The article in today’s New York Times by reporter Gina Kolata has a lot of truth, and perhaps a bit of misdirection.
It seems that we are hearing more and more about the lack of progress in treating cancer, or the failures of prevention and early detection. I’m not certain what is driving this sudden spate of articles in several highly regarded media venues, but it must be acknowledged as an obvious topic of interest. Otherwise, reporters wouldn’t be reporting it. At the same time, I also believe that we must put these discussions into balance and context.
It is undeniable that we have made progress in the prevention, diagnosis, and treatment of cancer. At the same time, we need to acknowledge the harms of our treatments and the limitations of our capabilities.
First, the concern: the article suggests that we have made little if any progress in reducing cancer deaths in this country since 1950, in contrast to dramatic declines in deaths from heart disease, flu and pneumonia.
A true statement, but maybe a bit misleading. It suggests no progress in reducing cancer deaths. Our top epidemiologist at the American Cancer Society, Dr. Michael Thun, says that’s like visiting base camp at Mount Everest before and after an ascent and concluding nothing had changed. It ignores the remarkable feat accomplished in the meantime.
There was a dramatic increase in cancer deaths from 1950 to 1990, in no small part due to our addiction to tobacco. As well, it took significant time to build the cancer research infrastructure that is now producing significant improvements in our understanding of how cancer works, and how we can design treatments that are beginning to attack even some of the cancers that have had the poorest prognoses.
As a result of that work, cancer death rates peaked in the late 1980’s and early 1990’s. Since then, there has been an 18% decline in cancer death rates for men, and a 10% decline in cancer deaths for women. The American Cancer Society estimates that we have avoided 534,500 deaths from cancer that would have otherwise occurred if we had made no progress from the cancer death rates we were seeing in the early 1990’s. That is not “no progress.”
It is true that common forms of cancer—once they spread—are not curable. But to say that survival has not improved is not true. There have been increases in survival in recurrent breast and colon cancer. We haven’t made much progress in lung and prostate cancer. Our treatments have improved survival in certain cancers and are lacking in others.
(The lack of progress in treating advanced disease may be the difference between looking at statistics for people who initially present with advanced cancer, compared to those whose disease progresses after primary surgery, radiation and/or chemotherapy. This may seem like a subtle comment, but it is significant in terms of the way cancer behaves.)
Another point in the article was the comment that there are those who claim that all you have to do is eat right, exercise and get screened and avoid cancer.
I think it is fair to say that if you adopt healthy lifestyles you reduce your cancer risk. Research does confirm that observation. But it doesn’t prevent every cancer. And not every breast or colon or cervical cancer can be found early with screening. Also, finding every cancer early doesn’t guarantees a “cure.” It is also fair to say that in the lifestyle war—such as obesity—we are not winning the fight. That is a counterbalance to some of the progress we have made in cancer, and other diseases including diabetes, hypertension and heart disease.
Cancer isn’t like heart disease or pneumonia. It is more subtle, more insidious, and not by any stretch of the imagination a single disease. It doesn’t cause a pain in your chest (until frequently too late) or send you to the emergency room for immediate treatment. We don’t have pills to generally reduce your risk, such as a blood pressure or cholesterol medicines, and those preventive strategies we do have such as drugs which reduce the risk of breast cancer in women at increased risk go woefully underused.
We can’t force people to go to the doctor to get screened for colorectal cancer. If we did, we could reduce deaths in a matter of years. We can’t force people to get screened for breast or cervical cancer.
If we did do what we already know, we could significantly reduce the risk of cancer and deaths from cancer. But we can’t force people to do what they don’t want to do. Our technologies may be crude, but they are what we have. And if we applied them, they would work. Not perfectly, but better than where we find ourselves today.
The observation that as a nation we don’t fund our innovative young researchers adequately is true, except that the American Cancer Society has a long standing tradition of providing research support to these young investigators at the beginning of their careers. Many of them have gone on to develop some of the most significant cancer breakthroughs. Our grant recipients have 42 Nobel prizes to show for our early investment in their promising careers, frequently when no one else would listen to them.
We don’t talk about cures, we talk about converting fatal cancer into a chronic disease like heart disease, diabetes and hypertension. We don’t talk about finding every cancer early, but how we can get more people access to better care. We don’t talk about the miracles of cancer screening, but that it offers the best option in an imperfect world.
So we will continue to hear the stories that what we do in cancer treatment and cancer research is for naught, and I will continue to write blogs explaining why I agree on some points and disagree on others.
I am not an apologist for the advances in cancer research, diagnosis and treatment—any more than I am an apologist for the “advances” in medical care in this country where 47 million people are uninsured, millions more underinsured, and many can’t get anywhere near the care they need when they need it—whether it is for the treatment of a cancer or for the treatment of their pneumonia.
But I am someone who has “been there and done that”, and I have no interest in returning to the good old days of medicine, when we had no understanding of how to prevent cancer, detect it early or treat it effectively. Those were days when we couldn’t do anything much to save a life from cancer, or prevent it or detect it early in its course.
I am someone who looks at the data—as we did in November with the Annual Report to the Nation, or the release at the same time of research showing the decline in cancer death rates in African Americans, especially men—and believe our glass is half full, rather than half empty.
I have not always been such an optimist, but I certainly look forward to our future with more optimism now than at any time past.