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Mind

Learning to Expect Less From the War on Cancer

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When the American Association for Cancer Research released its 2013 progress report last week, it was faced with a familiar dilemma: how to emphasize the good news and the bad news both at the same time. To keep government funding flowing in, the leaders of the research establishment bring out statistics suggesting that tax money isn’t being wasted -- that progress is really being made. But lest we become too complacent they are ready with numbers emphasizing how badly we are losing the fight. Sometimes they want to assuage and sometimes they want to frighten, and so they keep two sets of books. According to ledger number 1, we are winning or at least keeping up. The overall likelihood of an individual getting cancer and dying from it has been holding steady and even decreasing a little every year. But ledger number 2 clearly shows that more people than ever are dying of the disease. The reason for the discrepancy, of course, is the expanding size of the population and the famous demographic bulge -- the greater proportion of older people alive each year. With tragic exceptions, cancer is a condition of aging and entropy -- a matter of cells wearing out. Adjust for that inevitability and the numbers for incidence and mortality (the percentage of people getting cancer and the percentage succumbing to it) are not increasing. But remove the statistical filters and out comes the raw truth: the sheer number of cases -- and the burden on the clinics and hospitals -- is rising with no prospect of letting up. The dueling statistics can be seen every year in the National Cancer Institute’s Annual Report to the Nation and in publications of the American Cancer Society and other advocacy groups. The AACR’s new assessment is just the most recent example. We start off reading about “amazing progress” and “remarkable advances.” And then in the third paragraph comes the shock: Despite the gains in knowledge, “580,350 Americans will die from one of the more than 200 types of cancer in 2013.” Because of the growing, graying population that is more than ever before. After the report was released at a press conference in Washington, news stories focused on one of the AACR’s cheerier-sounding statistics: “the number of cancer survivors living today in the United States is estimated to be more than 13.7 million” -- and that too is more than ever before. So we have a record number of deaths and a record number of survivors. You have to reach pretty deep into the report and read between the lines to be reminded that “survival” is defined as still being alive five years after diagnosis. If you die in year six you go into the records as a survivor and as a fatality. Survival rates are also artificially inflated because of improvements in scanning technologies. The earlier your cancer is detected, the longer you will be said to have survived it -- even if the treatment had no effect. For all of that there have been genuine improvements. But these are almost always for tumors that have not metastasized. For a few of these primary cancers, like cervical and colorectal, early detection has allowed for the safe removal of dysplasias -- messed up cells that may sometimes become malignant. Screening for breast cancer and prostate cancer presents more of a dilemma, saving some lives but also leading to harmful and unnecessary treatments. Whether you look at the incidence, mortality, or survivability of cancer, most of the real progress has come from simpler solutions: smoking prevention, pap smears, HPV vaccines. The high-tech approaches -- the targeted drugs like Herceptin, Perjeta, Kadcyla, and the experimental immunotherapies so much in the news -- have yet to offer more than modest improvements, particularly with metastatic cancer, which accounts for almost all cancer deaths. (For two great articles on cancer immunotherapy see Dan Engber's "Is the Cure for Cancer Inside You?" in the New York Times Magazine and Jerome Groopman's "The T-Cell Army" in The New Yorker.) No matter how effective any of the new therapies or their successors might turn out to be, there is not going to be a complete victory in the war on cancer. We have to die of something. For every success in combatting other diseases, more people will be left to ultimately succumb to the breakdown of cellular functions that we call cancer. That is a number that can still be reduced but only somewhat. Maybe we need to lower the bar on what counts as a success. Victory would mean preventing and successfully treating more cancers that strike the young and even the middle aged -- and improving hospice care for the aged, who have managed to survive everything else. For a preview of my book The Cancer Chronicles, including the table of contents and index, please see the book's website. @byGeorgeJohnson

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