Why hasn't America won the war against cancer?

0 Comments | Insight on the News, August 18, 1997 | by Susan Crabtree

A 26-year battle has been waged involving intense research and thousands of clinical trials -- and billion of dollars -- to eradicate cancer, America's most vicious hirer. The results? Not good enough.

Imagine a futuristic McDonald's where the golden arches are a symbol of the best in fast health food, where the most ubiquitous purveyor of king-size fries voluntarily serves meals complete with the recommended portions of fresh fruits and vegetables. Or, envision a time when Joe Camel billboards have been eradicated and -- in fact -- lighting up a cigarette is considered a sign of insanity or slow suicide. In essence, consider the possibility that in the next century cancer will be no more life-threatening than pneumonia or polio in the United States today.

For many health professionals dedicated to preventive care, these are not idealistic visions but attainable goals. For too long they have witnessed the sometimes weekly fanfare of the latest magic-bullet cancer drug, its claims splashed across the pages of some of the country's most trusted newspapers and magazines. When the trumpetings of these "breakthroughs" begin to fade into ambient noise, as they inevitably do, hope for a cure falls to new depths.

Now the advocates of preventive medicine have rattled the cancer-research establishment with an announcement that the war on cancer has been fought on the wrong front. Research efforts, the preventionists say, have focused not on eliminating the threat of cancer by determining its origins and causes but on treating the disease -- and even that with scant success. Their emphasis on new preventive techniques and studies are earning national attention, refocusing the debate about how to fight the "Big C," a diagnosis still widely regarded as a death sentence.

Whatever happened to the war on cancer, anyway? That is a question John Bailar III was bold enough to ask in a New England Journal of Medicine article published in late May, titled "Cancer Undefeated." Despite a 26-year battle involving intense research and thousands of clinical trials of promising new cancer therapies, Bailar found that since President Nixon declared the "War on Cancer" in 1971, there have been only spotty advances in reducing casualties. Bailar, a biostatistician and oncologist, spent 22 years at the National Cancer Institute, or NCI, the federal nerve center for cancer research. But during the last 11 years he has become a familiar antagonist of the cancer establishment. As early as 1986, then at Harvard University, Bailar declared that "years of intense effort focused largely on improving treatment must be judged a qualified failure."

This year, with 11 more years of data, "we see little reason to change that conclusion," says Bailar, now professor and chairman of health studies at the University of Chicago. With coauthor Heather Gornick, he wrote: "The salient fact remains that age-adjusted rates of death due to cancer are now barely declining. Hopes for a substantial reduction in mortality by the year 2000 were clearly misplaced."

As the turn of the century creeps closer, the notion that the war has been a losing battle hardly is news to cancer patients and their loved ones. After all, 8 million Americans now suffer from the disease; this year, 1.3 million more will be diagnosed and approximately 550,000 will die, according to the NCI. Bailar's recommendation to shuffle resources, however, shook the foundation of the medical establishment.

In mid-June the Senate held a hearing on the controversy surrounding Bailar's article. During testimony, Bailar urged a massive reallocation of current NCI resources from treatment research to prevention, increasing the latter from one-fourth of the national cancer-research budget to two-thirds. Of course, any such shift in funds would mean a restructuring of the entire cancer industry, a dramatic change in focus that Bailar admits many devoted scientists and doctors in the field may not be able to make.

The resentment was fast and furious. During Senate testimony, Richard Klausner, director of the federally funded NCI, objected to Bailar's method of lumping all cancer types together. He pointed to success in reducing lung-cancer death rates in men and women under 65, stomach cancer and colorectal cancer and the recent decline in mortality from breast cancer in white women, which he said likely is the result of early detection and today's almost universal use of adjuvant treatment.

According to Klausner, the NCI already is strongly committed to prevention research. Thirty-eight percent of this year's budget, or $911 million, is earmarked for prevention (a 5.6 percent gain from last year), compared with an $845 million investment in treatment-oriented research or just 35 percent of the annual budget. Bailar dismisses these numbers, saying that much of what the NCI calls preventive is not.

Bailar's article, however pessimistic, contains a silver lining. He acknowledges that the steady increase in age-adjusted mortality for all cancers had plateaued around 1991, followed by a 1 percent decrease from 1991 to 1994. He attributes most of the decline not to improved treatments but to reduced cigarette smoking, improved screening and decreases in the incidence of certain types of rare cancers, such as Hodgkin's disease and testicular cancer. He also applauded the remarkable progress made in eradicating childhood cancers, a segment that has seen death rates sliced in half since 1970. Yet even this, Bailar says, barely has affected overall mortality from the disease, since fewer than one-third of 1 percent of all cancer deaths occur in children under 15.