Saturday, December 12, 2015

The Politics of Cancer

The book by DeVita, The Death of Cancer, is a well told tale of one in the fight against the disease. DeVita is well known and well accomplished in the field. His book tells the tale of dealing with many of the characters, especially in Washington, whose actions all too often is just not only counterproductive but can cause true harm. He tells the tale with keen insight and a wonderful turn of the phrase.

I recall seeing my first cancer patient while working in a medical center in the late 1950s. I was learning the basics when the Lab head asked me to come in and look at a blood slide of an eight year old. I think I knew something but this slide was filled with lymphocytes, a Leukemia.  At the time this was a death sentence. In fact unbeknownst to all one could not then identify the type of leukemia, just that this eight year old would not make nine.

DeVita comes to the stage at the same period. Not only could it not be diagnosed but the cure was beyond reach. He becomes one to lead the fight.

However in a New Yorker Review the author, not a physician as best as I can tell, nor even related to the field, takes some strong shots at the author[1]. The author states:

For the past half century, he has been at the forefront of the fight against one of the world’s most feared diseases, and in “The Death of Cancer” he has written an extraordinary chronicle. DeVita’s book is nothing like Siddhartha Mukherjee’s magisterial “The Emperor of All Maladies.” Mukherjee wrote a social and scientific biography of the disease. DeVita, as befits someone who spent a career at the helm of various medical bureaucracies, has written an institutional history of the war on cancer. His interest is in how the various factions and constituencies involved in that effort work together—and his conclusions are deeply unsettling.

DeVita has his career well established with a half century record of achievement and success. The book recounts the hurdles he had to jump and the intense difficulty of working in Washington. I am reminded of a friend’s spouse who went to DC as an Assistant Secretary. A mighty position. I warned her to beware of the professional “back stabbers”. Washington, unlike any other location seems to have a professional corps of “back stabbers”, nothing personal, it is just their job.

Two years later the individual informed me after they had moved on that at first I was the only one with such bad news, all others said good luck and take the hill. But alas the professional “back stabber” came out and did their job. DeVita brilliantly recounts them, including the antics of Senator Kennedy. The problem is that it is these very institutional barriers which are more critical than a sociological understanding of cancer.

The author in the New Yorker further recounts:

Later, when DeVita and his fellow N.C.I. researcher George Canellos wanted to test a promising combination-chemotherapy treatment for advanced breast cancer, they had to do their trial overseas, because they couldn’t win the co√∂peration of surgeons at either of the major American cancer centers, Memorial Sloan Kettering or M. D. Anderson. When the cancer researcher Bernard Fisher did a study showing that there was no difference in outcome between radical mastectomies and the far less invasive lumpectomies, he called DeVita in distress. He couldn’t get the study published. “Breast surgeons made their living doing radical or total mastectomies, and they did not want to hear that that was no longer necessary,” DeVita writes. “Fisher had found it difficult to get patients referred to his study, in fact, because of this resistance.” The surgeons at Memorial Sloan Kettering Cancer Center were so stubborn that they went on disfiguring their patients with radical mastectomies for years after Fisher’s data had shown the procedure to be unnecessary.

The fact is that surgeons for decades brought hospital the big money and thus they ruled. Threatening their purse could be problematic at best. DeVita was right, and he pushed forward. Then the author notes:

But here “The Death of Cancer” takes an unexpected turn. DeVita doesn’t think his experience with the stubborn physicians at Memorial Sloan Kettering or at Yale justifies greater standardization. He is wary of too many scripts and guidelines. What made the extraordinary progress against cancer at the N.C.I. during the nineteen-sixties and seventies possible, in his view, was the absence of rules. A good illustration was Freireich’s decision to treat Pseudomonas meningitis by injecting an antibiotic directly into the spinal fluid.

This is where the argument takes a brisk turn indeed. This is the beginning of the battle with the FDA and complexity of Clinical Trials. Anyone who has any proximity to Clinical Trials knows their cost and complexity. Each new therapeutic goes through some variation and a 3 Phase human trial with enormous costs and time. Safety first and then efficacy. Typically the trial patients are the sickest.

Take for example the new therapeutics in melanoma. Using combined therapies on Level 2 patients may be even more productive but the cost and time is extraordinary. Can this be changed, should it be changed? DeVita gives an experiential and emotional argument for why it can and should.

The author ends with:

When DeVita returned to Memorial Sloan Kettering years later, as the physician-in-chief, the hospital got better. But DeVita didn’t last, which will scarcely come as a surprise to anyone who has read his book. “The problem with Vince,” the hospital’s president reportedly said, in announcing his departure, “is that he wants to cure cancer.”

I do not know how best to read this remark. You want a physician to seek to cure your disease. Often patients are willing to commit to that step. I have even recently seen patients, close friends, take that “petri dish” approach, and yes, get cured. So perhaps we need more DeVitas.