Cancer Treatment vs. Prevention
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JIM LEHRER: The cancer story is next and to Elizabeth Farnsworth.
ELIZABETH FARNSWORTH: How successful has the war against cancer been? Not very, According to a report in today’s issue of the “New England Journal of Medicine.” The authors argue that treatments have fallen short of expectations and it’s time for a different strategy against the disease, which still claims ½ million American lives a year. We’re joined now by the lead author of the story, Dr. John Bailar, Chairman of the University of Chicago Medical Center’s Department of Health Studies, and by Dr. David Nathan, president of the Dana-Farber Cancer Institute. He also chairs the National Institutes of Health Panel on Clinical Research. Dr. Bailar, briefly describe your study for us and its conclusions.
DR. JOHN BAILAR, University of Chicago Medical Center: We have been concerned very much about trends in cancer death rates, so we–
ELIZABETH FARNSWORTH: About–
DR. JOHN BAILAR: About the trends in cancer death rate. How much is the risk for–of dying from cancer changing? What are the reasons for change? What kinds of cancer are involved? So we calculated the death rate year by year from 1970 up through 1994, the most recent year available, and then we have examined those data to try to find out what’s going on.
ELIZABETH FARNSWORTH: And what did you find out?
DR. JOHN BAILAR: The most important thing from our point of view is that the death rate for cancer of all kinds has been rising until quite recently. I must say it wasn’t rising fast. It was about 1 percent a year but very steadily. It may have flattened out and turned over, started down a little bit, but all the same the death rate for cancer, the risk of dying from cancer is higher now than it was when the war against cancer started in 1971.
ELIZABETH FARNSWORTH: And to you that indicates that the money that’s gone to new treatments, new therapies, chemotherapy, that kind of thing has not been spent wisely.
DR. JOHN BAILAR: I think it’s too strong to say it has not been spent wisely. It has not done what we all hoped and expected to accomplish. It’s important to recognize that there have been some successes. There are many, many different forms of cancer–one hundred, two hundred, three hundred–it depends on how you count. Some have been going up. Some have been going down. But if you take them altogether, the trend is up.
ELIZABETH FARNSWORTH: Okay. Let’s stop there for a minute. Dr. Nathan, what is your response to this study? What’s your view of it?
DR. DAVID NATHAN, Dana-Farber Cancer Institute: Well, as Dr. Bailar knows, these are data that actually Phil Cole and his co-workers published recently, and the data do show what Dr. Bailar points out. They also show that the increase has not only plateaued but has, in fact, started to decline. I think Cole and his co-workers.
ELIZABETH FARNSWORTH: This is Dr. Cole of the University of Alabama who’s a cancer researcher?
DR. DAVID NATHAN: Yeah. Cole and his co-workers pointed out that they too couldn’t quite tell why the decline was taking place. They thought it was a little bit of a lot of things. Prevention techniques have improved; early diagnosis improved; and therapy has improved, so that, you know, I see this all as a very optimistic situation. I think we are starting to get on top of this problem, and I think Dr. Bailar would have to agree, it’s very nice to see the curves beginning to plateau and, in fact, decline.
ELIZABETH FARNSWORTH: What about that?
DR. JOHN BAILAR: Well, first, we take strong exception to the analysis that Dr. Cole did. He got his–
ELIZABETH FARNSWORTH: We should say that the main–the headline of his report would be that cancer mortality rates are going down beginning in about ’91 about–he thought about 2 percent a year, right?
DR. JOHN BAILAR: He thought the total of about 5 percent, as I recall.
ELIZABETH FARNSWORTH: From ’91 until now.
DR. JOHN BAILAR: But he got that figure by projecting our current population and current cancer risks back to 1940 when the United States was a very different place; the distribution of ages in our population was different. Other diseases were having quite a different kind of impact. And we think 1940 is simply not an appropriate starting point for this.
ELIZABETH FARNSWORTH: But you do think that there’s a plateau and that the cancer mortality rates are going down somewhat? Let’s not–
DR. JOHN BAILAR: Yes.
ELIZABETH FARNSWORTH: It’s a debate over how much, but you think they are going down somewhat, but you think that the reasons for that are different than have bene publicized, is that right?
DR. JOHN BAILAR: That’s right.
ELIZABETH FARNSWORTH: Why do you think they’re going down a little bit, or plateauing?
DR. JOHN BAILAR: We think they have gone down perhaps 1 percent. I would like to wait a little bit longer to see this downturn confirmed, but if it isn’t here yet, it’s coming. When we look at the trends in different forms of cancer, as I have said, some going up, some going down, it’s pretty clear that the overall picture is largely a reflection of how many people are getting cancer. The risks have gone up and down. To some extent it’s a reflection of early diagnosis: mammography in women over the age of 50, the pap smear, other kinds of earlier diagnosis. We think that treatment has not had very much effect on a population-wide basis. There are some forms of cancer where treatment has been very effective, but they tend to be relatively uncommon.
ELIZABETH FARNSWORTH: Dr. Nathan, do you disagree with that, about the effectiveness of treatment?
DR. DAVID NATHAN: Well, the point that Dr. Bailar is making is that one form of treatment–chemotherapy–which I think he’s referring to here, because I don’t think Dr. Bailar would argue that surgery is an ineffective form of treatment, in fact, it’s extremely important, or that radiotherapy is an ineffective form of treatment. Those have been the standbys of cancer treatment for a long time. It’s chemotherapy that is probably the object of his inquiry here, and, of course, chemotherapy is, in fact, far more effective in young people than in old people, and cancer happens to be a disease which has an increasing risk as one ages. So one doesn’t see the enormous value of chemotherapy in these cancer statistics. But, you know, I’m a doctor, and I take care of patients. And I take care of them one at a time. And when I started out doing cancer care in little children, I had a 100 percent failure. I didn’t save a single child when I first went to the National Cancer Institute in 1956. And now my–my group at the Dana-Farber Cancer Institute and all around the world are salvaging children with cancer at a rate of 80 percent in childhood leukemia. Now, childhood leukemia is an uncommon disease, but it’s awfully important if you happen to be a child with leukemia. So it really is–depending on how you look at this cup–half full or half empty–I think it’s a triumph. But then again I take care of patients. Now–
ELIZABETH FARNSWORTH: Dr. Bailar.
DR. JOHN BAILAR: I think we might agree that the cup is half full.
ELIZABETH FARNSWORTH: Because you certainly are not recommending to people listening to us right now that they stop their treatment, right?
DR. JOHN BAILAR: Absolutely not.
ELIZABETH FARNSWORTH: However old they are.
DR. JOHN BAILAR: No. We are convinced that treatment has much to offer every person. Every person who has cancer or might have cancer deserves the earliest possible diagnosis and the best possible treatment. And that can save at least half of them, with a complete cure. It has a lot to offer for the ones who cannot be cured, and that also is very important. The problem–
ELIZABETH FARNSWORTH: You mean, in prolonging–making their life better.
DR. JOHN BAILAR: Making their lives better, as well as longer. They are much happier people. They preserve function. They can remain free. They stay on the job. They’re in good communication with their relatives, their friends, with society. All of this is terribly important, but it isn’t what we set out to do, which was to bring down the death rate. As I said, that’s now a little bit higher than it was when we started.
ELIZABETH FARNSWORTH: What do you think should be done differently? What is the ratio right now between money spent on prevention and money spent on treatment?
DR. JOHN BAILAR: It’s very hard to pin down.
ELIZABETH FARNSWORTH: I mean for research.
DR. JOHN BAILAR: It’s hard to pin down the precise distribution of funds. The best estimate I can make is about four to one in favor of research on treatment. And I think that that should be tipped the other way to some degree, maybe two to one in favor of prevention. We’re certainly not recommending that research on treatment be stopped.
ELIZABETH FARNSWORTH: Just a few examples of prevention. What would you do?
DR. JOHN BAILAR: Well, there are a lot of different approaches. One is to find out specific causes of individual cancers, individual forms of cancer, and get rid of them, such as turning away from the use of tobacco. There are some kinds of cancers that are caused by chemical hazards in the workplace. And we ought to deal with these wherever we can find the causes and remove them. But that is just the beginning of prevention.
ELIZABETH FARNSWORTH: Okay. Let me come back to that in a minute. Dr. Nathan, do you disagree about changing the–whether or not it’s this ratio–changing the amount of money spent on prevention vis-a-vis treatment?
DR. DAVID NATHAN: Well, I must say that priority setting is one of the toughest problems in all of research and research administration. And the National Cancer Institute spends hours at the leadership level trying to decide where the best leads may be. After all, they depend on us. We are the investigators. Dr. Bailor is an investigator. I’m an investigator. And all they can do is receive applications from us and judge those by a process of peer review. There is not sitting around a guttering candle saying what percentage should go here and there. The National Cancer Institute has got to receive the best ideas they can and fund them. They can’t fund all of them anyway because the budget won’t allow it. Only about 25 percent of applications are actually funded in the end, and those are very, very hard decisions to make. Lord knows if somebody comes up with a great idea in prevention, we want to fund it, obviously. That would be terrific. But then if somebody has a wonderful idea that some compound that comes out of the bark of an unusual tree might help ovarian cancer, we want to pursue that too. It’s very hard to know in advance. One has to take advantage of the science of the times. That’s what National Cancer Institute tries to do.
ELIZABETH FARNSWORTH: Dr. Bailar, are you saying that given the mortality rate staying about the same–except I know in the case of young people they have changed quite a lot–
DR. JOHN BAILAR: Yes.
ELIZABETH FARNSWORTH: Are you saying that it’s time to try prevention and see if that makes a difference in mortality rates?
DR. JOHN BAILAR: I’m saying it’s time to get serious about research on prevention. We know how to prevent some cancers now, particularly the tobacco-related cancers. We do not know how to prevent a lot of other forms of cancer, and we need to learn what we can about that matter. Now, I must say right now that we have no guarantee that we’ll ever be able to prevent all cancers, just as we have no guarantee that treatment will ever be fully effective. But we need to find out.
ELIZABETH FARNSWORTH: Okay. We have just a few seconds left, Dr. Nathan. Do you have anything else to add?
DR. DAVID NATHAN: The point is to do the best research possible in all phases: diagnosis, prevention, and treatment. If we do that, we’ll get there, and, in fact, we are getting there. I’m very optimistic right now.
ELIZABETH FARNSWORTH: Well, thank you both very much for being with us.