COLUMN ONE : Cancer Survives an Assault : There has been no steady progress in a war declared by former President Nixon. Researchers and physicians have advanced sharply on some fronts, but are fighting holding actions elsewhere.
Gathered beneath tents on the grounds of the City of Hope National Medical Center in Duarte, these 100 people arrived for a celebration of life.
Survivors of advanced cancers, they shared a picnic lunch with the physicians, nurses and technicians who had treated them with combinations of powerful drugs and bone marrow transplantation. For some, the state-of-the-art treatment had put their cancers into retreat. For others, it was too soon to claim victory.
But one thing is certain: Twenty years ago, there would have been no such reunion. None of these people would have lived long enough to attend.
They are the happy legacy of this nation’s “war on cancer,” declared 20 years ago next month when then-President Richard M. Nixon signed the National Cancer Act.
The “war on cancer” was to be Nixon’s answer to John F. Kennedy’s mission to the moon--a national scientific crusade to cure one of the world’s dread diseases. Some optimists predicted success within five years.
But there has been no steady, broad march forward in this war. Instead, although researchers and physicians have made sharp advances on some fronts, they find themselves fighting holding actions elsewhere.
As the gathering at City of Hope showed, some dramatic new treatments have emerged. Improvements in chemotherapy have elevated cure rates for some types of cancer while reducing the vicious side effects. Technological advances have made it easier to detect several forms of the disease, such as prostate cancer, at much earlier stages, boosting the odds for successful treatment. Scientists have a much greater understanding of how cancer is caused and may be prevented. Perhaps most impressive of all, two-thirds of children with cancer now survive at least five years.
But:
* Cancer remains the nation’s second-leading cause of death, claiming almost one life every minute in the United States. It still can be debilitating and painful, robbing its victim of dignity as well as life.
* Slightly less than half of all people who get cancer die within five years, only a 4.1% increase from survival rates of the early 1970s.
* Despite $22 billion in government funding over 20 years, the greatest gains have been made on rarer types of cancers while minimal improvement in death rates has been realized for the major cancer killers: solid carcinomas of the pancreas, breast, colon and lung, according to a 1988 Government Accounting Office report.
* Improvements in treatment have emerged largely from refinements in the tried-and-true methods--surgery, radiation and chemotherapy. Effective new strategies that could propel cure rates to new heights have not emerged.
* Because there is no universal access to health care, those advances in treatment that have been developed don’t always get to the patients who need them the most.
Experts today are humbled by the complexities of cancer. They acknowledge that there is no simple, sure-fire way to prevent or treat cancer--nor will there be soon.
“There has been a revolution in our understanding of cancer. But much of the payoff is still in the future,” says Dr. Lance Liotta, chief of the National Cancer Institute’s laboratory of pathology. “It takes a frustrating amount of time to go from the lab to application. You have to go through many complicated and time-consuming steps. . . . We are very enthusiastic about the promise of cancer research, but it takes some time.”
And says Helene G. Brown, director of UCLA-Jonsson Comprehensive Cancer Center’s community applications of research: “I think we’re doing pretty well, but I’m not overjoyed. Nobody is. Cancer has a lot of pain and suffering to it. But people have got to understand the complexity of this disease.”
Brown was among the inner circle of health activists who helped persuade Nixon to move ahead with the National Cancer Act. The act, signed before a standing-room-only ballroom crowd in the White House, was the result of prodding from a handful of medical philanthropists and scientists. They saw that the burgeoning field of biotechnology would soon give them the tools to crack profound medical mysteries.
With the Apollo program still landing astronauts on the moon, the heady feeling that American scientists could achieve anything they set their minds to was still prevalent in 1971.
The National Cancer Act was significant in several respects. With a separate, annual infusion of cash from Congress, it established special cancer centers under the auspices of the National Cancer Institute to oversee treatment and research, created an organized infrastructure on which researchers and practitioners could share findings and exchange ideas, and promoted public education.
Most important, the act gave the green light to pursue biomedical research at the molecular level.
Hopes surged. Some framers of the act even predicted a cure to coincide with the nation’s 1976 bicentennial.
“In the minds of many, there was a direct relationship between the federal commitment and the promise of what became known as the magic bullet--a single, simple answer to the cancer problem,” says Dr. Robert C. Young, who has held major posts with the NCI and the American Society of Clinical Oncology. “The concept of a magic bullet seems naive today.”
Nevertheless, there has been progress. In 1970, simplified theories of what caused cancer abounded. Some researchers thought that cancer was caused by a virus; others, by “outside” factors: what people did and how they lived. Now, experts think cancer is a genetic disease, involving a handful of particular genes whose normal functions go awry, either because the genes were faulty from birth or because of the natural aging process, environmental exposure or some combination of all these things.
Likewise, treatments of the 1960s and 1970s seem crude compared to those of today. Twenty years ago, it was not uncommon for a woman with a lump in her breast to awake from exploratory surgery with a Halsted radical mastectomy, in which breasts, underlying chest muscle and underarm axillary lymph nodes were gone, leaving, essentially, a cavity. Prostate cancer patients risked bleeding to death during surgery.
Today, women with breast cancer often keep their breasts while men treated for testicular or prostate cancer usually retain sexual function. Individuals with laryngeal cancers now keep their voice. People with bone cancer often retain their limbs.
From a doctor’s perspective, oncology, the field of medicine dealing with cancer, has undergone a great transformation in the last 20 years--not simply in scientific and technological advances but in its fundamental mind-set.
In 1970, this was a specialty bound tightly to the assumption that most patients were dying. Now it has become an area for physicians eager to pursue bold and ever-changing strategies for survival.
When a board-certified oncology title was first offered in 1972, fewer than 100 doctors were signed on. Now, more than 5,000 are board-certified oncologists.
And, when the National Cancer Act was signed, patients in search of the best cancer treatment went to one of three centers: M.D. Anderson in Houston, Roswell Park in Buffalo or Memorial Sloan-Kettering in New York. Today, the National Cancer Institute has created 54 “designated cancer centers” that must meet strict accreditation criteria in exchange for NCI support. Scores of other hospitals offer specialized cancer care.
This evolution has, in some instances, translated into spectacular successes.
Mortality rates for childhood cancer, which has been especially receptive to chemotherapy, have dropped 38% since 1973, according to a recent NCI analysis.
Testicular cancer, the most common cancer among men ages 20-35, is another example of stunning success. When Chicago Bears running back Brian Piccolo died of testicular cancer in 1970, he was among the 25% of the men stricken who succumbed to the disease.
Testicular cancer is now curable in 92% of all stages, largely due to a new class of chemotherapy agents, platinum drugs, discovered in the 1970s.
Among adults, cure rates have also soared for leukemia and lymphoma. Slight improvements have followed in colon, breast and ovarian cancer in which doctors have used potent drugs in combinations, with far greater effects.
Advances in cancer drug development have reverberated throughout medicine, experts say. Without much of the tedious basic research devoted to cancer in the 1970s and 1980s, medicine would have been embarrassingly unprepared to respond to AIDS, experts surmise.
For example, AZT, the first effective therapy approved for AIDS, was discovered in the 1960s in the search for a cancer drug, but was ultimately shelved because of its mediocre effects. In the early 1980s, AIDS researchers systematically reviewed cancer agents that had been tested over the years. AZT was dusted off and put to use.
“Every field of medicine has benefited from the money that was invested in cancer from 1970 on,” says Dr. Bruce Chabner, director of NCI’s division of cancer treatment.
Success rates have also improved among cancers that can be detected early.
Men who avoid undergoing a rectal exam to detect prostate cancer, for example, can now have a blood test, called the Prostate Specific Antigen test, which can detect a protein produced by cancer cells that circulate in the blood. Combined with the traditional rectal examination and ultrasound imaging to produce a picture of the prostate, the blood test resulted in a 73% increase in prostate cancer detection in a recent study.
“There is no data yet to prove you’re increasing longevity by picking it up earlier, but it’s only common sense that you’re going to cure more people. And it gives people more options for treatment,” says Dr. Allan M. Shanberg, a clinical professor of surgery and urology at UC Irvine and a principal investigator of the new blood test at Long Beach Memorial Medical Center.
With early detection opening more avenues to treatment, the standard cancer therapies--surgery, radiation and chemotherapy--have evolved to heightened sophistication.
High-tech, computerized imaging equipment such as computerized axial tomography (CT) and magnetic resonance imaging (MRI) have enabled radiation oncologists to see tumors in three-dimensional shapes and, thus, refine beams of radiation to attack cancer cells and spare healthy tissue.
But those triumphs, thus far, are tempered by setbacks.
Even the latest high-tech devices have had little effect on many advanced cancers. Lung, pancreatic and liver cancers have been largely immune to the combination chemotherapy that has yielded success in leukemia and testicular cancer. Bone marrow transplantation programs such as the one at City of Hope are one of the few new strategies for combatting late-stage cancer, but bone marrow transplantation is still considered high risk, costly and experimental for certain cancers.
Oncologists are also concerned that more new drugs have not been developed. Progress in chemotherapy has come about mainly from combining existing drugs. The physician’s relative inability to stop cancer once it has spread, or metastasized, virtually guarantees continued high death rates for several years to come.
“Serious obstacles to progress remain,” says Young. “ . . . These problems will not be solved with current treatment methods. . . . They will require new discoveries.”
Indeed, many experts predict that instead of new treatments the greatest turnaround in cancer deaths will come about from preventing cancer either through changes in the diet, elimination of smoking or avoidance of environmental carcinogens.
But results of these efforts in prevention are just beginning and may not be discernible for years.
“We will continue to make advances in treating metastatic cancer. There will be steps forward. But we’re all directing our efforts at trying to prevent cancer, detect it as early as possible and treat (it) as early possible,” says Dr. Martin D. Abeloff, president of the American Society of Clinical Oncology.
But this strategy relies on the patient’s unimpeded access to top medical care, something an increasing number of Americans lack.
Because the standards of care are constantly evolving, cancer patients are often faced with conflicting medical advice; or discover, too late, that they did not receive state-of-the-art care because no one at their local hospital had learned of it; or find government or third-party payers refuse to pay for the costly, cutting-edge care that is classified as experimental.
For all of these reasons, elderly people--who are most likely to get cancer--usually receive the worst care. According to a recent NCI analysis, cancer death rates increased by 12.9% from 1973 to 1988 among people age 65 and older while slightly declining for those under age 55.
Cancer experts acknowledge the need to bolster efforts in prevention, access to care and the treatment of cancer in the elderly. But these insights come at a time when legislators seem weary of the issue. The NCI budget has not grown, in real dollars, in more than a decade. In many areas, cancer research is being cut, not embellished.
Taking this perspective, it appears the war on cancer--the one backed by money--is waning. And the downturn in funding could knock the wind out of cancer research just when it is set to sail.
That’s because the real revolution in cancer, according to leading oncologists, has not yet reached people.
In the last decade, work with oncogenes, slightly different versions of normal genes that can cause abnormal cell growth, has enabled laboratory researchers to probe for the first time the basic question of what happens when a cell becomes cancerous.
About 50 oncogenes are now recognized, and some researchers think that a small number are related to most cancers--a finding that, if proved, would hasten progress toward far-reaching cures.
“The discovery of the oncogenes,” Young says, “is opening the door to a large number of therapy possibilities that were undreamed of when the war on cancer began.”
TARGETING A TUMOR: RADIATION THERAPY
Radiation Therapy
The use of high-tech equipment, such as that used at UCLA’s Jonsson Comprehensive Cancer Center, has enabled radiation therapists to deliver treatment to cancer patients in a way that maximizes destruction of the tumor while minimizing damage to the healthy tissue. Here’s how it works:
U.S. Killers
Cancer ranks as the second leading cause of death for Americans, accounting for more than 22% of all deaths.
% of Cause of Number of Total Rank Death Deaths Deaths 1. Heart Diseases 760,353 35.8% 2. Cancer 476,927 22.5 3. Cerebrovascular Diseases 149,835 7.1 4. Accidents 95,020 4.5 Other * 641,188 30.1 All causes 2,123,323 100
* Includes suicides, homicides and other diseases
SOURCE: CA-A Cancer Journal for Clinicians
Five-Year Survival Rates
Five-year survival rates vary from a low of 3% for pancreatic cancer to a high of 88% for testicular cancer. For all the cancers together, the average five-year survival rate is 52%.
% Once Type All Stages % It Spreads Pancreas 3% 1% Lung 13 1 Ovary 38 18 Oral 52 18 Colon-Rectum 53 6 Cervix Uteri 67 13 Prostate 71 29 Female Breast 75 18 Bladder 76 9 Melanoma 81 14 Corpus Uteri 85 26 Testis 88 54
Source: Cancer Facts and Figures 1991
Deaths by Site and Sex.
Lung and breast cancers are the most common killers in 1991.
Men Women 1. Lung Lung 92,000 51,000 2. Prostate Breast 32,000 44,500 3. Colon & Rectum Colon & Rectum 30,000 30,500 4. Pancreas Pancreas 12,000 13,200 5. Lymphoma Ovary 10,600 12,500 6. Leukemia Uterus 9,800 10,000 7. Stomach Lymphoma 8,100 9,700 8. Esophagus Leukemia 7,300 8,300 9. Bladder Liver 6,400 5,800 10. Kidney Brain 6,300 5,300 11. Liver Stomach 6,300 5,300 12. Brain Multiple Myeloma 6,200 4,500
SOURCE: American Cancer Society “Cancer Facts and Figures 1991”
Survival Rates for Children
Five-year survival rate s for child hood cancers have been steadily increasing . The data is from two different studies : one covers 1960 to 1973 and the other 1974 to 1988. Both use very limited sample groups and provide statistics on white children up to age 14 only.
Type 1960-63 1970-73 1974-76 1977-80 1981-87 All Types 28% 45% 55% 62% 67% Acute Lymphocytic 4 34 53 68 73 Leukemia Acute Myeloid 3 5 16 25 25 Leukemia Wilms’ Tumor 33 70 74 80 84 Brain & Nervous 35 45 55 56 58 System Bone 20 30 52 47 56 Hodgkin’s Disease 52 90 80 88 87 Non-Hodgkin’s 18 26 43 50 68 Lymphoma
SOURCE: National Cancer Institute
