Friday, December 4, 2015

DeVita, Cancer, and a Must Read

DeVita’s book, The Death of Cancer, is a personal recollection of one of the most well-known cancer specialists in the world. In a sense it is an Odyssey tale of a highly competent and prolific person who flows with his times and manages the Scylla and Charybdis of Government work. The book is well written and reflective of the man and his times. DeVita started out during the Vietnam era when any male graduating from Med School found themselves, unless otherwise excused, ready for immediate assignment to some military unit. Many of the top students were fortunate to get to go to NIH which was DeVita’s fate, and it was this flow of talent in the late 60s which made NIH and NCI one of the best institutions in the world. Thus the tale of DeVita and cancer starts here with NCI and a flow of excellent talent.

DeVita describes his work on the use of multiple chemotherapy regimens and the resistance from the likes of Farber in Boston, hardly an uncommon occurrence especially in Medicine. This was the MOPP therapy that most now know as a major breakthrough in Hodgkin’s. The discussion on how he and the team managed to persist and managed to go through the then significant administrative a bureaucratic complexities is amazing.

The discussion on his involvement in the “War on Cancer” and the political games is quite interesting especially for anyone who has not spent a tour of duty in Washington. There were games within games and DeVita was at times a willing participant but as see in the book and excellent observer. His description of the political gamesmanship is worth the read if nothing else. It is also worth the while for anyone seeking to grasp how Washington functions, and why it may work at times and often falls into total disarray.

On p. 159 I was interested to see the interlocutory between Benno Schmidt and Jim Watson while Watson was I gather performing one of his classic poses. This also is worth the read. I have had my students return from a talk by Watson and ask me: “Does he really think Physicians and Engineers are useless?” But I gather that is Watson, a scientist at heart.

On p 219 there is a great discussion of his time at MSKCC, a world renowned institution but at times falling behind in certain areas. DeVita states: “MSKCC had the potential to be the best cancer center in the world, it wasn’t” is a powerful statement and at times quite true. MSKCC has powerful backers and Board members and although it may try from time to time to be at the lead there is always the chance that it becomes insular. The lesson DeVita brings out here should be a warning for many such institutions.

On p 247 DeVita discusses the recent Hanahan and Weinberg paper on Cancer, a follow on to what the two authors had written in 2000. This is a paper on the hallmarks of cancer and is looked upon as a sine qua non in the literature. DeVita lauds it at length and rightly so. Yet what this paper also shows is that we have learned a great deal but the “War on Cancer” is just getting harder the more we learn. One could argue that the recent Hanahan and Weinberg paper albeit prescient and insightful lacks the depth on epigenetic factors which we are seeing more and more in cancers. The more that is learned the more complex the disease.

On p 253 DeVita discusses the inflammation relationship. We often ask what causes cancer and the more we understand inflammation the more we can see the nexus. This is a useful and important discussion as well.

On p 258 DeVita makes an interesting statement:

“In my opinion, when there is less than a 10% chance of the cancer recurring after a patient passes his or her cancer’s critical period, then the patient should be told, in all likelihood, he or she is cured.”

This is a powerful statement and one a physician with extensive clinical experience is wont to utter. However one should parse the statement. First, how does one determine a 10% chance? In prostate cancer we can perform a prostatectomy and monitor PPSA for several years and then see a met occur. When did the 10% level occur? Second, what is a critical period? How do we define it for each cancer? Then the catch phrase of “in all likelihood” is something the patient may or most likely not hear. Cancer patients often has selective hearing.

Overall the book is highly enlightening and a must read for anyone interested in the progression of cancer therapy. Also DeVita’s discussion of his battles with the FDA and Sen. Kennedy’s blatant interference with NCI if it in his opinion interfered with the FDA was quite interesting. DeVita bares the political quagmires of Washington and demonstrates that progress can often be made despite the Government overhead by dedicated and highly competent individuals.