by Clifton Leaf (2013). Vividly written account on “why we’re losing the War on Cancer – and how we can win it” (subtitle). Authored by a Fortune journalist over nine years, it is obsessively sourced – 80 pages of endnotes and 87 pages of references. Through lively portraits of individual patients, doctors and researchers, the book recounts some of the success stories of the War on Cancer (launched under President Nixon in 1971): Gleevec (dramatically reducing the mortality and morbidity of chronic myeloid leukemia), many childhood malignancies (acute lymphocytic leukemia), and the estrogen-blocking tamoxifen for breast cancer. The bulk of the book is about why we are not winning this book (something which is almost completely unacknowledged).
Upon closer inspection, the decline in cancer rates that the National Cancer Institute widely proclaim refer to death rates age-adjusted to the US 1970 population. When dissecting these wins, they turn into rather pyrrhic victories. Of course, other communities likewise express their progress using appropriate metrics; take an investment fund whose annual return is 8%. This hides the fact that the 8% is relative to the average return of the industry; in reality, the fund lost 10%, which was, however, less than the average fund in that industry.
While crude rates (how many deaths per 100,000 people) for all deaths combined (car accidents, lightning strokes, murder etc) excluding cancer fell by 24% between 1970 and 2010, the crude cancer death rate increased by 14%. In 2013, an expected 580,000 people in the US will die of cancer, and an estimated 7.6 million worldwide. Victory in the War on Cancer appears to be as illusive as the victory in the War on Drugs! By and large, diagnostic tools have improved – think pap smear, mammogram, and colonoscopy – allowing doctors to catch tumors earlier, when they have not yet metastasized or genetically diversified.
Leaf, a sympathetic (he suffered from s cancer as a teenager), thoughtful yet critical observer analyzes the cultural factors that led to this state. Some of them are a lack of risk-taking, an ever growing bureaucracy, few standards in the field, the lack of an effective national tissue registry and the complexity of the disease. But the primary culprit Leaf focuses on is a highly fractioned and non-collaborative clinical-academic cancer culture that maximizes winning of R01 NIH grants and the publication of papers in high-impact journals. Grants and papers make for great experiments on model systems or model organisms (which does not include humans), advance basic science, but does little to help patients. The massive investment in cancer science (an estimated $30B/year worldwide) produces studies but not cures!
It is interesting that the original 1971 recommendations of the committee charged by President Nixon with proposing how the War on Cancer aught to be carried out had been to take the cancer effort out of the NIH, creating a NASA-like National Cancer Authority, whose mandate would be to approach the problem like the successful moon shot, looking at the overall systems-aspects of cancer and cancer mortality. The committee was quite explicit in this matter, testifying that they would not recommend continuation of the present organizational arrangements within the existing NIH. However, heavy lobbying by the clinical and scientific communities for the autonomy of the basic research enterprise scuttled this plan. Instead the NCI received a massive increase in research funding and the status quo remained.
One wonders what would have happened if the NIH/NSF would have been charged by President Kennedy in 1961 to bring a man to the moon by the end of the decade and return him safely to the planet? Probably a lot of basic science papers on planetary formation, the geology of the early moon and the existence of unique solutions of the Navier-Stokes equations that mimic the aerodynamics of re-entry into the atmosphere!
Leaf argues for a much more focused engineering effort, one that emphasizes all aspects of the cancer problem and not just the biology of cancer, that enforces common standards, protocols and tissue repositories, in an expeditious and efficient manner. One that takes risks, just like NASA did in its early years. Yet that is unlikely to occur within the current ossified structures that serve the cancer and the university research communities so well.