BOOK REVIEW: ‘The Death of Cancer,’ overcoming disease in spite of ourselves
The Death of Cancer
By Vincent T. DeVita Jr., M.D. and Elizabeth DeVita-Raeburn
After Fifty Years on the Front Lines of Medicine, a Pioneering Oncologist Reveals Why the War on Cancer Is Winnable — and How We Can Get There
Sarah Crichton Books $28 336 pages
“The Death of Cancer,” by Dr. Vincent T. DeVita, Jr., is about the heroes and heroines of America’s forty-year, $100 billion war on cancer. It’s also an exposé of the least admirable bureaucrats, regulators, and lawmakers our federal government has to offer. Interspersed throughout those stories are lessons in oncology, genetics, and cell biology. (DeVita is the co-author of a leading oncology textbook.)
Dr. DeVita has been a clinician and researcher at the National Cancer Institute (NCI), director of the NCI, physician-in-chief at Memorial Sloan Kettering Cancer Center (MSKCC), director of Yale University’s Cancer Center, president of the American Cancer Society, and is himself a recent survivor of cancer. DeVita was the first to demonstrate that chemotherapy could cure advanced cancers of major organ systems in adults, a breakthrough the American Society of Clinical Oncologists has called the top research advance in half a century of chemotherapy.
In the early 1960s, there were just two widely accepted treatments for cancer: surgery and radiation. At that time, most oncologists (including Dr. DeVita) believed cancer research was for “nuts, losers, or both.” Most cancer patients were sent home to die, and doctors who wanted to do more for them were, according to the former chief of medicine at Columbia University, “part of the lunatic fringe.” But, by 1963, combination chemotherapy was well on its way to vanquishing childhood leukemia, and, by 1969, the lymphomas had become largely curable by similar regimens. Then, in 1971, President Richard Nixon signed The National Cancer Act into law. This legislation launched the national war on cancer by overhauling the structure of the NCI and increasing its funding. During the long struggle to get the bill passed, DeVita was frequently dismayed by the political maneuvering, the power plays, and the overall level of duplicity that marked so many of his interactions with high-ranking Washington insiders. He was especially disappointed by Senator Edward Kennedy’s behavior.
Early in the game, writes DeVita, “The government’s financial investment in the war on cancer had turned into a miniversion of the Pentagon, riddled with fiefdoms, favoritism, and decision-makers intoxicated with the power that comes from having large sums of money to distribute.” The NCI’s priorities were “more about egos than helping patients.” There were “frequent turf battles with radiotherapists and surgeons, who did not like the idea that chemotherapists might become as important in the treatment of cancer as they were.” “You might hope,” he writes, “that oncologists were concerned with the welfare of their patients most of all, but that’s unfortunately not always the case.”
Nevertheless, Dr. DeVita now believes we are winning the war on cancer. He also believes we’d be winning it faster were it not for certain obstacles that, surprisingly, are not scientific but bureaucratic. “We are not limited by the science,” he explains, “we are limited by our ability to make good use of the information and treatments we already have.
“People are dying not because drugs don’t exist but because they can’t get them.” He provides plenty of specifics, and he pulls no punches.
A promising new drug for colorectal cancer, 5-fluorouracil, had shown little efficacy in clinical trials because it had been administered improperly by people who clearly misunderstood the fundamental biology of tumor growth (i.e., growing cancer cells do not take holidays). “Unless you believed in magic,” writes DeVita, “you couldn’t treat actively growing cancer cells on an every-six-weeks schedule.” Many years after the ill-conceived testing protocols had been abandoned, 5-fluorouracil proved to be a highly effective treatment for colorectal cancer and is now, DeVita says, “part of every effective treatment regimen used around the world.” But the “FDA set the drug and the approval process back two decades.” Twenty years. During those two decades, thousands of colorectal cancer patients died, needlessly.
Here’s another example of death by government regulation: When your best friend is one of the most skilled and knowledgeable oncologists in the world, you should feel pretty optimistic about your chances of beating cancer. DeVita had the medical know-how to save his friend, Lee, but he couldn’t apply it. “We were at the end of the line, but not for the right reasons. It wasn’t because we were out of options; it was because regulations and research protocols stood in the way.” Without access to the one cancer drug that would have saved Lee’s life, DeVita had to watch his friend die. “It was awful to watch. I kept thinking about the treatments Lee didn’t get.”
“Too often,” DeVita laments, “lives are tragically ended not by cancer, but by the bureaucracy that came with the nation’s investment in the war on cancer, by review boards, by the FDA, and by doctors who won’t stand by their patients or who are afraid to take a chance.” Because cancer is still so extremely difficult to understand and treat, DeVita has little patience with government bureaucrats who are incapable of comprehending the value or meaning of our best researchers’ hard-won knowledge as it applies directly to saving individual lives. DeVita gives numerous examples of how FDA regulators such as Robert S. K. Young failed to comprehend fundamental principles of medical oncology, especially when it came to combination chemotherapy. At one point, Young had “virtually shut us [NCI’s Division of Cancer Treatment] down. He told me he didn’t believe in the usefulness of cancer drugs and meant to stop their development.” It wasn’t the last time weak FDA leadership would allow a single mid-level staffer to hold up all of cancer drug development. “Young persisted in blocking cancer drug approval. As part of his paralyzing tactics, he held up approval of the drug cisplatin for three years, even though every doctor in the country knew it was an effective agent and very useful in testicular cancer.” DeVita tries in vain to make sense of Young’s irrational behavior: “Even when they defied logic, he preferred regulations . . . My feeling is that it was a compulsion with him.” DeVita’s best explanation for regulatory overreach, in general? “This has more to do with control than with reason.”
Clearly, DeVita is no friend of the FDA or its champions in Washington. Partisan politics have allowed the FDA to seize control over matters of clinical practice that are outside the scope of its original mandate and far beyond the limits of its medical expertise. “The FDA now routinely regulates research and practice,” DeVita writes. It has “turned the NCI’s clinical trials program into a muddy morass,” and the review process has become “an end in itself.”
Nobody is better at denying science than a scientist. Especially a cancer scientist with prestige or money at risk. Or turf to protect. Or a new drug to oppose or promote. Such folk abound in federal government agencies, especially the NCI and the FDA. In the power struggles that go on daily between government agencies (and also between competing rock-star oncologists at cancer centers), scientists routinely deny the validity of their rivals’ science. In academia, science denial is a commonplace substitute for professional rigor. And when a culture of science denial takes root in a cancer center or is imposed upon it by the FDA, patients pay with their lives.
When Vincent DeVita took over as the new chief of medicine at MSKCC, he found the place “full of fiefdoms of old-guard physicians mostly interested in defending their own turf.” He had a good idea of what to expect, because ten years earlier he had witnessed a disturbing scene in an auditorium at Rockefeller University, right across the street from MSKCC: While surgeon Bernie Fischer was in the middle of a presentation about the advantages of lumpectomy over radical mastectomy, Jerry Urban, chief of breast surgery at MSKCC, stood up and screamed, “What you are saying is pure nonsense” and walked out of the room, followed by a few hundred of the world’s finest doctors. DeVita watched in horror, because he knew exactly why these practitioners hated new treatment protocols: “Surgeons could charge more for a radical mastectomy than for the less invasive lumpectomy.” In other words, they could make more money on outdated treatments than modern ones. And, a decade after this incident, long after the lumpectomy had become the standard of care for breast cancer throughout the world, MSKCC, still following Jerry Urban’s lead, continued performing radical mastectomies. MSKCC patients like Happy Rockefeller and Betty Ford would need to have known, completely on their own, that better treatment options existed outside of the “very best” cancer center in the world.
It’s easy to disregard DeVita’s accomplishments if you simply deny the science behind them. Which is exactly what dozens of cancer experts did when DeVita first presented his findings on new lymphoma treatments. The majority of oncologists at the time (mainly surgeons and radiotherapists) were convinced DeVita’s claims couldn’t possibly be true; They thought “something had to be wrong with my data,” DeVita recalls. As Emil Freireich once said, “People can’t see beyond their own certainties.”
Vincent DeVita’s ego has got to be the size of a small planet. But medical doctors in general (especially males), have long been famous for their astonishingly high self-esteem. You can describe this as either self-confidence or arrogance. Whatever you choose to call it, oncologists need truckloads of it. Many of the world’s finest medical practitioners are driven — at least in part — by hubris, and Vincent DeVita may be one of them. However, the stories he tells demonstrate just how important it is for oncologists to be decisive and fearless under pressure. Over the years, he learned from his mentors to have “the confidence to question dogma” and to believe in what he saw more than in what he was told. So DeVita’s book is worth reading, if only to see vivid examples of how doctors with huge egos can sometimes accomplish the impossible.
Consider the colossal ego of Dr. Emil J. Freireich, the putative father of clinical cancer research and one of Vincent DeVita’s most important mentors at the NCI. In “David and Goliath,” Malcolm Gladwell tells the story of how Freireich led the way in developing the first effective treatment for childhood leukemia. He and Emil Frei were the first to have success with combination chemotherapies. This was soon after the NCI’s clinical director had said to Freireich, “You’re insane,” and told him he‘d be fired if he kept doing the platelet transfusions that were keeping leukemia patients from bleeding to death before they could receive treatment for their cancer. Using highly toxic chemotherapy drugs in combination was unprecedented. Experts considered it too dangerous, even unethical, especially with small children. NCI clinicians and other champions of medical orthodoxy openly denounced Freireich and refused to cooperate. “I had to do it all myself,” Freireich says. “I had to order the drugs. I had to mix them. I had to inject them.”
Most doctors in Freireich’s position would have played it safe. But a timid oncologist is like a timid lion tamer. The situation for his patients was dire: “When they came to the hospital,” he told Gladwell, “ninety percent of the kids would be dead in six weeks.” Emboldened by a strong belief in his own instincts and by the (lukewarm) approval of his boss, Gordon Zubrod, Dr. Freireich defied the experts, ignored the heckling of his peers, and made the most significant cancer breakthrough of the 20th century. “It was crazy,” he says, “but smart and correct. I thought about it and I knew it would work.”
Today, thanks to Emil Freireich and his partner Emil Frei, childhood leukemia has a cure rate of over 92 percent. “Did he care what people thought of him?” DeVita asks. “Maybe. But not enough to stop doing what he knew was right.”
A few years later, Freireich mentored DeVita and cheered him on at critical moments in the development of new chemotherapy regimens for Hodgkin’s lymphoma. “Freireich told us to do things that we had been taught were heretical,” DeVita told Gladwell.
What does DeVita think we have to show for the $100 billion America has spent fighting the war on cancer? “Little or nothing,” he’s heard people say, “The war on cancer has been a failure. People are still dying, because you can’t solve a problem by throwing money at it.” DeVita disagrees: “We are winning this war,” he insists. “People still get cancer, and people still die from it. But thanks to this concentrated effort, far more people survive than was true when this war was launched . . . For a long time, it didn’t look so good. It was 1990 before the overall incidence of cancers in the United States began to decline.”
Yes, the incidence of all kinds of cancer has declined, and so has the mortality rate. Childhood leukemia and several types of advanced lymphoma are now almost completely curable. Many other types of cancer have seen mortality rates drop — by 40 percent in the case of colon cancer, 25 percent for breast cancer. How do we put a price on these successes? What’s the value in dollars and cents? Economists Kevin Murphy and Robert Topel at the University of Chicago looked at the economic benefit of improvements in the health of the workforce. They calculate that for every 20 percent drop in cancer mortality, about $10 trillion is added to the economy. Even if their numbers are wildly optimistic, the high return on investment is staggering.
So, what’s keeping us from eradicating cancer altogether?
It’s “not the science,” says DeVita, “but the regulatory environment we work in . . . The death of cancer is inevitable. It is a question not of if but of when. And when will be determined by what we do next . . . The war on cancer has been one of the most successful government programs ever. But we have outgrown the original act, and we need a new one, with a new organization.”
He’s realistic, though: “I don’t think there will ever be a world in which cancer doesn’t occur. It’s in our biology. In the millions of cell divisions that take place in our bodies every day, there are too many opportunities for mistakes.”
“The true story of the war on cancer is not just a war against nature but a war of us against ourselves . . . We have the tools to eradicate cancer and will soon reach the day when ‘cancer’ is no longer the scariest word in the English language.”