Cancer Wars

Scientists should lose the hype and just get on with the work

This week I went to the funeral of an unsung great man of math education, Steve Sigur, who taught at a local school for thirty-five years. He was always described as a gentle bear of a man, and that he was.

With his great height, huge belly, and big red scraggly beard, he looked like a mountain man, and he did spend summers roaming the Rockies. Alone, off trails, with a couple of pounds of dried rice and lentils and a keen knowledge of edible plants, he would draw strength in this wandering solitude, and come back ready to change lives.

He consistently had a national-prize-winning math team–from Georgia?! was the classic response–and he spawned other math teachers, including my son. But the memories pouring in from indifferent math students are just as grateful and loving as those from geeks. Solitary by nature and childless, he gave of himself to the students in and after school and had hundreds of non-biological offspring.

We taught a short course together on math in biology, where I supplied the biology and marveled at the math, and he was exquisite. He loved math and made the kids love it, with a seemingly effortless grace. So you don’t want to watch a man like this having his brain eaten away by a malignant glioma. You want to beg God or the universe or something, Please, any other organ, not his brain.

I am no stranger to cancer. My late wife, friend, constant companion for thirty years, and devoted mom to my three kids struggled with breast cancer for eight years. Her brain was spared, but her lovely body was slowly and cruelly destroyed. I was angry at medical science–Where are the cures?–and this was rekindled by an editorial in the June 19th New England Journal of Medicine, “Cancer Immunotherapy–The Endgame Begins.”

It accompanies a review of recent advances in cancer immunology by Olivera Finn–she just sticks to the facts, many of which are promising-and a case study by Naomi Hunder and colleagues, who took a melanoma patient’s own T-cells, prepared them to specifically attack the tumor, and re-injected them, with good results for three months. They too are very modest, saying their findings “support further clinical studies.”

Not so the editorialist, Louis Weiner: “In 1987,” he begins, “an editorial…asked whether the field of immunotherapy was at ‘the beginning of the end’ or ‘the end of the beginning.’ In retrospect I would say it was at ‘the beginning of the beginning.’ Have we made progress since then? Finn, in her review…answers emphatically in the affirmative, and the report by Hunder et al…underscores the remarkable potential of the immune system to eradicate cancer, even when the disease is widespread.”

His own recognition of the misleading language in the 1987 editorial does not prevent him from ending his own this way: “Do the findings of Hunder et al. represent a mirage, an oasis, or an early sighting of the destination? Time will tell, but I suspect that if the destination is not yet at hand, it is in sight. The endgame has begun.”

I am no cancer expert, but I understand the written word, and both these editorials, more than twenty years apart, abused it.

I first saw cancer in the early ‘60s, when I volunteered to help children who were dying of it. Around then, the bulletin of my little synagogue carried an anguished letter by the president of the congregation, whose sister had just died a horrible cancer death. His letter was an open one, to another president-the one in the White House-begging him to fund the search for a cure.

I vividly remember Richard Nixon’s “war on cancer” about ten years later, in 1971. He committed $100 million, a small fraction of what we were spending in Vietnam, and fought both wars to a standstill, if not defeat. As Bernadine Healy, a former director of the National Institutes of Health, wrote recently, “Some 37 years later, 565,000 Americans yearly are dying because of unchecked cancer, and their ranks are swelling. It is now the No. 1 killer of adults under age 85.”

This is partly because we have done so much better against cardiovascular disease–you have to die of something. But between 1970 and 2000, there was a six-year increase in U.S. life expectancy, and 3.9 of them were due to improvements in heart disease and stroke. Cancer improvements contributed two or three months. For young cancer patients, the improvement in survival has been nil.

There have been advances, and every additional survivor is a life saved. But we were led to expect much more. When I was in medical school in the early ‘80s, and again when, about halfway through my wife’s illness, I attended the 1993 national breast cancer conference, I learned that cures were just over the horizon. Why?

New science: genes for cancer were being directly studied; blood vessels, the lifelines of tumors, would soon have their growth blocked; new drugs would target metastasis, the process that kills; and the patient’s immune system would be strengthened and directed against the tumor, perhaps through vaccines, or mimicked by drugs.

Some of these predictions have come true in small but important ways. Gene studies led to Gleevec, useful in some leukemias, and herceptin, which saves a small fraction of women with breast cancer at a cost of increased heart disease; some drugs that restrict tumor blood vessels help a bit together with standard treatments; interferon and interleukin-2, immune system drugs, have limited roles; and the only approved cancer are those that protect against viruses that cause cancer.

In 2008, as in 1908, the mainstays of cancer treatment are “slash, burn, and poison”-surgery, radiation, and toxic chemotherapy.

Of all things we face in medical science, cancer is the hardest, because it is the most like life itself. It is not a foreign agent, or a starkly abnormal process like inflammation or injury. It is an exaggeration of what most normal cells must do–multiply and survive. That is why the treatments are almost as bad as the cancer, and sometimes worse.

So as the widower of a cancer victim, I wish we could have a moratorium on such phrases as “war on cancer,” “endgame,” “beginning of the end,” and “end of the beginning.” They are hurtful to some of us who have lived a lifetime, heard the frequent hype, and seen very limited gains. I believe in science and I am optimistic, but please, spare me the predictions and get on with the work.

Minutes after I posted this, the phone rang and I learned that a friend from college just died of lymphoma, in his mid-60s. Somehow, we have to do better.

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