Sometimes it seems like we're not making much headway against cancer. Are we?
The answer is clearly yes, but with qualifications.
First, the good news. According to the statistics published by the National Cancer Institute, the Centers for Disease Prevention and Control, and the American Cancer Society, the death rates from all cancers combined have decreased in both men and women and in most racial and ethnic groups. These advances were primarily driven by reductions in the death rates for the three most common forms of cancer in men (lung, colon, and prostate) and for two of the three key forms of cancer in women (breast and colon), coupled with a plateau of lung cancer deaths in women.
Taken together, cancer death rates in the middle of this decade decreased by more than 18 percent among men and nearly 11 percent among women, compared with the statistics in the early '90s. More than a half-million deaths from cancer were avoided during these time intervals because of advances in prevention, early detection and diagnosis, and treatment. Younger adult age groups have experienced the most notable progress. And for certain childhood cancers (like acute lymphoblastic leukemia) or certain cancers that target younger adults (such as testicular cancer), the progress has been very substantial by any measure.
There has been considerable progress in using adjuvant chemotherapy, or treatment given after surgery before detectable spread of cancer cells to distant sites, to prevent relapses. There have also been advances in minimally invasive surgery and in the field of radiotherapy. For instance, there has been progress in "3D" radiation treatment planning to match the spatial distribution of the radiation dose to the shape of the tumor, and also in internal radiation treatment, called brachytherapy, in which radioactive sources are inserted into cancers. These advances spare normal anatomy and improve the lives of cancer survivors.
Indeed, some critics of the nation's cancer programs have now revised longstanding sentiments of pessimism or even futility. For example, John Bailar who famously coauthored a scientific review in the late 1990s entitled "Cancer Undefeated," was recently quoted in the Wall Street Journal as saying, "My general sense is that mortality rates for cancer are going down. There's no doubt about it, and that's very good news."
But much unfinished business remains. Cancer, particularly when it is in an advanced or metastatic state, remains a formidable challenge. We have made enormous progress in understanding the molecular biology of cancer and developing molecular diagnostics to get the right drugs to the right patients—-what is sometimes called personalized medicine—-but for certain tumors, we still do not know how to translate this knowledge into curative treatments.
And even when there is a clear road map to reducing death rates, the path may be strewn with obstacles. For example, smoking represents one of the most important causes of cancer, especially lung cancer. Nevertheless, it is still widespread. Indeed, lung cancer death rates among women have actually increased in many states, most notably in the South or Midwest, where the percentage of women who smoke remains unfavorable and thereby prefigures a future "harvest" of lung cancers and other smoking-related illnesses. All of this is incredibly tragic because lung cancer was once a comparatively rare disease, and there is no fundamental reason why it could not become so again. Alton Ochsner, a surgeon who helped identify tobacco as the major cause of lung cancer, is quoted as follows: "When I was a medical student at Washington University in 1919, a patient died of lung cancer. Our professor called us all in to see the autopsy. He said this condition was so rare we might never see another one." Imagine: In 1919, lung cancer was felt to be so rare a professor predicted that his medical students might never see another case.
Here are a number of steps I think we should be taking to build on the gains already made and to intensify efforts where progress has been more difficult:
1. Expand commitment to research. A strong commitment to research should be part of any healthcare reform agenda, and not just for cancer.
2. Government policies should encourage private enterprise. Many innovative programs in pharmaceutical and biotechnology companies transfer basic knowledge into useful products. The National Cancer Institute is the premiere sponsor of cancer research, but it cannot produce new therapies and diagnostics alone.
3. Encourage cross-disciplinary research. During the 1970s, cancer research was the engine that powered the revolution in modern molecular biology, thereby advancing knowledge about virtually every disease. Moreover, the work done at the National Cancer Institute played a pivotal role in reducing the death rate due to HIV-1/AIDS. By the same token, research in many disciplines may have bearing on progress against cancer today. In particular, we are learning that many forms of human cancer may have a viral or in some cases a bacterial origin.
4. Individualize treatment approaches. For example, some women with very early forms of breast cancer may have a higher probability of dying from a "competing cause" (e.g., heart disease) than from a recurrence of their breast cancer. In these cases, it is certainly appropriate to take steps to reduce a recurrence of the cancer, but such women should also take measures to prevent a heart attack.
5. Apply the knowledge at hand now. And with some urgency, whether it is a critical discovery in the laboratory or the proven effective smoking-cessation campaigns.
6. We need better community service and outreach, particularly to ensure that underserved minorities enjoy the benefits of modern prevention, diagnosis, and treatment regimes.
7. Expand research on surrogate markers of cancer-drug efficacy. Right now, clinical trials may take years to complete. This represents a bottleneck for anticancer drug development. Surrogate markers, which may predict efficacy with shorter observation periods, could permit novel therapies to reach patients more rapidly than is now possible.
8. Guard against triumphalism. Nearly 40 years ago, when the National Cancer Institute was reconstituted to lead a newly declared "War on Cancer," many people expected cancer would be "defeated" rather quickly. But we did not know how much research would be required and did not reckon with how long it would take to transfer discoveries from the lab to the bedside, complete clinical trials, or implement knowledge gained from such trials at a community level. We need to recognize how much we still don't understand about the cancer cell and, equally, that sometimes there may be no alternative to progress in incremental steps.
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