Cancer Death Rates Falling, But Cure Ellusive

BOSTON---Nearly 40 years after President Nixon declared the War on Cancer, victory remains elusive.

While death rates have been falling, over half a million Americans die each year of the disease and researchers are still unclear on what causes it as well as how to treat it.

We spoke with Dr. Jerome Groopman of Harvard Medical School and the Beth Israel Deaconess Medical Center. His latest book is “How Doctors Think,” a transcript follows.

Robing Young: So let's start with a thumbnail, where are we overall?

Well, we’ve made progress and we’ve reduced the death rate. A lot of it has to do with changes in lifestyle and medication. For breast cancer, for example, we know that estrogen is not the cure-all for women after menopause that appeared to be promoting breast cancer in women, and there are some new drugs, but we still have a far way to go before we can declare victory.

And when you say the death rate has dropped overall, it has because more people have died and there are more of us. The population has grown so much. But let’s just, so start at the beginning. Do we know more about what causes cancer? We had the amazing human genome project in 2003, which mapped things out that told us a lot genetically. But what else do we know about what causes cancer?

Well, we know that those breaks or mutations in the genes in cancer cells can be caused by the environment, toxins in those environments, radiation exposure. But we really don’t know in most people why one person develops cancer and another person doesn’t.

Right. There's a very interesting study, for instance, that shows if a blow to the breast or surgery or infection can spur cancer cells.

Well there’s a lot of interest in the relationship between inflammation and cancer where that might actually promote it. Again, what are called free radicals – oxygen molecules that damage the DNA – can potentially lead to cancer.

"We still don’t have the tools where we can say, don’t worry about this (tumor), or that one really needs to be found early because that could save your life."

--Dr. Jerome GroopmanBacteria, virus…that’s all still in the pot. What is the cause…what are the causes?

Most of them don’t seem to be infectious, but certainly cancers like cervical cancer are clearly related viruses that infect women and we know which viruses those are. And indeed a vaccine was just developed, which seems very effective in hopefully will protect the next generation of young women against these cancer related viruses.

What about detection? Stay with the idea of early detection. Do we know that that’s leading to a drop in death rates?

That appears to be certainly the case for cervical cancer with pap smears in older women. Certainly the case…in terms of mammograms for women 50 and above. Mammograms in the 40 to 50-year old range does save lives. The question is what are you trading off…and it’s a very complex and individual decision for women - to have the anxiety of a mammogram, to have a biopsy and so one. Most women I know are willing to have that for the idea that you could catch a cancer and potentially save their lives.

We now know there are as many as 20 different kinds of breast cancers and some of them, you know, appear as tumors and such, but you can live with them your entire life.

Right, so some of them appear to be relevantly slow growing. Others appear to be very aggressive. For some we can distinguish, but unfortunately for the majority we still don’t have the tools where we can say don’t worry about this one or that one really needs to be found early because that could save your life.

And what about treatment? Dr. Steven Edge of Roswell Park Cancer Institute in Buffalo says it’s scary how much variation there is in cancer treatment across the U.S.

I think that’s true – there are still areas in the country that don’t give cutting edge treatments. But it’s also still true that most of the large academic cancer centers have the newest experimental drugs. On the other hand, many outstanding cancer center specialists and oncologists have been trained are now in the community and the National Cancer Institute is trying better programs to bring cutting edge treatments to…every community in the country. The worst care, unfortunately, is in the minority and poor areas. They are really underserved in terms of cancer treatment. A lot of it has to do with money and the fact that people don’t have coverage, that Medicaid pays very poorly and one hopes, although I’m not that confident that some of the reform measures improve this.

One of the exciting treatments, at least for a while, was angiogenesis, cutting off the blood supply to the tumor so that it can’t grow. That was really big headline in the 90s – where are we there?

Well that’s made some improvement…again, you choke off the blood supply to a cancer – this was Judah Folkman’s work. But initially not Judah, but others said this is the cure. And there was a front-page article in the New York Times. Like everything, it helped with certain cancers…by extending life for a month or year or two, but it’s not our panacea.

I mentioned earlier Nobel Prize-winner James Watson, who is out in Stonybrook in Long Island. And he writes that yes we now know there are genetic drivers in a cell that drive the cancer and you may be able to get a drug to fight one driver of one cancer, let’s say herceptin in breast cancer. But until that drug can be given in combination with other drugs that can get all the drivers…the drivers can keep mutating…and that’s the only way to get a cure. Your thoughts on that and why we aren't closer to a cure for most cancers.

Well he’s right to some degree and that is that there are multiple parallel pathways…There are multiple drivers working together in a cancer cell and you need to put combinations together and that would be more effective. And that’s being done now. It’s slower than all of us would like because of regulatory hurdles and so on, but, on the other hand, cancer cells are just terribly diabolical in terms of how clever they are. That not only do they have mutations when you begin to treat them, but they develop new mutations as you’re treating them. So it's almost like that Greek god Proteus... that you’d grab hold to one arm and he would sprout out a new one.

Right. But where have there been successes….where have death rates been going down and where have they been going up?

Well what’s going down is breast cancer for sure. That mainly, as we said earlier, seems to be related to estrogen use, although Herceptin is helping a certain fraction of women –

The blocker.

The blocker, the targeted therapy. Certain drugs for lymphoma – a drug called Rituxan is really improving the cure rate against really aggressive lymphomas. On the other hand, we haven’t had much progress at all in lung cancer or really in melanoma, which is increasing.

And how much of this overall report card on the war on cancer, has to do with the way the battle's been fought? Some people don’t like that phrase…some people say no no, we're not at war, they’re trying to be peaceful about their approach to ridding cancer and I want to respect that. But there’s a raging debate on where the money went. Again James Watson said when he was on the first task force he said let’s put all the money in research right away, instead it went into clinics. Part of the current debate it that it has gone into the last few moments or months maybe of a cancer life as opposed to into finding a cure. You’ve called this the iron lung syndrome. What does that mean to you?

Well, it meant that instead of looking for an innovative vaccine for polio, it was as if you were investing in just more iron lungs. You were taking care of symptoms rather than getting at the root cause or protecting the person. I think the initial Nixon war on cancer was really fraught with huge sums of money misspent and really wasted in both looking for viruses as the cause which turned out not to be the real cause and also "me too" studies, really very mundane studies of different chemotherapy drugs which didn’t advance things in the least. For sure, we need more basic science research right now.

But that is the hardest thing because when it comes to your loved one and the last few months, who isn’t going to want, even when you know it may not help, that's where you want that money to go to try.

Right, and I’m an oncologist and I take care of many people and I believe that sometimes you try and you gain very important time. My mother died of breast cancer about a year and a half ago...

I'm sorry

And the last months of her life were tremendously improved by receiving drugs, some of them experimental, which really improved the quality of her life and was invaluable to us. I think as a society it’s still worth investing in those kinds of people and at that time of life. There are other moments though where an intelligent and compassionate discussion can prevent people being kept on respirators and in intensive care unit beyond any help, when things are futile.

And we’re also talking about institutional leadership, where the dollars are directed. We heard an anecdote from you that is going to stun some people, about how a lot of people try to do prevention and feel more money should be going into teaching people about prevention, though if we don't know all the causes that's difficult. But a lot of people feel intuitively: I know that it’s toxins and I know I can protect myself with vitamins. Your thoughts on that.

Well that’s probably one of the most overturned conceptions in the last few years. Prostate cancer, for example, vitamin E and selenium was supposed to protect against prostate cancer. So a placebo control, very rigorous scientific study showed that it had no benefit at all. Vitamin A which we get from carrots was supposed to protect against lung and throat cancer. It turned out it promoted lung and throat cancer. People developed more cancer by taking high doses the vitamins.

Why?

Probably because in our diet we get what we need in terms of the level of vitamins just by eating healthy. And cancer cells that grow very quickly, they love vitamins, because it feeds their growth. So there’s a huge industry claiming that vitamins cure cancer and there’s almost no scientific data to support it.

Well that will be something for people to chew on. In the mean time, we’ve had all these disturbing reports on what to do, what not to do – give me one bottom line, you, an oncologist, on what people should do.

In terms of a lifestyle — I would say, first of all, absolutely stop smoking. I also think that women who are beyond menopause should be very careful in terms of taking estrogen or how long they take estrogen. I think that a really good physical exam and I still believe that colonoscopy, mammogram, pap smear can really save lives.