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We examine the ongoing war on cancer, why we're not closer to a cure already and where the promising research is now.
The big news from the world of cancer research this week was about how we talk about cancer — how we define it, describe it, when a patient has some early evidence in the breast or prostate or lung.
But it raises the question, even the complaint — never mind the semantics — where's the cure? The war on cancer is decades old. The number of cases still soars. The answers, elusive.
A top reporter with us says we've lost our way. A top research chief says we're on it.
This hour, On Point: Where’s the cure for cancer?
-- Tom Ashbrook
Clifton Leaf, contributing editor at Fortune Magazine and author of the new book "The Truth In Small Doses: Why We’re Losing The War On Cancer — And How To Win It." (@CliftonLeaf)
Dr. Edward Benz, president of Dana-Farber Cancer Institute and professor of medicine, pathology and pediatrics at Harvard Medical School.
Dr. Jonathan LaPook on the new recommendations about overdiagnosis and cancer terminology:
There’s no doubt that screening for cancer has saved a lot of lives. The problem is with all these tests that we’re doing, you pick up a lot of abnormalities that turn out they’re never going to hurt the person. And yet we go ahead and do all sorts of testing and procedures on them.
They [the researchers making the recommendations] give an example of breast cancer. There’s a type of breast cancer biopsy abnormality called DCIS (ductal carcinoma in situ), stage zero breast cancer. They’re saying that this is something, if just left alone like that, it doesn’t harm a woman. But sometimes it goes on to invasive breast cancer and sometimes it doesn’t. And they’re saying let’s get rid of the word “carcinoma.”
And another example is with a kind of abnormal prostate biopsy called high-grade PIN, which is a kind of neoplasia or abnormal tissue growth. And sometimes that can be a precursor to prostate cancer. But even if you do go on to get prostate cancer, most people who get prostate cancer don’t die from it. So they’re saying get rid of the word “neoplasia.”
They’re saying, look, these words are scary — “carcinoma,” “neoplasia,” “cancer” — and they make people so worried that when the doctor says you got this in them, they immediately have a knee-jerk reflex and say, “Listen, get it out. Let’s do a lot of testing and a lot of procedures.” And they’re saying sometimes maybe you’re going to be aggressive, maybe you’re going to do treatment or some middle treatment or maybe — just maybe — the doctor may say to you, “You know something? We’re not quite sure what to do. Let’s just wait and see.”
This is really all about personalized medicine, and the one size does not fit all. And you really have to be able to be willing as a doctor to take the time — and, by the way, I don’t think there’s enough time these days that we give to our patients — to go through all this complicated thinking and the algorithms and explains what the risks and benefits are.
In 1971, President Nixon declared a war on cancer, but Clifton Leaf said we're losing it:
I think you have to reframe the question from looking for cures to what the burden of cancer is … We’ve got all these people getting cancer or being diagnosed with cancer and there’s a treatment associated with that.
We have, as you mentioned, nearly 600,000 Americans dying of cancer each year. We have 1.7 million Americans being diagnosed with cancer, and that number has gone up three times faster than the population since we began this war.
There’s a burden associated with that … it’s the treatment, it’s the cost of that treatment, it’s the lost work, the wages, everything associated, the emotional/spiritual burden of being diagnosed with cancer. It comes with a lot of baggage. Anyone who has heard that diagnosis carries — whether they’re called cured or not — they carry it for the rest of their lives.
We’re losing the war because the burden of cancer has gone up every way you can measure it. As you say, the number of people who are dying is close to 600,000 — that number, the raw number, is going up year after year after year. The number of people getting it is going up. What we’re spending on this war. It’s more of a threat to the nation, to our public health, than it was when President Nixon declared that war on this disease.
Dr. Edward Benz on research funding and young scientists:
I come down somewhat more optimistic about the trajectory of where things are going in the last few years, in particular, both with respect to what we’re learning about cancer, how we’re applying it and how we’re going about supporting it … I’ve begun to see changes … Some of it within major funder of federal research, which is the National Cancer Institute, but the NIH in general — [they] have done a lot of self-examination of the peer review process, have tried to find ways to encourage high risk, high rewards research, to focus much more on potential impact, recognizing — remember — you can’t predict serendipity and you can’t predict innovation … We need better ways to provide more support, security, predictably for career growth of our younger scientists. Medical training and Ph.D. training is taking longer and longer, so people are already older when when they’re getting into their training. The process of getting funded is slower still, so they’re very old when they get their first grant … People are older getting funded now than when some people were when they did their Nobel Prize work.
Benz on the future of cancer research:
The ultimate goal still has to remain that you could cure these cancers. The realistic goal is that will be true with some, and it will come with time or it will come with a great insight. But for most cancers, recognizing that typically they occur increasingly in older people with other medical problems, I think that you’ll find that the progress over the next couple of decades is better and better ways to hold off the cancer being the cause of your death, so that you can live out the rest of your life, in effect — as is often true with people’s prostate cancer: die with the cancer not of it. Even though we can’t eradicate it from your body, it will not be something that harms you.
Leaf on thinking about cancer as a process, in the same way we think about heart disease:
Cancer as a process, not as a disease or state of being. And this is what we really have to fundamentally think of it as like heart disease, at least in this one respect. We don't say that heart disease starts with the heart attack ... we say it's a long, dynamic, evolving process. And we look for biomarkers along the way: hypertension, high cholesterol, all of these things we can look at and say this is a process. We can intervene in that process. And through that strategy we've had one of the most successful interventions in public health of all time. We've reduced the death rate from heart disease in the last 50 years by 60 percent. In raw numbers, there are fewer people dying of heart disease today than there were in 1970, even though we have 100 million more people in the country.
Benz on how to prevent cancer:
Prevention, or detection at the earliest stages, is ultimately the best way to be sure you don’t die of cancer or suffer from it. Getting there is a real challenge. But I can tell you: If you want to get rid of about one-third of cancer deaths worldwide, ban tobacco, ban tanning parlors, use sunscreen and — one very important one we could be doing now and we’re not — is vaccinate everybody against HPV that causes cervical cancer, less of a problem in the West, but one of the major causes of cancer mortality worldwide.
Leaf on the HPV vaccine and colonoscopies:
We know that certain strains of HPV increase the likelihood of causing cancers to develop in the uterine cervix. That's one very clear way where we can take a vaccine, which is a lot of bang for the buck.
We also didn't talk enough about colonoscopies ... if you want to talk about great successes in cancer, it's not coming from medicines with colorectal cancer. It's fighting those pre-invasive lesions, those pre-neoplastic lesions called polyps that you can remove in a colonscopy and they can't later become a cancer.
Excerpted from THE TRUTH IN SMALL DOSES by Clifton Leaf. Copyright © 2013 by Clifton Leaf. Excerpted with permission of Simon & Schuster, a Division of Simon & Schuster, Inc.
Prologue: How Did We Get Here?
Two years before I came to believe that we were losing the “war on cancer,” I had concluded that we were on the brink of victory. The notion had spun out of an extraordinary conversation I’d had in February 2002 with Daniel Vasella, then the chief executive officer of the Swiss pharmaceutical firm Novartis. He was in New York for the World Economic Forum, the annual gathering of business titans, statesmen, movie stars, and savants traditionally held in Davos, a resort town tucked high in the Swiss Alps. But this particular winter, the first after 9/11, the gathering had moved to midtown Manhattan, and the forty-eight-year-old Vasella had settled into the lobby bar at the St. Regis Hotel for a string of interviews with the business press.
I was reluctant to join the line. It was late in the day, and I was sure I was in for a lengthy pitch on some revolutionary age-spot cream then in clinical trials, or a rundown of the company’s ever-expanding portfolio of medicines. I was then an editor at Fortune and oversaw the magazine’s investing coverage, among other things, so such conversations were common.
But this time the phrase drug pipeline was not uttered once. Nor was revenue stream. Nor share price. Vasella hardly mentioned his company at all.
Instead, he spoke about the anguish caused by endemic malaria, the soaring cost of prescription drugs, and the preventable diseases still plaguing half the world. His industry, he said with surprising candor, had not done enough to address these crises. He spoke of the challenges of innovation in a big corporation and of dismantling the walls of ancient corporate fiefdoms. (Vasella had helped engineer, in 1996, the merger of two century-old Swiss chemical companies, Sandoz and Ciba-Geigy, and had become CEO of the newly formed Novartis.)
As the conversation continued in the dim light of the hotel bar, the subjects grew more personal and raw, and dotted lines between our histories emerged. Vasella spoke of his older sister Ursula’s battle with Hodgkin’s disease, a cancer of the lymph system, and of watching her waste away during a grueling three-year fight. Vasella was ten at the time of her death; she was eighteen.
I too had struggled with Hodgkin’s (at age fifteen), but had survived thanks to a unique chemotherapy regimen that had been pioneered at the National Cancer Institute (NCI) a decade or so prior to my diagnosis in 1978. The discovery had, unfortunately, come a few years too late to save young Ursula.
An uncannier connection was Vasella’s work in the late 1980s. In his first managerial job at a pharmaceutical company, he was responsible for an obscure injectable drug, somatostatin, that was shown to relieve some of the worst symptoms of carcinoid syndrome, a rare intestinal cancer. My mother had been one of the few people in the world to rely on the drug, which had alleviated some of the daily diarrhea and near-constant skin flushing that made her disease so debilitating. Like Vasella’s sister, she would eventually succumb to her cancer, in 1995.
Vasella had been surrounded by illness and tragedy as a child. At the age of five, his asthma grew so severe during the summer months that his parents sent him to live on a farm in the mountains, away from the family. When he was eight, a bout with tuberculosis, followed by meningitis, forced him to spend a full year in a hospital and sanatorium. Five years later his father, a history professor, died of complications from surgery. Then a second sister died as well, from a car accident.
Vasella related only a tiny portion of this story as we sat with our Scotches in the hotel bar.
He had gone to medical school, received his degree, and practiced medicine in Bern, Switzerland, before giving it up for a junior marketing position at Sandoz. Six years later he was in the corner office. Among the chief executives of major drug companies, Vasella was the only physician, the only one who had ever taken care of patients.
A few journalists would later venture that it was this clinically trained eye that helped him see the vast potential of the leukemia drug called Gleevec, which many oncologists were then hailing as a genuine breakthrough and as a model for cancer therapy in the generation to come.
Others involved in the drug’s development would give Vasella far less credit. I knew none of this at the time.
What I did know, what I could hear in our first conversation, was how Vasella spoke of the drug, which had been approved by the Food and Drug Administration just nine months earlier. He spoke the way a firsttime parent speaks about his child’s first recital.
Gleevec worked, he explained, in a radically new way: by homing in on a “mutant” protein found in the white blood cells of patients with an uncommon form of leukemia. This aberrant protein, created as the result of a genetic glitch, relayed instructions that sent those white blood cells into a continual replicative loop. They divided and divided until eventually they crowded out every other type of cell in the blood, and the patient died. Novartis’s remarkable molecule blocked that protein from passing along its deadly message. And it was so precisely aimed that, even as it shut down the mutants, it spared the healthy cells around them. (Traditional chemotherapy, by contrast, is a sledgehammer: it decimates many normal cells as it strikes the malignant.)
Gleevec, said Vasella, had established the principle of targeted cancer therapy. Now it was only a matter of time until scientists designed molecules to disable the wayward signaling mechanisms central to every cancer.
From Tom's Reading List
The Boston Globe: Scientists’ Report Cites Need To Redefine Cancer: "A group of scientists advising the nation’s premier cancer research institution has recommended sweeping changes in the approach to cancer detection and treatment, including changes in the very definition of cancer and eliminating the word entirely from some diagnoses."
The New Yorker: World War Cancer [BOOK REVIEW]: "The title comes from a 1959 pamphlet that tells doctors to trickle out information to cancer-stricken patients, since most of them 'couldn’t stand' to know the truth: the disease would kill them and there was little that could be done about it. Today, draped in ribbons of every hue, blinded by the promises of targeted therapies and antioxidants, we have, according to Leaf, neglected a basic truth: 'the cancer problem is, in reality, as formidable a challenge as ever.'" (Also see: The T-Cell Army)
The Journal of the American Medical Association: Overdiagnosis And Overtreatment In Cancer: An Opportunity For Improvement: "The word 'cancer' often invokes the specter of an inexorably lethal process; however, cancers are heterogeneous and can follow multiple paths, not all of which progress to metastases and death, and include indolent disease that causes no harm during the patient’s lifetime. Better biology alone can explain better outcomes. Although this complexity complicates the goal of early diagnosis, its recognition provides an opportunity to adapt cancer screening with a focus on identifying and treating those conditions most likely associated with morbidity and mortality."
This program aired on August 1, 2013.
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