharmaco-
dynamic modeling and its extension, quanti-
tative systems pharmacology, can help
translate preclinical findings to the clinic.
This book is comprised of many excellent
chapters written by experts in the field that
address some of the challenges highlighted
in the previous paragraph. The first section
focuses on “Techniques for identifying and
quantifying drugs and metabolites.” Chapters
1–3 introduce the readers to the latest ad-
vances in bioanalysis, in particular mass
spectrometry for the analysis of drugs, their
metabolites, and endogenous biomarkers. In
contrast to 20 years ago, high-resolution
mass spectrometry has now become routine
and it has had a great impact on the study
of biotransformation. Of course, mass spec-
trometry is frequently not sufficient to iden-
tify the definitive structure of a metabolite,
and hence Chapter 4 focuses on strategies
for generating metabolites and characteriza-
tion via NMR. Supercritical fluid chromatog-
raphy has become easier to interface and it
can greatly facilitate chiral separation; the
Foreword
latter topic is covered in Chapter 5. The last
chapter in the first section (Chapter 6)
focuses on accelerator mass spectrometry,
a powerful tool to study ADME and the
absolute bioavailability in humans.
The second section addresses “Drug me-
tabolizing enzymes, transporters and drug drug
interactions.” Cytochrome P450-mediated
and non-cytochrome P450-mediated metab-
olism is discussed in Chapters 7 and 8.
In vitro to in vivo prediction of drug-drug in-
teraction is described in Chapter 9 while
Chapter 10 specifically focuses on the role
of transporters in drug disposition and
drug-drug interaction, and Chapter 11 on
the clinical relevance of these drug-drug
interactions. Making predictions using PBPK
modeling relies on accurate knowledge of
physiologic constants and, most recently,
mass spectrometry has been used to deter-
mine the abundance of drug metabolizing
enzymes and transporters in various tissues.
This is addressed in Chapter 12. Finally,
Chapter 13 focuses on disease-drug interac-
tions mediated by therapeutic proteins such
as interleukins.
The third section focuses on “Strategy re-
lated to drug metabolism and safety.” Metabo-
lites in safety testing continues to be a
highly relevant area of research in drug dis-
covery and development and it is addressed
in Chapter 14. A close look at the (patent) lit-
erature indicates that finding drugs that bal-
ance potency and metabolic stability can still
be problematic, and therefore many com-
panies incorporate deuterium to enhance
metabolite stability and lower the dose—
see Chapter 15 for details. The focus on novel
chemical space and more molecular diversity
has introduced more chirality in molecules
and the impact of that on pharmacology, tox-
icology, and drug metabolism is described in
Chapter 16. Drug-induced liver injury and
new predictive models for renal injury are de-
scribed in Chapters 17 and 18, respectively.
 Foreword
Finally, Chapter 19 focuses on immuno-
genicity as a key component of antibody
development.
The fourth and last section is dedicated to
“Translational sciences.” The use of geneti-
cally modified rodents is explored further
in Chapter 20, while Chapter 21 speaks to
the use of CRISPR to advance in vitro ADME
models. In vitro to in vivo extrapolation of
hepatic and renal clearance is discussed in
Chapter 22. The breadth of our science is
nicely illustrated by Chapter 23 which de-
scribes the role of mathematical modeling
in translational sciences. Last, but by no
means least, Chapter 24 elegantly defines
ways to predict the human efficacious dose
using PK/PD modeling.
As is the case with many compilations, a
lot of effort has gone into assembling an
xvii
excellent set of chapters that describe the
state of the art in ADME sciences as it
relates to drug discovery and development.
The efforts by all authors, and in particular
the editors Shuguang Ma and Swapan
Chowdhury, are greatly appreciated. This
book will be used as a resource for many
years to come.
Cornelis E.C.A. Hop
References
[1] B.B. Brodie, Pathways of drug metabolism, J. Pharm.
Pharmacol. 8 (1) (1956) 1–17.
[2] A. Mullard, 2019 FDA drug approvals, Nat. Rev.
Drug Discov. 19 (2) (2020) 79–84.
[3] M.D. Shultz, Two decades under the influence of
the rule of five and the changing properties of ap-
proved oral drugs, J. Med. Chem. 62 (4) (2019)
1701–1714.
 Preface
Some 15 years ago, one of us (SKC) com-
piled the first edition of this book that
covered the most up-to-date information
previously available on the strategies,
methods, applications, and implications of
scientific data on the role of enzymes and
transporters in the disposition of pharma-
ceuticals. The book was a great success and
was widely used as a valuable resource by
scientists in both industry and academia.
Since then, a lot has changed in the field of
drug metabolism, including how recent
scientific advances are being utilized to dis-
cover and develop safer medicines. There-
fore, it has become apparent that a new
edition of the book is required to fully cap-
ture these profound changes, which involves
the implementation of newer technologies in
the discovery and development of medicines
to treat a wide range of maladies. With much
enthusiasm from the publisher, we collabo-
rated to assemble a comprehensive treatise
that would capture how the latest scientific
findings are having a fundamental impact
on the utilization of these novel advances
in drug research. This second edition is
completely updated and provides an over-
view of the last decade’s numerous improve-
ments in analytical technologies for the
detection and quantification of drugs, metab-
olites, and biomarkers. This new edition goes
beyond conventional LC-MS and features
all-new chapters, including: how to evaluate
drug absorption, distribution, metabolism,
xix
and excretion (ADME), the potential for he-
patic and renal toxicity, immunogenicity of
biotherapeutics, and translational tools for
predicting human dosage, safety, and effi-
cacy of small molecules and biologics.
This book is organized into four sections:
(1) techniques for identifying and quantify-
ing drugs and metabolites, (2) drug metabo-
lism enzymes, transporters, and drug-drug
interactions, (3) strategies related to drug
metabolism and safety, and (4) translatio-
nal sciences. The book contains 24 chapters
covering the most recent, novel scientific
breakthroughs and how they are utilized to
develop medicines in the modern era. It is
our sincere hope that this material will serve
as an important tool and desk reference for
pharmacologists, toxicologists, clinical scien-
tists, and students interested in the fields
of pharmacology, biochemistry, and drug
metabolism.
Finally, we wish to acknowledge the con-
tributions of the many scholars who partici-
pated in and contributed to this book from
conception and passion into print. We also
want to extend our gratitude to the contribu-
tions of the editorial staff and production
manager at Elsevier, and last but not least,
the families of the editors for their encour-
agement, love, and support.
Shuguang Ma
Swapan K. Chowdhury
 C H A P T E R

1
Bioanalysis of small and large
molecule drugs, metabolites, and
biomarkers by LC-MS
Naidong Weng, Shefali Patel, Wenying Jian
DMPK, Janssen R&D, Spring House, PA, United States

1 Introduction

Bioanalysis, often shortened to BA, is a subdiscipline within pharmaceutical research and

development (R&D). Contemporary bioanalysis quantitatively analyzes very low quantity
but highly variable levels (pg/mL-μg/mL) of drug candidates, their metabolites, endogenous
biomarkers, etc. in extremely complicated biological matrices such as plasma, blood, urine,
and tissues which are harvested from different types of animal species (rodents, dogs,
nonhuman primates, etc.) and humans [1]. Bioanalysis supports discovery, nonclinical
(tox), and clinical studies (Fig. 1). Fig. 1 shows typical studies an integrated bioanalytical func-
tion would support.
Bioanalytical data are used for calculating pharmacokinetic parameters such as bioavail-
ability, bioequivalence, drug and metabolites exposure, clearance, their distribution into
various body organs, correlation of pharmacokinetics (PK) effects and pharmacodynamics
(PD) changes, etc. Thus, bioanalysis plays a pivotal role in moving drug candidates from early
discovery all the way to regulatory filing and postmarket surveillance in the entire drug dis-
covery and development process. In today’s dynamic drug discovery and development
environment, bioanalytical scientists not only provide pivotal data but also actively engage
in project/program go/no-go discussions, along with colleagues from other functional areas.
While the most essential element of bioanalysis is to use analytical chemistry knowledge and
state-of-the-art instruments to provide reliable and accurate measurement, knowledge from
relevant disciplines such as biotransformation, pharmacokinetics, biology, pharmacology,
etc. is invaluable for ensuring appropriate conduct of bioanalysis.

Identification and Quantification of Drugs, Metabolites, Drug Metabolizing 3

Enzymes, and Transporters # 2020 Elsevier B.V. All rights reserved.
https://doi.org/10.1016/B978-0-12-820018-6.00001-6
4 1 Bioanalysis of small and large molecule drugs, metabolites, and biomarkers

Discovery Preclinical Clinical

In vitro
Plasma protein binding
Transporter
Inhibition-induction
Metabolic stability
Plasma-blood distribution
In vivo
Salt form selection
Formulation
Dose range finding
Tissue distribution
Short term (2wk, 4 wk) TOX SAD, MAD
Long term (3mts +) TOX Metabolite assessment (MIST)
Reproductive TOX Food effect
Carcinoma studies Drug-drug interaction
Micronucleus studies Comparator study
Animal ADME Human ADME
Bioavailability (IV/ORAL ) Population PK
Special population study (renal
impaired, pediatric, etc.)
Adaptive design clinical trial
Bioequivalence

Drug-like? Known liabilities? Superior efficacy?

FIG. 1 Exemplary bioanalytical support in drug discovery and development. TOX, toxicology; SAD, single ascend-
ing dose study; MAD, multiple ascending dose study; ADME, absorption, distribution, metabolism, and elimination;
IV, intravenous.

In this book chapter, we try to provide a brief overview of contemporary bioanalysis using
the LC-MS platform. It is an impossible task to provide a detailed and comprehensive review
of LC-MS bioanalysis in a book chapter. The case studies and literature are no doubt incom-
plete and biased toward our own experiences and publications. Interested readers are
referred to the excellent bioanalysis handbook by Li et al. for a more comprehensive overview
of this discipline [1]. Nevertheless, we hope the readers can appreciate the complexity and
dynamics of modern LC-MS-based bioanalysis for small and large molecule drugs, metabo-
lites, and biomarkers.

2 Complexity of contemporary bioanalysis

Bioanalytical support is required for important decision-making for all types of studies,
from discovery (non-GLP), to development (GLP), and to clinical (GCP) studies. Yet there
are many unique and complicated attributes of cost, quality, and timely delivery at each of
the abovementioned stages (or substage within each stage). For bioanalysis, the quality
and integrity of the bioanalytical data are ultimately the most important attributes. The right
scientific and compliance vigor must be applied to each study. The current regulatory land-
scape for regulated bioanalysis is highly complicated, with guidance from multiple regional
health authorities [2–6]. Since guidance from different regions are not totally harmonized, and
compounded by individual interpretation of different inspectors, it is still quite a challenge to
fully understand and execute the right level of compliance that can be acceptable in the global
filing. Efforts are currently being made to harmonize the guidelines into one single global
guideline ICH-M10 [7].
While timely delivery of bioanalytical data to support project decisions is a must-do item to
meet the ever-tightening drug discovery and development timelines, cost is another attribute
that should not be overlooked. The cost of bioanalysis activities should be carefully managed
to ensure that it stays within the predetermined budget. On the other side, the application of a

I. Techniques for identifying and quantifying drugs and metabolites

 2 Complexity of contemporary bioanalysis 5
tiered approach, which typically consists of three tiers of assay qualification—screening as-
say, qualified assay, and validated assay with the increased levels of validation parameters—
can be used with a balance of scientific vigor and cost [8]. The European Bioanalytical Forum
(EBF) recommends exercising this approach for “nonregulated” nonclinical bioanalysis in
drug development and using “fit-for-purpose” elements in metabolite quantitation for
establishing safety coverage (MIST); urine bioanalysis; and tissue bioanalysis [9, 10]. Of
course, the actual implementation of which tier to use depends on each individual study.
For example, for urine bioanalysis, while a qualified assay could be used for most clinical
studies for understanding the urinary excretion of a drug candidate, validated assays should
be applied if renal clearance is the main route of elimination (PK end point) and/or the drug
target action is at the kidney.
There is an expansion of bioanalysis scope over the past decades. In the early days,
bioanalysis focused on supporting small molecule PK and bioequivalence (BE) from standard
formulations such as tablets and capsules. Analysis of metabolites and biomarkers rarely
occurred. Currently, PK and BE for both small and large molecules, as well as many hybrid
forms of large and small molecules such as antibody drug conjugate (ADC), are supported
by bioanalysis [11, 12]. Even for small molecules, advancement in formulation presents new
challenges for bioanalysis. For example, liposomes are widely applied in the pharmaceutical
industry due to their unique capabilities such as encapsulating and protecting the therapeutic
analytes from degradation, controlling the release rate, facilitating on-target delivery, and
reducing toxicity for drugs [13, 14]. For liposomal drug product development, validated
bioanalytical methods to determine the concentration of the encapsulated and nonencapsulated
forms (both the protein-free and protein-bound) of the active substance in biological samples
should be employed. However, establishing such bioanalytical assays can be quite challenging
due to the potential rapture of the liposome during sample collection, shipping, storage, and
analysis, which can artificially elevate the nonencapsulated concentrations [15, 16].
Peptide and protein drugs have evolved in recent years into mainstream therapeutics,
representing a significant portion of the pharmaceutical market [17]. Peptides and proteins
exhibit highly diverse structures and broad biological activities as hormones, neurotransmit-
ters, structural proteins, and metabolic modulators and therefore have a significant role as
both therapeutics and biomarkers. Unspecific proteolysis is a major elimination pathway
for peptides and proteins instead of the oxidative hepatic metabolism that is typical for most
small molecule drugs [18]. In addition to the typical PK support, bioanalysis has been actively
engaged in newly developed areas such as PKPD correlation, biomarker research in target
engagement/tissue distribution, simultaneous quantitation and metabolite identification
for small molecules and biologics, and antidrug antibody (ADA), etc., for many of which both
science and regulatory requirements are still evolving.
Historically, bioanalysis support can be categorized into two distinct areas—liquid chro-
matography for small molecules, usually chemically synthesized, and ligand binding assay
for large molecules, such as those which monoclonal antibodies typically produce by cell
culture. With the development of modern instrumentation, especially mass spectrometers,
measurement of large molecules by liquid chromatography in conjunction with a mass spec-
trometer (LC-MS) has become a reality. There is also a need to use LC-MS to investigate the
in vivo fate of some of the new modalities such as a half-life extended peptide constructed
by conjugating or fusing an otherwise short-lived peptide with an antibody or Fc to exten-
sively extend its in vivo half-life through decreased clearance and increased stability [19].

I. Techniques for identifying and quantifying drugs and metabolites

6 1 Bioanalysis of small and large molecule drugs, metabolites, and biomarkers

LC-MS has also been increasingly used for discovering and measuring endogenous protein or
peptide biomarkers [20, 21].

3 Bioanalytical requirements for supporting discovery, nonclinical, and clinical

studies

Let us take a further look at bioanalytical requirements for supporting discovery,

nonclinical development, and clinical studies using LC-MS methods. These three stages
should not be viewed as three separate and consecutive ones since each can extend well into
the next stage, in particular between nonclinical development and clinical phases. Many of the
longer-term toxicology studies are running in parallel with the clinical studies. Discovery
bioanalytical support is performed under non-GLP conditions. Generic LC-MS methods using
gradient mobile phase elution and protein precipitation sample extraction are typically used to
analyze the drug candidates in plasma and tissues. The results are used to rank the drug can-
didates as well as to obtain other important information such as tissue distribution and basic
pharmacokinetic parameters, for example, Cmax, Tmax, AUC, T1/2, and clearance. Usually an
internal bioanalysis/PK guideline is used for the conduct of this type of study. Some level of
method verification such as accuracy, precision, and critical stability is performed before the
sample analysis. Run acceptance criteria are usually a little bit wider than those used in GLP
studies. Even though discovery bioanalysis does not follow strict GLP rules, the data generated
in the discovery stage are still pivotal for compound selection, and therefore many companies
institute some levels of compliance to ensure data integrity. Nonclinical bioanalytical support
in development is under GLP regulations where the data generated should withstand rigorous
regulatory scrutiny [2, 3]. For each method, vigorous method development and validation is
performed as per regulatory guidance and internal Standard Operation Procedures (SOPs),
even though method validation itself is non-GLP. Any deviation during the sample analysis,
which follows the GLP principles, should be thoroughly investigated, documented, and jus-
tified. Once the candidate moves into the clinical stage, automation and other means of im-
proving the throughput of sample analysis become more relevant. The same clinical
bioanalytical method can be used by multiple bioanalytical chemists within or even among
different organizations to meet the demand for analyzing a large number of samples. At the
clinical stage, especially for studies in first in human (FIH), a bioanalytical method with better
sensitivity than those in nonclinical studies may be required. Extensive method optimization
for both sample preparation and LC-MS conditions to maximize recovery and minimize matrix
effects is often pursued.

4 Current regulatory landscape for bioanalysis

Both nonclinical development and clinical bioanalytical support are required to follow in-
ternal SOPs and regulatory recommendations. Dozens of SOPs are usually used to address
many aspects of bioanalytical activities ranging from instrument qualification, maintenance,
and calibration, to bioanalytical method validation, sample storage, analysis and destruction,
to data management and archiving, etc. The goal of these SOPs is to ensure the highest data

I. Techniques for identifying and quantifying drugs and metabolites

 5 General considerations for bioanalysis for sample collection
TABLE 1 Bioanalytical full validation, partial validation and cross validation [2].
Full validation
Used for measuring analyte
concentrations in biological samples.
A full validation of a bioanalytical
method should be performed when
establishing a bioanalytical method
for the quantification of an analyte in
clinical and in pivotal nonclinical
studies
Developing and validating an assay
for pivotal regulatory submission
(IND or NDA)
Implementing an analytical method
that is reported in the literature
Partial validation
Modifications to a fully validated
analytical method may be evaluated
by partial validation. Partial
validation can range from as little as
one accuracy and precision
determination to a nearly full
validation. The items in a partial
validation are determined according
to the extent and nature of the
changes made to the method
Analytical site change using same
method (i.e., bioanalytical method
transfers between
laboratories)
A change in sample processing
procedures
7
Cross validation
Where data are obtained from
different methods within or across
studies, or when data are obtained
within a study from different
laboratories applying the same
method, comparison of those data is
needed, and a cross validation of the
applied analytical methods should
be carried out
Data are obtained from different
fully validated methods within a
study
Data are obtained within a study
from different laboratories with the
same bioanalytical method

integrity which can pass the regulatory scrutiny. These SOPs are usually drafted based on spe-
cific regulations and the regulatory guidance from the Food and Drug Administration (FDA)
and other international regulatory agencies, such as the European Medicines Agency (EMA),
and other federal/state requirements, as well as policies at each institute. One of the most im-
portant regulatory guidelines is the US FDA guidance on bioanalytical method validation [2],
which provides a general guideline on establishing important parameters, some of which are
specificity/selectivity, sensitivity, linearity ranges from a lower limit of quantitation (LLOQ) to
an upper limit of quantitation (ULOQ), accuracy, precision, stability, matrix effects, carryover,
recovery, dilution integrity, incurred sample reanalysis (ISR), etc. The method should also
demonstrate reproducibility and accuracy for incurred samples and its suitability for its
intended use. However, it is up to each institute to formulate its own SOPs based on this general
guidance. Typically, method validations can be categorized into full, partial, and cross valida-
tions (Table 1). Most of the validations are conducted in the form of full validation, whereas the
partial or cross validation can be used when a full validation is not required, as shown in the
examples in Table 1.

5 General considerations for bioanalysis for sample collection

During the project discussion, it is important to understand the objective of the study so
that important parameters such as matrix type, sample volume, ways of sampling (regular
sampling or microsampling), analytes to be measured (parent or parent plus metabolites),
anticoagulant selection, condition of centrifugation for harvesting plasma, sample storage
container, shipping condition and instruction, sample storage condition (
20°C vs.

70°C), etc. can be provided to the project team. While during the early stage of drug

I. Techniques for identifying and quantifying drugs and metabolites

8 1 Bioanalysis of small and large molecule drugs, metabolites, and biomarkers

discovery/development it is not always possible to conduct the full spectrum of a stability

test, it is, however, always good practice to evaluate whether there is potential instability
of a metabolite that can impact the accurate quantitation of the parent analyte and/or the me-
tabolites. Detailed PK or TK (toxicokinetic) sample collection information, including labeling,
will be entered into the lab manual or study design. The following is just one typical example
in a lab manual supporting a Phase 1 clinical study. It includes three parts of the instruction
(material and labeling; preparation of PK samples; and shipment of PK samples). As one can
see from this example, an extremely detailed instruction is needed to ensure successful con-
duct of bioanalysis.
Materials and labeling:
• Blood must be collected in a glass or plastic K2EDTA containing blood collection tubes
(e.g., Vacutainer).
• No tubes with separation gel should be used. The resulting plasma samples must be stored
in polypropylene storage tubes with polypropylene or polyethylene caps.
• All tubes and containers will be labeled with preprinted labels. The preprinted information
will include the study number, participant identification number, treatment or treatment
period, scheduled sampling day and time as stipulated in the flow chart, and the analyte
name if applicable. No other information will be written on the labels. Labels should be
attached to the storage tubes at least 12 h before being frozen to ensure proper adherence.
• Labels should be applied to the sample tubes as follows:
• Apply labels to the sample tubes so that they do not overlap and obscure any
information. If possible, expose an area between the two ends of the label to allow
viewing of the contents of the tube.
• Do not alter the orientation of the label on the sample tube.
• Apply labels to all tubes in the same manner.

Preparation of pharmacokinetic samples:

• Collect 4 mL of blood into the appropriate K2EDTA-containing collection tube (e.g.,
Vacutainer) at each time point.
• Record the exact date and time of sampling.
• Before processing, gently invert the tubes 8–10 times to afford mixing; blood samples must
be kept on melting ice at all times during processing.
• Centrifuge blood samples within 1 h of collection in a centrifuge at 1300g for 10 min at 4°C,
to yield approximately 1.5–2 mL of plasma from each 4-mL whole blood sample. Plasma
samples must be kept on melting ice at all times during processing.
• Transfer plasma immediately to a prelabeled polypropylene tube. Plasma samples must be
kept on melting ice at all times until storage in a freezer.
• Store plasma samples in an upright position in a freezer, at a set temperature at
20°C until
transfer to the bioanalytical facility.
• The time between blood collection and freezing the plasma will not exceed 2 h.
• Ship samples according to the instructions provided. Ship specimens to the bioanalytical
facility, sorted by participant, sample collection date, and time.
• Questions regarding handling the plasma pharmacokinetic specimens should be
addressed to the contact person for the sponsor.

I. Techniques for identifying and quantifying drugs and metabolites

Another random document with
no related content on Scribd:
The Project Gutenberg eBook of The conquest of
cancer
This ebook is for the use of anyone anywhere in the United States
and most other parts of the world at no cost and with almost no
restrictions whatsoever. You may copy it, give it away or re-use it
under the terms of the Project Gutenberg License included with this
ebook or online at www.gutenberg.org. If you are not located in the
United States, you will have to check the laws of the country where
you are located before using this eBook.

Title: The conquest of cancer

Author: H. W. S. Wright

Author of introduction, etc.: F. G. Crookshank

Release date: October 25, 2023 [eBook #71960]

Language: English

Original publication: London: Kegan Paul, Trench, Trubner & Co,

1925

Credits: Tim Lindell, Donald Cummings and the Online Distributed

Proofreading Team at https://www.pgdp.net (This book was
produced from images made available by the HathiTrust
Digital Library.)

*** START OF THE PROJECT GUTENBERG EBOOK THE

CONQUEST OF CANCER ***
THE CONQUEST OF CANCER
TO-DAY AND TO-MORROW
A List of the Contents of
this Series will be found
at the end of this volume
 THE
CONQUEST OF CANCER
BY

H. W. S. WRIGHT, M.S., F.R.C.S.

With an Introduction by

F. G. CROOKSHANK, M.D., F.R.C.P.

“Malum immedicabile cancer.” (Ovid, Met. x, 127)

London
KEGAN PAUL, TRENCH, TRUBNER & CO., LTD.
New York: E. P. DUTTON & CO.
1925
 Printed in Great Britain by
F. Robinson & Co., at The Library Press, Lowestoft
 THE CONQUEST OF CANCER

INTRODUCTION
The phrase “Conquest of Cancer”, though perhaps emotive rather
than scientific, nevertheless implies the existence of a very real and
important problem. And this problem, it may be confidently affirmed,
is one that will never be solved, in action, by the efforts of the
medical profession alone. Whatever be the future, and as yet
reserved, revelations of Science, and whatever the further
developments of Art, cancer will not cease to exact its toll unless
medical science and art obtain the intelligent co-operation of an
instructed public. It is for this reason that it has been thought useful
to place before the public this little book, written by a practical
surgeon who has given special attention to the problems of the
laboratory. The book itself, which not only states in simple language
the essential points that should be comprehended by the public, but
puts forward a plan for concerted action, is based upon one of a
series of University Extension lectures given during the winter of
1922–23, at the Shantung Christian University, Tsinan, China, where
Mr Wright is actively engaged in the Surgical Department of the
School of Medicine.

The task of prefacing this essay by some words of introduction has

devolved upon the present writer, not because he either has, or
desires to present, any claim to speak with special authority
concerning Cancer, but by reason of a close personal and
professional friendship that has led him to appreciate very warmly
the knowledge, the sincerity, and the disinterestedness that
characterize Mr Wright’s thought and work. And he is confident that
we may accept what has been said about Cancer at Shantung as an
honest and candid attempt to instruct and to construct, in
detachment from the pribbles and prabbles that have sometimes
confused discussion nearer home.
Now, although the public has the undoubted right to demand
information on this subject, and although, as has been suggested,
without admission of the public to the arena of discussion little can
be done to diminish the present mortality from Cancer, yet is there
real difficulty in communicating knowledge, without engendering
unnecessary fear and alarm and sending the hypochondriac to those
quacks and charlatans who diagnose non-existent disease in order
that they may reap reward by announcing its cure.
Some weaker minds there will always be: so, whenever attention
is directed towards some public danger, there are those who adopt
the possible contingency as a peg on which to hang some ragged
vestment of distracted emotion or thought. Thirty years ago, the
insane feared the telephone: during the Boer War, many thought that
the “scouts were after them”; now-a-days lunatics babble of
persecution by wireless, by Bolsheviks, or even by psycho-analysts.
So, in Victorian times, the malades imaginaires who then thronged
consulting rooms spoke with bated breath of Bright’s disease: to-day,
the hysterical secretly hope to hear the blessed word “Colitis”, and
the hypochondriac as secretly dread the verdict of “Cancer”!
The task of the medical profession is to enlighten the laymen, that
their help may be enlisted, and yet to avoid alike exaggeration and
smooth sayings, false hopes and false fears. Macaulay, in a familiar
passage, once said that there is nothing more ridiculous than the
British public in one of its periodical fits of morality. At present, the
British Public is less concerned than formerly with questions of
morality, but is very much concerned with questions of health.
Perhaps it is not so much health that is sought and desired as
absence of pain and avoidance of death—which is not quite the
same thing. But, though there is nothing intrinsically ridiculous in
seeking the “advancement of morality” or the “conquest of disease”,
the one, no less than the other, may be pursued in a ridiculous and
dangerous manner.
 The adoption of ill-conceived measures, designed to improve
morals or to abolish disease, may, and often does entail
consequences that are even less desirable than the evils it is hoped
to combat. While the prohibition of the consumption or sale of
alcoholic drinks may diminish certain ills, it has yet to be shewn that
the casting out of devils in the name of Beelzebub may not be
followed by possession with others yet more violent. A few years ago
we were adjured to boil all milk, lest we became poisoned by certain
microbes: we are now told that, if all milk be boiled, we are as if
deprived of vitamines, and must suffer accordingly. Instances might
be multiplied; but it should be obvious that moral and physical health
must be considered, not as physical objects, but as relations, or
states of equilibrium. Like all states of adjustment or equilibrium, they
are the result of accommodation: of poise and counterpoise. They
are not always and everywhere to be secured by the throwing of a
certain weight into one or other scalepan, or by the cutting-off so
many inches from the table-leg that seems the longest. So much, at
least, should be recognised by a seriously disturbed public told by
the daily press that so many more people than formerly now die of
cancer; that science has not yet discovered the “cause of cancer”;
but that all may be well if only we live on Nebuchadnezzar food
washed down by paraffin.
Mr Wright’s essay, combining as it does a well-balanced and
sufficient statement of what is known, with the outline of a
constructive proposition that merits careful consideration, and at
least indicates to the public the kind of way in which relative safety
may be obtained under present conditions, seems one that is
eminently suitable for what may be called general reading. The
problem is fairly and lucidly presented: the resources of surgery are
quietly and reasonably demonstrated: and the advantages are
shown of exhibiting that kind of prudence which leads the business
man to seek auditing of his accounts and the sportsman to enquire
how his score stands. But some words may perhaps be added from
the standpoint of one who is a physician, and no surgeon.
 Cancer is a class name given to certain kinds of growths,
otherwise spoken of as tumours (or swellings) and ulcers, which are,
as we say, characterised by malignancy. A growth, tumour, or ulcer
which is not malignant is not called a cancer. By malignancy we
mean a tendency to spread, by local and direct extension (as
spreads a fire), or by convection, as when sparks fly from a
locomotive to a haystack. Malignant tumours or ulcers tend to recur
when removed, and, in the long run, to destroy life.
These general features are associated with certain microscopical
characters found in the tumours or ulcers, so that the nature of any
growth—whether malignant or otherwise—can be sometimes
determined by the surgeon or physician, and sometimes by the
pathologist or microscopist alone, but, as a rule, is most certainly
settled by the physician or surgeon acting in conjunction with the
microscopist. Yet, and this is important, not every cancer does
actually destroy life. Surgeons of the greatest experience, such as
the late Sir Alfred Pearce-Gould, have affirmed that undoubted
cancers do occasionally undergo spontaneous cure, or at least
arrest of growth, even in the absence of any treatment. Again, if
excision is practised early, and sufficiently extensively, recurrence
does not happen, in a certain proportion of cases. Finally, pain is no
necessary or inevitable concomitant of cancer. In many cases pain is
absent, or almost so; death may be due to mechanical
consequences entailed by the growth rather than to destruction of
any vital or sensitive part.
Now, medical men are in the habit of splitting up the group or class
of malignant growths (or “cancers”) into two subsidiary groups or
classes. One of these is named Sarcoma; the other Carcinoma.
Sarcoma is the name given to a group of malignant growths taking
origin in the structures and tissues developed from the “middle layer”
of the embryo: the growths themselves—sarcomata—partake the
nature of the tissues formed from this middle layer. The other group,
of carcinomata, consists of growths taking origin in, and partaking
the nature of one or other of the two remaining embryonic layers and
the structures developed from them.
These two layers form respectively:
 (1) The skin and related structures, and
(2) The lining of the tube passing through the body; its backwaters,
out-growths and appendages.
It is these two layers which, as Mr Wright so aptly remarks, are in
direct contact with the outer world. Now, while the carcinomata
(which constitute the class of cancers chiefly discussed in this book)
in general affect people who have passed the midpoint of life—those
for whom, as Rabelais says, it is midi passé—the sarcomata, which
are less common than the carcinomata, are rather more frequently,
yet not exclusively, found in young people; in those indeed, who
have not reached life’s apogee. It is important that these facts should
be borne in mind, for generalisations founded upon the study of
carcinomata alone cannot be necessarily true in respect of all
Cancer, unless the use of the term cancer be restricted to the class
technically known as carcinoma. To say that Cancer can be
prevented if constipation is avoided is clearly misleading, when we
remember that quite young children, nay, infants, may be the subject
of sarcoma; unless of course we define cancer, as some would do,
as the kind of growth that, ex hypothesi, is prevented when
constipation is avoided. It is confusion of this sort, bred by slovenly
expression out of loose thinking, that is in great part responsible for
the present bewilderment of the public.
Another fertile source of confusion is the obscurity that attends
both the popular and the professional use of the words “cause”,
“causation”, and the like. The public demands that “the” cause of
cancer be discovered, and is prepared to pay generously that this
discovery be made. Unfortunately neither the public, nor men of
science, care overmuch to discuss what they mean by cause and
causation. This is no place in which to trench upon a province
unsuccessfully explored by Locke, by Hume, and by Kant. Yet it is of
vital importance that all doctors, scientists, and laymen should
recognise two different uses of these words.
When we speak about “the” cause of a “disease”, in a generalised
or conceptual sense, as when we say that Koch’s bacillus is “the
cause of tuberculosis”, we are really defining our concept of the
disease in terms of one correlative. We are saying that tuberculosis
is a disease in which Koch’s bacillus is invariably present. A circulus
in definiendo is only just escaped because we happen to know that,
if Koch’s bacillus is injected into certain animals, the “disease” as we
say, develops. Koch’s bacillus is the one constant correlative found
in all cases of the kind that we agree to call tuberculous, by reason
of certain clinical and pathological signs that we find. Possibly even
this statement is not to be taken as absolutely true; though it
represents what we find it convenient to say. But, when we thus
declare Koch’s bacillus to be “the” cause of tuberculosis, we have by
no means exhausted the study of all the correlations that may be
called causal in respect of particular cases. Of ten cases of
tuberculosis, each one exhibiting Koch’s bacillus, we may say that
for each particular case “the” cause of the illness is different.
Thus:
A. is tuberculous because he was gassed in France;
B. is tuberculous because he was infected by his sick wife;
C. is tuberculous because he drank tuberculous milk;
D. is tuberculous because he worked in an ill-ventilated factory;
E. because he was exposed to wet and cold; and
F. because he drank and was dirty.
The difference between a medical cause in the generalised sense,
(where cause means a defining correlative for a concept), and a
medical cause in the particular sense (when we seek to find out or
state the antecedent without which this man would not be as he is
here and now) is one of enormous importance, and one that should
be constantly borne in mind when discussion is commenced. It is
true that it involves the oldest of logical and metaphysical problems
in respect of scientific thought—the question of universals and
particulars; but that does not make it any the more easily shirked. Its
relevance to the question of cancer is this: that the proof of the
production of cancer in men or in animals under one set of
circumstances does not warrant us in saying that that set of
circumstances as known to us involves all the factors without which
cancer cannot occur. And, even if research work demonstrated that,
in every case now called cancer, some parasite or growth-form,
some irritating factor that can be isolated, does actually obtain,
unless it could be shewn that this parasite or factor is never found
except where there is cancer as we now define it, we should have to
proceed to investigate why and how cancer does not always occur
when this factor is present. Just so are we at present seeking to
explain why and how, of so many persons exposed to infection by
Koch’s bacillus, only certain ones do become diseased. If we find
that only those persons who possess a character that we may call
“X” become infected, we shall then have to say that, not Koch’s
bacillus, but the character “X” is “the” cause of tuberculosis. It is thus
that science progresses: not by making the absolute and positive
discoveries that the public is taught to expect, but by arranging and
rearranging our experiential knowledge, as such grows, in terms of
so-called laws and generalisations, that are found progressively
convenient. But such laws and generalisations are not necessarily
the one more “true” than the other, except in relation to the
knowledge that they summarize. If such considerations as these
were more frequently borne in mind, there would be less
unconscious deception, less disappointment, and greater economy
in work and thought.
Explanations of the causation of cancer have been sought in many
directions; and three chief theories have been set out. The most
important, and the most interesting from the point of view of the
practising physician, is that which considers cancer as provoked by
long continued irritation under certain circumstances. This doctrine
seems more “true” in respect of the Carcinomata—the cancers of the
adult and the old, and of tissues in contact with the extra-personal
world—than it is in respect of the Sarcomata—the cancers of the
young, and of those inner parts not exposed to irritation by contact
with the world. Yet sarcomata in real life do often seem to follow
injury, and the tissues in which they form may be obnoxious to
injurious influences of which we know nothing.
Another view is that cancer may be due to a parasite of some kind
or another. Certainly, so far as some lower animals are concerned,
this is true, for certain rat and mice cancers are now known definitely
to be associated with parasites. But then we may say, and properly,
that in such cases the parasites are merely acting as do other
irritants, and are not “specific” causes of cancer.
The third doctrine, or set of doctrines, regards cancers as arising
when parts of the body (or rather, elements in the tissues of certain
parts) no longer act in due subordination to the needs of the whole
organism, but comport themselves “anti-socially”: developing
irregularly; propagating themselves illegitimately; and so becoming
parasitic to the commonwealth of the body. Those who hold this will
admit that, in many cases, this revolutionary tendency is one
provoked by irritation and the like: that sometimes it is a mere
manifestation of irregular decay; and that, when it occurs in young
subjects, it is because some islets of tissue have become misplaced,
tucked away, ill-formed, and hampered in development, and so liable
to provoke trouble later under stress of greater or less urgency. Such
a view has much plausibility; there are flaws in a steel girder; there
are tucked-in edges in even the best bound book, and there are
developmental errors in most of us.
Moreover, there is Dr Creighton’s doctrine of physiological
resistance. A part not put to its proper use is more apt than another
to become cancerous. Certainly, unmarried women are more liable
than are married to suffer cancer of the breast or ovary. Yet married
women are more apt than unmarried to suffer cancer of the womb.
Are we to say that in these latter there has been physiological
misuse, or irritation produced by unhealthy child-bearing? So far is
the problem removed from simplicity!
On the other hand, it is certainly as true as ever, that the gods still
cancel a sense misused, and, if we leave out of account for the
moment the cases in which cancer seems due to developmental
error—and who can say whether even then a child does not suffer
vicariously for some physiological transgression by its parents?—the
doctrine that cancer is due to irritation, whether produced by a clay
pipe, hot drinks, constipation, or crude paraffin, does not really tell us
much more than that. The difficulty is this: How to walk in the way of
physiological righteousness, and how to preach it, without falling into
a dogmatism as stupid as unbelief? Mr Wright tells us how, in
medieval times, the Church declared cancer of the tongue to be
sometimes a judgment on sinners for their blasphemy. Well, I for
one, am not prepared to limit the “misuse” that entails physical
disease and suffering to misuse in the material, or physiological
sense. Organs, through the nerves of the “sympathetic”, are directly
connected with the play of emotions and of feeling-states. I am not
sure that investigation would not shew a correlation—sometimes—
between certain persistent and voluntary mental states (morbid
mental states, that is) and the development of cancer in certain
organs. The “argument” that cancer is infrequent in lunatic asylums,
where the majority are mindless rather than wrongly thoughtful,
evades the question.
The quest for a single causal factor, whose “discovery” will lead us
to “abolish cancer”, is then, it would seem, just one more hunt for the
philosopher’s stone. Yet, to use the formula of “right living” does not
seem to be merely a verbal solution of the difficulty.
If we agree that to live rightly is the best insurance we can make
against cancer, we are probably stating, as compendiously as
possible, all we do and shall ever know, in respect of the causation
of cancer. It is then our duty to ascertain how to live rightly in every
sense of the word, and we may so come to realise that almost every
one of what we call the blessings of civilisation has been purchased
at the expense, in some respect, of right living. For this, heavy
interest has to be paid, and even the efforts of science to put matters
right seem too often not more than the borrowing of fresh capital to
pay off old debts. It is right to call attention to the fact that certain
“uncivilised” races, who live healthily and naturally in respect of food,
drink, and sexual activity, do not suffer from cancer. But it is wrong to
suggest that therefore we should adopt either their dietetic or their
sexual customs. What is one man’s meat is another man’s poison.
Adjustment to our surroundings, right living here and now is what we
need. Though Papuans and Sikhs may be very properly adjusted in
their contexts, it is not their adjustments that may best suit our
cases.
 This problem—that of right living—is the problem of prevention of
cancer put upon the broadest basis. But, until or unless we work this
out, we have to consider how best to avail ourselves of the
knowledge already in our possession. Herein is one merit of Mr
Wright’s plan. He tells people what, in his judgment, they can best
do, here and now. It is a plan to be discussed; but, let it be clearly
understood, it is one submitted by the author for individual
consideration and action. Supposing it to be found, on analysis and
trial, of real value, a cry might at once be raised for its putting into
execution by central or local provision of the necessary facilities: at
first for voluntary acceptance, then for compulsory adoption. Nothing
could be a greater error. In matters of health what is advantageous
for the individual is often not so, or even grossly disadvantageous,
for the State.
Let every member of the State have the opportunity to avail
himself or herself of what Science and Art can do for him: let none
who has the will suffer because he has not the means. But the too
easy provision of means for the avoidance of consequences of
neglect does, very seriously, put a premium on neglect and penalise
those who themselves make effort in the right direction. Again: hard
on individuals though it would seem, there is a very real racial
advantage in the elimination—natural and inevitable, unless we
interfere—of those who will not take advantage of opportunities
offered them. We are not automata: we exercise choice; when the
opportunity of choosing rightly is offered us, if then we choose
wrongly, we have no right to demand escape from the
consequences, at the expense of others.
At any rate, if the facts relating to Cancer are plainly stated, every
man has but himself to blame if he shrink from obtaining such
diagnosis and treatment, as is now available, at the earliest moment.
It were better still that he avoid from the beginning all what we know
to be predisposing causes of cancer: all the errors of omission and
commission in respect of the physiological and spiritual—or physical
and psychical—functions and relations of his Self.
It is the principle, the pursuit of the unattainable ideal, that really
counts. The simple injunction to eat greens and take paraffin is the
physiological counterpart of seeking to make people moral by act of
Parliament, religious by church-going, and intelligent by attendance
at evening lectures. But even if we make all possible effort, we
cannot all hope to escape, and the necessity for seeking early
diagnosis when things go not well is as imperative as is true the
maxim that “A stitch in time saves nine”.
There is perhaps one more question that may be touched upon:
that of the so-called increase of cancer. It is commonly stated that
cancer is increasing: it is as commonly asked if this is really so. As a
matter of fact, the question (which we are usually told can be only
answered by statisticians) is one that statisticians can only answer
when we have agreed what they are to understand by it. And that is
not so easy as may be at first thought.
It is certainly true that, in the British Isles, the number of deaths
certified each year as due to cancer of one form or another is
gradually and steadily increasing, both absolutely and relatively to
the population. But then we have in the first place, to consider
whether cancer is not diagnosed more frequently in ratio to the
cases seen than was formerly the case, and, in the second, to
remember that cancer is, on the whole, a disease suffered during the
second half of life. Now, our population is an older one than it was:
the birth-rate is falling: so many youths who would now be vigorous
men of thirty-five to forty lost their lives in the war; and lives are, on
the whole, longer than they were, owing to a diminishing liability to
suffer from certain ailments other than Cancer.
Supposing that children ceased to be born, at the same time that
the Ministry of Health succeeded in “abolishing” all diseases except
cancer, and the Home Office and Police reduced the probability of
death from accident, from homicide, and from suicide, to vanishing
point. Would we not then all die from either “old age” or from
“cancer”? If so; should we be justified in declaring that cancer had
“enormously increased” since the successful institution of control of
our own deaths and other peoples’ births?
We are, indeed, again confronted with the old problem of the one
and the many, under one of its numberless aspects. From the point