by Alexandra Bowie
Vincent DeVita opens his memoir “The Death of Cancer” with a story: in a chapter titled “Outrageous Fortune” he recounts the history of his close friend Lee–from Lee’s diagnosis with prostate cancer through efforts to find the best treatment, surgery, radiation and a lengthy remission. When the cancer recurred, Lee joined a study that examined the effect of a set number of treatments. The drugs slowed but didn’t stop the cancer and Lee’s treatment ended with the study. Eleven years after the initial diagnosis, Lee died. Soon thereafter, a new drug that did push Lee’s type of prostate cancer into remission became available and in Dr. DeVita’s view would have been likely to save Lee’s life. If Lee had been able to take the study drug in a regular maintenance dose, Dr. DeVita believes, he would have survived until the drug that worked became available. To Dr. DeVita, this is more than bad luck; it’s an indictment of a system that “limits our ability to make good use of the information and treatments we already have.”
DeVita started his career as a research chemotherapist, a clinical associate at the National Cancer Institute, part of the National Institutes of Health, after medical school at George Washington. It was one of those serendipitous turns careers can take; he wanted to become a cardiologist (but botched, he says, the interview at the National Heart Institute) and he did not want to be a medic in Vietnam – service at the NIH would count as military service. Eventually, he became director of the NCI, served as physician in chief at Memorial Sloan Kettering Cancer Center in New York and later became the director of the Yale Cancer Center. Working with others, in the face of opposition by practitioners who believed that surgery and radiation were the keys to cancer treatment, he developed the first combination chemotherapies that successfully treated Hodgkin’s disease and paved the way for successful combination treatments for many additional cancers. Bucking conventional wisdom also gave him a strong belief in his own judgment.
“The Death of Cancer” includes clear explanations of how tumor growth rates and chemotherapy interact, the different roles chemo, surgery, and radiation play in cancer treatment, and a cogent explanation of how cancer cells develop and what characterizes cells as cancerous. There are many touching stories of treatment success, and several moving descriptions of failure, including the unsuccessful treatment of DeVita’s own son for aplastic anemia. DeVita outlines the history of our understanding and treatment of cancer, focusing on three paradigm shifts (his word) in cancer treatment over the past half century.
The first was the recognition that combination chemotherapy could cure advanced cancer. That led to the decline in mortality of the leukemias and the lymphomas . . . [a]nd it gave rise to the use of adjuvant chemotherapy–cancer drugs paired with surgery and/or radiotherapy–that led to the decline in mortality of common cancers like those of the breast and the colon.
The second . . . was the result of research that gave us proof of principle that targeted therapy–drugs aimed at specific molecular lesions . . .– was successful and that it could convert a previously fatal leukemia into a chronic disease that did not reduce the patient’s life span . . . The third . . .was the understanding that immunotherapy . . . can work in a majority of patients.
Together, these breakthroughs have resulted in treatment modifications and extended lives. As DeVita writes, they have “changed the experience of having cancer.” His concern is that too many other promising approaches are slowed by caution, or doubt, or pessimism, all of which are built into a regulatory structure that frustrates the cancer doctor’s ability to take action based on promising early results. And delay is something to which Dr. DeVita cannot resign himself. He prescribes a new cancer act of Congress, one that will include a position of cancer czar with budget authority over “all government components of the cancer program,” funding for an expanded network of comprehensive cancer centers, and delegation of spending authority to center directors so that they can build fast-acting, flexible treatments. Perhaps most important, he argues that the FDA (whose approach may already be changing) and the NCI should delegate all authority for early clinical trials to cancer centers, allowing doctors flexibility not permitted under today’s regulatory structure: one that, Dr. DeVita believes, tightly over-regulates cancer therapies.
But success in cancer treatment is difficult to define – does it mean removing all measurable signs of cancer? Continuing treatment with maintenance drugs? Which of the many treatments under study are those going to be? At every point there are things we don’t know, and some we will know in the future. The doctoring Dr. DeVita describes is muscular and creative, based on a deeply held belief that if patients can hang on a little longer a new drug that will work is just around the corner. I’d definitely want to speak with him if I, or a close family member, were diagnosed with cancer. But I’m not persuaded by his prescription for the cancer research infrastructure. The problem is that generalizing from the particular doesn’t always work out: we don’t know what we don’t know. Dr. DeVita is correct, as a society we need widespread basic research, broad access to clinical trials, and a better way of translating research into practice. But because not every doctor has the time and inclination to do the careful research and follow detailed protocols–as Dr. DeVita’s recollections show–we need administrative structures that won’t allow the quick and easy widespread adoption of treatments that may work only for a small number of people.
“The Death of Cancer” is a useful contribution for the general reader, a good supplement to “The Emperor of all Maladies” by Siddhartha Mukherjee and “The Breast Cancer Wars” by Barron Lerner. But it’s hard not to take Dr. DeVita’s conclusions without a grain or two of salt. Do you agree? Let us know in the comments.
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