The title of this book certainly got my attention and made me curious about what the author had to say. Is the “death” of cancer, or the end of cancer as a deadly disease, really possible? Can we actually win the war on cancer, which has been pronounced a failure by many?
Dr. Vincent T. DeVita Jr. joined the National Cancer Institute as a new doctor during the 1960s. There, he worked directly on some of the most important developments in cancer research coming out of that decade, including the development of a cure for Hodgkin’s lymphoma using combination chemotherapy, a treatment approach that was viewed as exceedingly radical at the time.
DeVita eventually became the director of the NCI, and remained in that position for most of the 1980s. He left the NCI to become physician in chief at Memorial Sloan Kettering Cancer Center and later became the director of the Yale Cancer Center and then president of the American Cancer Society. And in his 70s, DeVita gained yet another perspective on the cancer medical world when he was himself diagnosed with prostate cancer.
In this book, co-authored with his daughter, science writer Elizabeth DeVita-Raeburn, he gives a compelling account of the early days of the war on cancer, as well as his unique perspectives on the progress that’s been made since those days.
New hope for patients in the 1960s
DeVita started working at the NCI at a time when the study of cancer was “a no-man’s-land populated by only a handful of doctors and researchers regarded by most of their colleagues as nuts, losers or both.” Patients with advanced cancer were generally written off as hopeless.
In the early 1960s, there were only two well-accepted ways to treat cancer: radiation and surgery. But a small group at NCI was studying a new approach. Chemotherapy, considered by most a radical idea at that time, was based on the recognition that cancer was a systemic disease, and that was why surgery or radiation alone was usually not enough to prevent cancer from coming back.
DeVita relates how some at NCI believed that combining chemotherapy drugs, an even more radical idea, was necessary to achieve cures. In the beginning of the book, he tells the story of how this group, led by researchers Emil Freireich and Emil Frei, developed the first successful combination chemotherapy treatments for childhood leukemia.
DeVita goes on to give a fascinating account of how he and his colleagues built on the successes with childhood leukemia to develop a combination chemotherapy treatment for adults with Hodgkin’s lymphoma that led to long-lasting remissions or cures for most patients with that disease.
Progress in the war on cancer
The striking successes of the 1960s in treating blood cancers inspired the “war on cancer”, which began when president Richard Nixon signed the National Cancer Act in 1971, designating substantial new funding for cancer research.
The activist and philanthropist Mary Lasker had been a passionate supporter of the legislation. DeVita tells the story of how Lasker’s efforts began in ernest after a friend of hers was treated successfully by him for non-Hodgkin’s lymphoma. The man’s then surprising recovery led Lasker and others to believe that more types of cancer could be cured in a similar way if only enough resources were dedicated to the mission.
DeVita says that the 1970s activists overpromised on how much could be delivered how quickly. Nevertheless, in his view we’ve made much more progress than suggested by news stories that proclaim we’re losing the war on cancer. He suggests that the notion we’re losing the war does not give enough recognition to the advances we’ve made in our understanding of the biology of cancer. Much of this knowledge gained through basic research he says has yet to work its way into the clinic.
He reviews recent advances in treatment including targeted therapies, anti-angiogenesis therapy and therapies aimed at boosting the immune system’s ability to fight cancer. And he says he believes that combination therapy–customized treatments combining these new approaches, with or without traditional chemotherapy–offers “the most hope for the death of cancer if we can learn to harness it effectively and apply it to patients in a personalized way.”
Putting an emphasis on flexibility
A startling theme that DeVita comes back to repeatedly in the book is his view that many more patients with advanced cancer could be treated successfully just with the tools that we have right now.
From his perspective, advances in cancer treatment require that physicians have a willingness to fight for their patients, and that they be allowed flexibility in caring for their patients. In some situations he believes this means using available treatments and approaches that are not usual practice at the time for the particular cancer type. He says this:
When I was a young oncologist working the wards at the National Cancer Institute, we had the freedom to try anything and everything for each individual patient. We had fewer tools then, and you had to be flexible to maximize the chances for each patient. There was no prescription for how to handle a specific cancer because we were inventing it as we went along. Gradually, day by day and week by week, we figured out how to cure more people.
He goes on to say that, as we’ve gained more tools for treating cancer, we’ve lost the ability to be flexible and adapt. Treatment guidelines are issued by professional organizations or government institutions which establish standards of care, and physicians tend to follow these guidelines.
Having standards, frankly, doesn’t seem like a bad thing, and patients have been harmed by practices that evolve without the benefit of standards based on sound science. But DeVita points out that there are risks with too rigid an approach to standards in a time when new advances are occurring rapidly:
But this state of affairs also raises problems. Guidelines are backward looking. With cancer, things change too rapidly for doctors to be able to rely on yesterday’s guidelines for long. These guidelines need to be updated frequently, and they rarely are, because this takes time and money. But if they’re not revised to reflect advances in treatment, patients who might have been cured by newer approaches will die. Reliance on such standards inhibits doctors from trying something new.
Is the war on cancer now winnable?
Is the “death of cancer” achievable now? DeVita is pretty convincing that in theory yes, it is. Cancer is complex, but not impossibly so he suggests. The advances in understanding of the biology of cancer that he talks about, together with the technological tools that we have today, have opened the door.
But what will it take to get there? DeVita recommends a number of changes that would give doctors more freedom to innovate and that would allow new treatments to move more quickly through the clinical trials and approval processes.
But if we do learn to treat cancer so that it’s no longer a life threatening disease for most, we’re going to have to find a way to make the new treatments accessible to everyone. This is already becoming a huge problem as the prices for new cancer drugs are astronomical and continue to rise. This is a critical issue that is not mentioned in the book.
Also, to achieve the death of cancer we’re going to need to do more than just be able to treat people who get cancer more effectively. We’re going to have to learn how to prevent it. DeVita briefly mentions work on developing preventive vaccines, but he seems to minimize the importance of understanding and addressing external environmental factors that increase risk for cancer.
With all that said, I felt more hopeful after reading this book. Someone in about as good a position to know as anyone believes that the war on cancer is now winnable. That’s saying a lot. But there’s a long road ahead and much more work to be done in order to know how to end most deaths from cancer.
On a certain level I appreciate where he’s coming from. I definitely appreciate a physician who’s willing to step outside the paint-by-numbers kit because she/he thinks something else might be more effective. On the other hand, chemo is so barbaric that even when “cancer dies,” I feel like it wins in terms of the collateral damage.
I absolutely agree, Eileen. Especially in cancer, where no two patients’ situations are exactly alike, I think we want doctors who are willing to think outside the box if necessary to do the best they can for their patients. But that said, there are a lot of issues he doesn’t address. Certainly one is that we won’t be able to say we’re winning the “war” until we have treatments that are effective with good quality of life, i.e. minimal collateral damage. The newer targeted treatments are supposed to have fewer adverse side effects but that isn’t always the case. I also have concerns with the “never stop fighting” approach, unless it’s careful to consider a patient’s goals and desires. For some patients a time comes when “enough is enough” and that has to be considered too.
Medicine also needs to include lifestyle changes in the treatment protocol. You can treat the symptoms, but the body could remain ripe for recurrence.
Evidence does support, for breast cancer at least, that a number of complementary therapies including meditation and stress management help with a variety of physical and emotional issues that arise from treatment or the cancer itself. In my view these should be part of treatment plans as appropriate as well as survivorship plans. There are also studies that suggest exercise can reduce the risk of breast cancer recurrence. Thank you for mentioning another important area that is part of any “win”.
Hi Lisa, Thank you for your thoughtful review. I find the guidelines thing very interesting. I do think sometimes oncologists stick too closely to them, but of course, there has to be a standard of care, too. And I’m not sure what is meant when it’s implied many more patients with advanced cancers could be helped today with tools we already have. Is this because of the outlandishly high cost of drugs? Or access disparity? Or what exactly? I will put this book on my to-read list, but will likely wait for the paperback edition. Thank you for re-kindling my interest in it with your great review.
Hi, Nancy. When he says many more patients with advanced cancers could be helped with tools we have now, I think he’s referring mainly to the issue of needing more flexibility in the guidelines and standards. It came up in the context of that discussion anyway. The comment is his opinion of course and others may disagree, but it’s certainly thought provoking.
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