Download Catherine Hercus 40 years after the war on cancer

Catherine Hercus
40 years after the war on cancer – How far have we come?
President Nixon famously declared a war on cancer in 1971 – with the goal to find a
cure by 1976, the US bicentennial year. 1 Fuelled by the recent victory of the Space
Race, a growing number questioned why a similar victory couldn’t be achieved
against cancer. Mary Lasker was a prolific activist in the mid 1900s in America,
recruiting politicians and people of influence to recognise cancer; Neil Armstrong’s
(and indeed America’s) triumph compelled her to describe a War on Cancer as the
conquest of ‘inner space’ (as opposed to ‘outer space’). A ‘moon shot for cancer’ was
initiated. 2 In 1971, Ann Landers, an advice columnist from Chicago, a friend of
Lasker’s, published a column asking, ‘If this great country of ours can put a man on
the moon why can’t we find a cure for cancer?’ An election was approaching in 1972,
and Nixon felt pressured to find an end to one of two wars: the war in Vietnam or the
war against cancer. 2 As Siddhartha Mukherjee alludes to, ‘an end to the war in
Vietnam was nowhere in sight, but a campaign against cancer seemed vastly more
tractable’ – hence in December of 1971, Nixon signed the National Cancer
Act. 2 However, this Act, born of political activism, and expanding the scope and
funding of the National Cancer Institute considerably 3, was greeted with skepticism
by a number of scientists at the time. Sol Spiegelman, a Columbia University cancer
scientist, stated, ‘An all-out effort at this time would be like trying to land a man on
the moon without knowing Newton’s laws of gravity’. 2 Others thought that the
metaphor of war would ‘whip up a froth of hype and hope’, for people to inevitably
be crushed. 2 Irvine Page, editor of a scientific journal at the time, referred to people
being impatient with perceived lack of progress, and commented on this mindset:
‘Having seen what can be achieved by systems analysis, directed research and great
coordinated achievements such as the moon walk, they transfer the same thinking to
the conquest of cancer all too readily.’ 2
A ‘war’ that began with controversy continues to cause debate today. Have we won
this war, a war deemed by so many at the time to be futile? Clearly a ‘cure for cancer’
had not appeared by the aforementioned 1976 (the original indicator of ‘winning the
war’) but have enough developments been made to evidence substantial progress
against cancer?
In the 1980s and 90s, many sources drew on increases in cancer related mortality rates
to conclude that we had in fact lost the war. Between 1962 and 1885, cancer related
deaths indeed increased by 8.7%. 2 Bailar and Smith, in an article published in 1986,
asserted, ‘We are losing the war against cancer, notwithstanding progress against
several uncommon forms of the disease, improvement in palliation, and extension of
the productive years of life.’ 4 However, this assessment focused primarily on ageadjusted mortality rates, sparking criticism from many of the fact it didn’t take into
account years of life gained, for example by curative treatment of childhood
leukaemia. This trend of increasing continued into the early 1990s, as death rates per
100,000 from cancer had increased from 1970 to 1990 in women and men. 5 The War
on Cancer had been seemingly futile. Yet by 2006, these death rates decreased again.
For men, the death rate increased from 249.3 deaths per 100,000 in 1970, to 279.8 in
1990, and dropped to 221.6 in 2006. For women, 163.0 deaths per 100, 000 were seen
in 1970, rising to 175.3 in 1991, and dropping to 153.7 in 2006. 5 These figures are
thought to reflect reduced tobacco use, increased screening allowing early detection
of several cancers, and modest to large improvements in treatment for specific
cancers. 5 The Victorian Cancer Registry published figures in 2007 indicating that
Catherine Hercus
from 1990 to 2004, rates of 5-year survival from cancer of any type or morphology
had increased. 6
Yet different cancers, affecting diverse organs and with many morphologies, bear
profoundly different prognoses since ‘cancer is in truth a variety of diseases’, as
Klausner, Director of the National Cancer Institute maintained in 1997.2 Rates of
mortality in Jemal’s study decreased for all the major cancer sites in all age groups –
colorectal, prostate, breast and lung. Conversely, rates of death increased for liver
cancer in both sexes, oesophageal cancer in men, pancreatic cancer in women and
melanoma in men. 5 Likewise Victorian statistics reveal that in 2007, statistics for
survival were far more sombering for certain cancers than others, and others much
more heartening. 6
Breast cancer is the most common cancer in women, and projections are that
incidence will continue to rise; moreover it is the second most common cause of
cancer-related mortality in Australian women after lung cancer, making it a highly
topical issue. Despite this rise in incidence, mortality in Australia has been declining
since the mid 1990s. In 2006, the 5-year relative survival was 88% for women
diagnosed with breast cancer in 2000-2006; this was a vast improvement from 19821987 when the 5-year relative survival was 73%. 7 Improvements in survival have
been largely attributed to better targeted adjuvant systemic treatment, increasingly
effective chemotherapy; the screening program may also have had some impact
(introduced in Australia in 1991 8). 6 In his book, Mukherjee refers to the different
expectations women over time may have regarding breast cancer; before the 1900s
surgery was the only treatment option – and was often quite brutal in technique. The
discovery of X-rays as a treatment modality in the 1900s however offered new hope,
and in the 1970s adjuvant combination chemotherapy became widely used. No longer
was every cancer viewed as similar, but awareness of hormone receptors allowed use
of drugs like tamoxifen. The 1980s brought discovery of the Her-2 receptor, and
consequent use of Herceptin. Finally in the 1990s the significance of the BRCA-1 and
2 genes came to light; suddenly women were being categorised regarding whether or
not they expressed these genes, and they and their families were screened more
emphatically if they expressed the genes. 2 These vast changes in treatment and
screening modalities over time reflect veritable progress – but still metastasised breast
cancer, breast cancer that is oestrogen receptor negative, or Her-2 negative, or
unresponsive to standard chemotherapy carries a similar prognosis to that of the
1700s. 2 Sufferers from these cancers would understandably doubt how far we really
have come.
As with breast cancer, bowel cancer screening has changed the landscape regarding
the disease, especially since during colonoscopy polyps can be removed at a precancerous stage; therefore screening can in fact decrease incidence. 5 5-year survival
in Victoria in 1990 was 47%, as compared to 63% in 2004. 6 Additionally, better
treatment and multi-modality treatment have contributed to these improvements.
Paediatric leukaemia perhaps represents one of the greatest success stories of the
twentieth century; in the 1950s the overall survival was about 10% - now it is 8090%. 1 But still the stories of relatively poor outcomes from cancer dominate many
people’s assessments – for example, survival for lung cancer remains poor. Even
though the major aetiological factor of lung cancer has been validated, and mortality
has thus decreased, the survival rate once one is diagnosed with the disease hasn’t
drastically changed. 6 The 5-year survival for Victorians with pancreatic cancer in
2004 was still a mere 5%, confirming that the disease generally presents at a stage too
advanced for curative treatment. 6
Catherine Hercus
One could question, and many have, why we can eradicate smallpox and polio, but
not cancer. In the 1960s a battle against smallpox began, and 10 years later with 300
million dollars having been invested, the disease was a thing of the past. Likewise,
polio, after 21 years and 18 billion dollars, became a nightmare we no longer had to
worry about. In 2009, the War on Cancer had already cost 100 billion dollars.
Reduction in cardiovascular disease death rate had been far greater, at 64%, dwarfing
progress made in the War on Cancer. 9 The natural question to ask is: why can’t the
same level of advancement be seen in cancer?
Rehemtulla implies that the sheer complexity of cancer makes such rapid advances
impossible; ‘the more we study cancer the more complex it appears.’ He also alludes
to the relatively new knowledge regarding cellular and molecular biology tools to
interrogate tumour cells – without this knowledge our fight was far less meaningful. 9
Cancer research, he maintains, ‘can also be distracted by fads and political agendas
that come and go over time’. 9 As early as the 1940s, Mary Lasker was working on
this principle – that scientific advances will depend heavily on government
involvement and funding.
John Cairns, a Harvard biologist, referred to the difference between eradication of
cancer and eradication of infectious disease in 1985:
‘The death rates from malaria, cholera, typhus, tuberculosis, scurvy, pellagra
and the other scourges of the past have dwindled…because humankind has
learnt how to prevent these diseases…to put most of the effort into treatment
is to deny all precedent.’ 2
Richard Klausner stated that it is ‘unlikely we will soon see a magic bullet’. 2
Regardless of whether prevention or treatment is the key, one point seems relatively
certain: the War on Cancer declared by Nixon in 1971 was exceedingly ambitious.
Progress has certainly been made over the years in cancer knowledge and treatment,
even though it hasn’t matched the hope of a cure by 1976. In the 1890s, a ‘radical
mastectomy’ involved slicing through the collarbone, reaching for lymph nodes
beneath it, if not cutting through the pectoralis major, leaving women deformed. 2
This operation was done without any concept of staging, even to women who would
now just have a lumpectomy. These radical mastectomies were also done to women
whose cancers had metastasised, even though as early as 125 AD, Galen (a physician)
referred to the problem of removing cancers surgically being that ‘black bile’ would
flow right back – it was everywhere. 2 He thought cancer was the result of a systemic
malignant state, an overdose of black bile. The differences in knowledge now from
the 1890s, and the time of Galen, are astounding. We now know how to stage cancer;
some may be removable through surgery, but some may be associated with the ‘black
bile’ Galen referred to, in essence metastatic.
Furthermore, considerable improvement has been made in mortality and survival for
many of the common cancers since Nixon’s war was declared. A number of cancers
have not progressed nearly so much, but as Klausner stated, the problem with
declaring a war on cancer in general was that it ignored the existence of cancer as a
variety of diseases, rather than one entity. The war was also widely acknowledged to
be a premature fight, prompted by advances in entirely different fields, such as space
travel. With the prematurity and complexity of the war taken into account, Mukherjee
suggests that perhaps in order to ‘win’ the war on cancer we should redefine victory.
He states that ‘we do not know the biological basis for cancer’s heterogeneity…what
is certain, however, is that even the knowledge of cancer’s biology is unlikely to
Catherine Hercus
eradicate cancer fully from our lives.’ 2 Therefore, although we haven’t won the war
in the terms stipulated by Nixon in 1971, perhaps we have won a more reasonable
fight in having come as far as we have. In 2003, Dr Andrew von Eschenbach, the
director of the National Cancer Institute (US), made a challenge to ‘eliminate the
suffering and death from cancer’ by 2015. 9 This would be a far more reasonable aim
than Nixon’s, and is one with which we have already made significant progress.
It will be the task of the doctors of the future to continue in this battle against cancer,
and the most important means of doing this will be to adequately integrate clinical
with laboratory research; in 2010 Brennan et. al maintained that ‘without better
integration across clinical research and laboratory research questions may remain
about where we stand in the war on cancer.’ 1 Furthermore, as Mary Lasker realised in
the mid-1900s, our fight will be futile without the support of leaders of our respective
countries. Forthcoming doctors should not be discouraged by our failure to ‘cure’
cancer by 1976, and should instead focus on relieving ‘suffering and death from
cancer’, as Eschenbach eloquently promoted.
Catherine Hercus
References:
1
Brennan R, Federico S, Dyer MA. The war on cancer: have we won the
battle but lost the war? Oncotarget. 2010 Jun;1(2):77-83. Available from:
http://www.ncbi.nlm.nih.gov.ezproxy.utas.edu.au/pmc/articles/PMC2945373/?t
ool=pubmed.
2
Mukherjee S. The emperor of all maladies : a biography of cancer. 1st
Scribner trade paperback ed. New York: Scribner; 2011.
3
Okon T, Schwartzberg L. Are we winning the war on cancer? J Oncol Pract.
2011 May;7(3 Suppl):62s-4s. Available from:
http://www.ncbi.nlm.nih.gov.ezproxy.utas.edu.au/pmc/articles/PMC3092456/?t
ool=pubmed.
4
Bailar JC, 3rd, Smith EM. Progress against cancer? N Engl J Med. 1986
May 8;314(19):1226-32. Available from:
http://www.nejm.org/doi/full/10.1056/NEJM198605083141905.
5
Jemal A, Ward E, Thun M. Declining death rates reflect progress against
cancer. PLoS One. 2010;5(3):e9584. Available from:
http://www.ncbi.nlm.nih.gov.ezproxy.utas.edu.au/pmc/articles/PMC2834749/?t
ool=pubmed#pone.0009584.s004.
6
Cancer Council Victoria. Cancer Survival Victoria 2007. [Internet]. c2007
[cited 2012 April 20]. Available from:
http://www.cancervic.org.au/downloads/cec/survival-2007/Cancer-Survival2007.pdf.
7
AIHW 2009. Breast cancer in Australia: an overview, 2009. Cat. no. CAN
46. Canberra: AIHW. Available from: http://www.aihw.gov.au/publicationdetail/?id=6442468297.
8
Australian Government Department of Health and Ageing 2012. [Internet]
c2012 [cited 2012 April 19]. Available from:
http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/
breastscreen-about.
9
Rehemtulla A. The War on Cancer rages on. Neoplasia. 2009
Dec;11(12):1252-63. Available at:
http://www.neoplasia.com.ezproxy.utas.edu.au/pdf/manuscript/v11i12/neo091
866.pdf.