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RAY SUAREZ: The National Cancer Institute reported this week a drop in new cancer cases and in deaths, news government officials welcomed as incredible progress. The report found between 1992 and 1998 the number of new cancer cases dropped 1.1 percent. The number of cancer deaths also dropped by 1.1 percent, much of that among black men. Four cancers– lung, prostate, breast and colorectal– make up 56 percent of all new cancer cases. Among those, only breast cancer cases continued to increase by more than 40 percent between 1973 and 1998. What’s behind these numbers? For more on the ups and downs of cancer research, we turn to Dr. Richard Klausner, director of the National Cancer Institute; and Dr. Jerome Groopman, chief of experimental medicine at Beth Israel Deaconess Hospital and professor of medicine at Harvard Medical School. Dr. Klausner, let’s start with you. In a broad overview: A large population, a lot of separate diseases, what are we to make of these numbers taken as a whole?
DR. RICHARD KLAUSNER: You said a very important part of this and that is cancer is many different diseases. It’s hard to know how to take it as a whole. This report represents a snapshot of these many diseases and the burden within the American population, a very diverse population. The burden is not equally shared across different cancers and across different groups. With this snapshot, we can compare it to previous numbers and get a feeling of whether we’re losing ground, whether we’re holding steady or whether we’re actually making some gains. And the encouraging news is, overall, we’re making some gains.
RAY SUAREZ: Well, maybe you could take a couple of examples out of the pile of data that enlighten this for you, maybe some places where the rate of progress has been disappointing and others where you think it has been great.
DR. RICHARD KLAUSNER: Well, in this report we actually highlight a number of cancers whose incidence or death rates are continuing to increase, or where losing ground. That makes up about 13 percent of the total burden of cancer. For the vast majority, we either are holding steady or importantly, pretty much for the first time in history, seeing real and significant and sustained drops in cancer rates. What do these drops mean? Let’s take breast cancer. The breast cancer mortality rates until about 1990 were gradually rising. In 1990, they started going down. In the last five years, that drop has accelerated to about 3.6 percent per year. What does that number mean? What does 3.6 percent per year mean? If the breast cancer mortality rates continued where they were before 1990, we would predict about 57,000 American women would die this year of breast cancer. But because of those drops and the fact that they’ve been sustained, the number of breast cancer deaths instead of being 57,000 this year will be about 41,000. Still a lot — still a very common and important disease with an enormous burden. But that’s a flavor for the difference these sorts of changes mean.
RAY SUAREZ: Dr. Groopman in your recent article in the New Yorker you took a look at the decades-long war on cancer, the so-called war on cancer, and questioned some of the premises under which it’s fought and some of the ways the money has been spent. When you look at the new report and its numbers what do you see?
DR. JEROME GROOPMAN: I see the same positive trends that Rick Klausner just talked about. Primarily they be attributed to early detection and early intervention, early treatment. Which is very, very important. That wasn’t particularly the focus of the initial war on cancer. The focus was much more on curing all cancers and particularly focus on so-called metastatic cancer, cancer that had spread beyond the primary site. I think when we learned lessons from the war on cancer, as you said, first we have to change our thinking. We should not conceive of cancer as a single disease, a single entity. The second is that there is no single magic bullet that will just eradicate cancer. The third is that you can’t mandate discovery. You can’t direct and order, if you will, progress. It was believed by President Nixon and the experts who launched the war on cancer that all of cancer would be eradicated by 1976 as a gift for the bicentennial. In 1985, when it was clear the trends were actually increasing, again a promise was made, or a commitment, to reduce cancer mortality by 50 percent. I think we’ve learned not to make those predictions. We’ve learned that we can’t predict progress. But there clearly is progress.
RAY SUAREZ: If you were to design a research program yourself or were given money to begin inquiries, how would you use a report like this as a tool? What does it tell you that helps point you in certain directions?
DR. JEROME GROOPMAN: Well, I think first it teaches us that the earlier you find a cancer clearly the better, because the interventions, the treatments we have which are curative are still primarily surgery and radiation; to some degree for women with early stage breast cancer, chemotherapy is given at that time. The second, I think, as Rick Klausner implied, is to make sure that we extend services of detection and treatment throughout all parts of the society, particularly under- served minority communities. And the third is that no one, in terms of treatment of people with metastic or spread disease, no single person has all the answers. We still don’t fully understand the biology of cancer. So you want a balanced portfolio. You want to invest in a variety of different research projects and also encourage innovative research that questions conventional wisdom.
RAY SUAREZ: Dr. Klausner, when you get numbers that show incidents, that is the raw number of people who have a disease, rising, but survivorability rising at the same time or certain groups in society dying at a rate much higher from the same disease, can it also tell you things about American medicine that have nothing to do with cancer?
DR. RICHARD KLAUSNER: Yes, it can. But it’s very important to remember that these numbers that give us a picture don’t give us answers. They don’t give us explanations. What they actually give us are questions. They’re very hard to answer. It is actually remarkably difficult to explain a lot of the numbers. But by knowing them, by seeing how they change over time, by monitoring other things such as behavior, smoking, reproductive behavior, the use of best practiced medicine, where it happens, where it doesn’t, we can then both formulate questions and begin to answer them. We have some hints as to what is behind some of these numbers, as Dr. Groopman referred to. And they’re different for different cancers. The leveling off and drop in lung cancer is due to decreased smoking — very little in the way of advances in either early detection or treatment. For breast cancer, as Dr. Groopman said, it is from, from our analysis, mostly treatment, but treatment that is shifting to more early stage disease. For prostate cancer, which is also dropping in terms of its mortality rate, quite significantly, in fact, we’re not sure what it is. It looks to us like it is a combination of treatment and early detection. And for colorectal cancer, it is probably early detection — but other changes in the pattern of disease that remains mysterious.
RAY SUAREZ: And so something that someone untouched by a diagnosis can take away from this? More frequent checkups for one thing?
DR. RICHARD KLAUSNER: Well, I think it is important to avail yourself, especially if you can, that is you have access to a healthcare system of the best recommendations about changing behavior. If you don’t smoke, don’t start smoking. If you smoke, do what it takes to try to overcome that addiction and stop smoking — other aspects of healthy lifestyles and healthy behavior. Make sure you get regular checkups with recommendations for early detection. And then it is very important that if one gets the diagnosis of cancer, one is not to assume that it is the death sentence that often people think it is. It isn’t. We’re seeing that more and more. There are more options, more treatments — and part of our optimism, and I don’t think this is hype — I think this is reasonable optimism based on the advances in science, lead us to expect that over the next “x” number of years– and we don’t know how long it will take– there will be improving and changing treatment where we will go after one disease at a time. We do them simultaneously, where we expect that as we understand the complexity of these diseases, we will finally be able to develop treatments possibly even for the types of advanced disease that currently we’re not able to treat.
RAY SUAREZ: Dr. Groopman, what should your colleagues in the research community take away from this?
DR. JEROME GROOPMAN: Well, I think what we take away is the sense that discovery, as Dr. Klausner was saying, is unpredictable. We have an unprecedented pace of discovery. We have an explosion in new knowledge. There are still major gaps in understanding and it is still very, very difficult to actually create safe and effective drugs that change the ultimate outcome that save lives, that prevent death. You can’t predict from a test tube or from a test in an animal which drug will work or which won’t. So you need very well designed, very focused, so-called clinical trials to do that — clinical testing in people. It’s clearly a time of great hope. But I think what concerned me, and I wrote about in the article, is that there’s been an important advance, Glevac, a drug for myeloid leukemia and that led for statements that were really overreaching and raised expectations above reality that in the next ten or 15 years, all we’ll need to do is pop a few pills and all cancers will be controlled. Where an oncologist quoted in Time Magazine saying he will be out of a job within 20 years because there will be no cancer to worry about.
RAY SUAREZ: Doctors Groopman, Klausner, thank you both very much.
DR. RICHARD KLAUSNER: Thank you, Ray.