‘War on Cancer’ Strategy Challenged by Critics

Each year, more Americans die from cancer than perished in the Vietnam War and World War II combined.

And that grim rate has inched up about 0.5% annually since the nation officially declared “War on Cancer” nearly two decades ago. This year, cancer will kill about 500,000 Americans--about 170 deaths per 100,000 people.

Most of the increase has been driven by lung cancer, two-thirds of which is linked to smoking. But progress in loosening the deadly grasp of the 100 other types of cancer has also been slight, with their combined mortality rate falling only 0.1% per year between 1975 and 1986.

Critics say those figures indicate a failure in the battle plan--and that the strategy must change dramatically to achieve the goal of cutting cancer deaths in half by the year 2000.

But others, like Dr. Vincent DeVita Jr., former director of the National Cancer Institute, say the single-minded focus on “body counts” is obscuring the solid groundwork already laid toward conquering cancer.

They argue that sticking to the original strategy, rather than switching in midstream, will produce major, life-saving returns by the turn of the century.

“Within the next decade, I think we will know all we need to know to control cancer,” DeVita said, adding he thinks that scientists will also have developed “mechanisms” to thwart the uncontrolled cell growth characteristic of the disease.

Benefits Coming

“The big trick is not, ‘Can you manipulate those mechanisms?’ the big trick is, ‘Can you translate them?” into routine practice by ordinary doctors and hospitals, DeVita told a recent seminar.

DeVita, who became chief physician at Memorial-Sloan Kettering Cancer Center in New York in 1988 after 25 years at NCI, said Americans are just beginning to reap the benefits from the $20 billion spent since 1973 to unravel the biological underpinnings of cancer.

Only recently have scientists had the tools to turn their laboratory discoveries into practical, cancer-fighting strategies such as combination chemotherapy, immune system boosters and sophisticated diagnostic tests.

And it is still too early for most of the impact of new technology to be reflected in cancer mortality figures, DeVita said.

But DeVita noted that since the 1971 Cancer Act, doctors have made significant gains in treating cancer in people under age 65, as well as improving survival from some types of cancer once considered hopeless.

The death rate for all types of cancer fell 3.2% in people under 65 from 1973 through 1986, and if lung cancer is excluded, the decline was a more striking 9.5%.

From a statistical standpoint, the most impressive cancer success story is in children.

The cancer death rate for youngsters under age 15 fell 34.8% from 1973 through 1986, and the five-year survival rate for children with cancer rose from about 55% to 65% during the same period.

But children are just a drop in the bucket when it comes to cancer, comprising only about 6,500 of the nearly 1 million cancer cases diagnosed in the United States each year.

Adult cancer is not without a few bright spots--advances often lost in the shadow of the overall picture, DeVita said.

Doctors can now save about 15,000 of the 50,000 people diagnosed annually with 12 types of advanced cancer once considered fatal, he said. And aggressive use of chemotherapy after surgery is also improving survival among subgroups of colon and breast cancer patients.

Quality of life is also improving for many cancer patients.

DeVita said fewer cancer patients are having to undergo mutilating operations such as limb amputation or breast removal. Doctors have also figured out ways to save potency in some patients with prostate cancer and to avoid colostomies in many colon cancer patients, he said.

Huge Effort Needed

Dr. Peter Greenwald, an NCI researcher who helped draft the cancer goals for the year 2000, emphasized that achieving that target hinges on a “huge national effort” to combat cancer.

Crucial in the effort is reducing smoking, which Greenwald said is responsible for 30% of all U.S. cancer cases.

Greenwald, who directs NCI’s cancer prevention division, said “some progress” is being made in reducing smoking-related cancers. The Journal of the National Cancer Institute recently reported that lung cancer rates fell among Americans under age 45 between the mid-1970s and mid-1980s, with the greatest drop--about 29%--occuring among white men.

More also must be done to detect breast cancer in its earliest stages. Greenwald claims that U.S. breast cancer deaths could be cut by nearly one-third if all women over 40 routinely underwent mammography.

In a letter published in a recent issue of The New England Journal of Medicine, doctors from the California Department of Health Services reported new data they interpreted as signs cancer’s grip is slipping.

The death rates for lung cancer among men in the San Francisco-Oakland area declined since 1980, while the rates among women appear to have peaked and may also be beginning to decline, they said.

In addition, the researchers said there has been a slight overall decline in the death rate from breast cancer, apparently due to increased early diagnosis.

“We believe that the data on lung cancer and breast cancer are the consequences of primary and secondary prevention, respectively, and constitute substantial progress in the war on cancer,” they wrote.

Money is another hurdle facing cancer fighters as newer medical woes, such as AIDS, grab public attention and federal funds.

For the first time since the Cancer Act was passed, the NCI has seen its budget shrink. The fiscal 1990 budget stands at $1.56 billion, down from $1.57 billion in fiscal 1989, and far below the institute’s ideal budget of $2.2 billion. That means that NCI can finance only about 15% to 20% of research projects it considers worthwhile, compared with 30% to 35% a decade ago.

Given all the obstacles, Greenwald said he still thinks cutting cancer deaths by one-half, or perhaps one-quarter, by the year 2000 is a “reachable goal.”

Doctor Has Doubts

But Dr. John Bailar III, a former NCI staffer and a professor at Canada’s McGill University medical school, disagrees: “There is no hope whatever of obtaining that goal.”

“Overall prospects for the average cancer patient have not changed very much in recent years,” said Bailar, a statistical consultant to the New England Journal of Medicine. He pointed out that five-year survival rates for cancer patients have been flat since 1974, standing at 48.6% of patients surviving that long from 1973-78 and 49% in 1978-84.

“We’re not getting where we wanted to get,” Bailar said.

NCI currently spends three to four times as much money on treatment research as it does on prevention research, Bailar said. And he wants to see that situation almost reversed, with two times as much funding for prevention as treatment.

Greenwald objects. “I don’t think we want to minimize treatment research for prevention,” he said, adding “we can’t ignore” the 1 million Americans diagnosed with cancer each year.

Dr. Gerald Murphy, chief medical officer for the American Cancer Society, also voiced support for NCI’s current tactics. “In general, we have found they (federal researchers) are doing very well. Of course, they could use more money,” Murphy said.

But Bailar contends that a major change is necessary if the U.S. cancer death toll is to be lowered.

“No one seriously doubts that there have been enormous increases in our understanding of cancer. Unfortunately, we have not been able to translate those findings into a decrease in cancer deaths,” he said.