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.
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