De­feat­ing can­cer was once a ‘war’; now it’s a ‘moon­shot’

The Star (St. Lucia) - - INTERNATIONAL - By Lau­rie McGin­ley

For more than a cen­tury, we have used mil­i­tary terms — such as wars, bat­tles, sur­vivors and vic­tims — to dis­cuss our re­la­tion­ship with can­cer. But some crit­ics are both­ered by the im­plicit sug­ges­tion that those who die might not have fought hero­ically enough.

When the Obama ad­min­is­tra­tion launched its anti-can­cer ef­fort ear­lier this year, “moon­shot” rhetoric came to the fore, but that, too, drew dis­sent. Some say it sug­gests that cur­ing can­cer in­volves a mas­sive en­gi­neer­ing ef­fort rather than a mul­ti­tude of new in­sights into the bi­ol­ogy of hun­dreds of dif­fer­ent diseases.

Bar­ron H. Lerner, au­thor of “The Breast Can­cer Wars” and “The Good Doc­tor,” and a pro­fes­sor in the di­vi­sion of med­i­cal ethics at New York Univer­sity, has spent years think­ing about these is­sues. He re­cently talked to health-care jour­nal­ists about the his­tory of can­cer ac­tivism and an­swered some fol­low-up ques­tions posed by The Wash­ing­ton Post.

When did Amer­i­cans start fo­cus­ing on can­cer?

Peo­ple got in­ter­ested in the dis­ease in the early 20th cen­tury be­cause of de­clin­ing rates of in­fec­tious diseases. In the 19th cen­tury, peo­ple died of TB and pneu­mo­nia. In the 20th cen­tury, heart dis­ease and can­cer be­gin go­ing up. In 1913, the pre­cur­sor to the Amer­i­can Can­cer So­ci­ety was formed: the Amer­i­can So­ci­ety for the Con­trol of Can­cer (ASCC). The group stressed the im­por­tance of early de­tec­tion and ag­gres­sive treat­ments. They talked about dan­ger signs that peo­ple should not ig­nore, like ir­reg­u­lar bleed­ing, sores that don’t heal and lumps that got larger. Peo­ple in those times tended to wait a long time to go to the doc­tor, so the ques­tion was: How do you change that?

How did they change that?

One strat­egy was the war metaphor, which was be­ing used as early as the 1920s. The ASCC adopted the “Sword of Hope” as its sym­bol, and in the 1930s started the Women’s Field Army, with khaki uni­forms and in­signia, to spread the word and raise money.

A big fo­cus was on women be­cause deaths from breast and cer­vi­cal can­cers were very high and women tended to be more mo­ti­vated than men about their health. The ASCC seized on the Pap smear [the screen­ing test for cer­vi­cal can­cer] when it be­came avail­able in the 1940s, with lead­ers barn­storm­ing the coun­try urg­ing women to get tested. It was a home run: Cer­vi­cal can­cer mor­tal­ity plum­meted. That served as a model for other can­cers. In breast can­cer, for ex­am­ple, the group be­gan push­ing for early de­tec­tion through self-exam.

Was there any­thing wrong with that?

Not at the time, be­cause doc­tors be­lieved breast can­cer was a lo­cal dis­ease that was highly cur­able when found early and treated with the rad­i­cal mas­tec­tomy, some­times with ra­di­a­tion.

Such ag­gres­sive treat­ment was re­in­forced by the fa­mil­iar mil­i­tary lan­guage, which was ubiq­ui­tous af­ter World War II. We had just won a war against the Nazis and the Ja­panese, and the mind-set was “We beat the Axis pow­ers, and now we can beat can­cer.”

What was the next stage in the ef­fort against can­cer?

In 1944, the ASCC changed its name to the Amer­i­can Can­cer So­ci­ety, and Mary Lasker, the so­cialite wife of a prom­i­nent ad­ver­tis­ing ex­ec­u­tive, de­cided her goal was to make it a vi­brant or­ga­ni­za­tion. She worked closely with jour­nal­ists to pub­li­cize it. Life mag­a­zine ran a story about cured pa­tients head­lined: “Vic­tims Turned Vic­tors.”

Surgery was seen as the best bet for most pa­tients. In 1963, Time mag­a­zine wrote: “If they can op­er­ate, you’re lucky.” Another com­mon phrase from this era was “A chance to cut is a chance to cure.”

These were the days of the mu­ti­lat­ing super-rad­i­cal mas­tec­tomy for cer­tain breast can­cers. Sur­geons would re­move parts of a woman’s rib cage and ster­num in ad­di­tion to the mus­cles of the chest wall. From our mod­ern phys­i­o­log­i­cal stand­point, this makes no sense. These pa­tients weren’t cured, as their can­cers had al­ready spread too far. But the idea was that if the sur­geons just tried hard enough, good things would re­sult. The sur­geons were highly de­voted, and their pa­tients loved them. But at some point their zeal to help peo­ple got car­ried away from what the data were say­ing.

Still, some good things were hap­pen­ing. Breast can­cer was in­creas­ingly be­ing caught at stages 1 or 2, when it’s more cur­able. And in the 1960s, chemo­ther­apy even started to cure some women with ad­vanced dis­ease. My mother had breast can­cer in her 40s, and by great good luck got into one of the first clin­i­cal tri­als of chemo­ther­apy. She’s still alive to­day, and that’s why.

The big­gest suc­cess dur­ing these years was with blood can­cers. The most com­mon child­hood leukemia be­came a cur­able dis­ease. Op­ti­mism grew about what chemo could ac­com­plish for some can­cers, with or with­out ra­di­a­tion.

What was hap­pen­ing with other types of ma­lig­nan­cies?

There was no progress on cer­tain can­cers, like lung, colon and pan­creas. And can­cer treat­ment was of­ten grue­some. Chemo and early ra­di­a­tion were very toxic. Surgery could be ex­tremely dis­fig­ur­ing.

Then, in the early 1970s, we got the War on Can­cer leg­is­la­tion that pro­vided tens of mil­lions of dol­lars for ad­di­tional re­search. Mary Lasker used her con­nec­tions be­hind the scenes to lobby Congress, and Ann Lan­ders was the jour­nal­ist who pushed the hard­est. Pres­i­dent Nixon, at the White House sign­ing cer­e­mony for the law, said that more Amer­i­cans died ev­ery year from can­cer than lost their lives in all of World War II. Did every­one ap­prove of the “war”? No. At­ti­tudes started to shift in the mid-1970s, just a few years af­ter war had been de­clared. For ex­am­ple, women be­gan chal­leng­ing doc­tors about the need for the rad­i­cal mas­tec­tomy when they had only tiny can­cers.

Fe­male jour­nal­ists with breast can­cer be­gan re­search­ing the pro­ce­dure and de­nounc­ing it. One of them was Rose Kush­ner, who col­or­fully wrote, “Viet­nam will have to wait while I fin­ish a cru­sade to tell Amer­i­can women — and through them Amer­i­can doc­tors — what I have learned.” And crit­ics, such as the writer Su­san Son­tag, had be­gun to warn about the faulty as­sump­tions en­cour­aged by war metaphors.

Was the med­i­cal es­tab­lish­ment start­ing to ques­tion the way breast can­cer was han­dled?

Yes. In 1975, John Bailar, a bio­statis­ti­cian and head of de­mog­ra­phy at the Na­tional Can­cer In­sti­tute, wrote an ar­ti­cle ti­tled “Mam­mog­ra­phy: A Con­trary View,” which was highly crit­i­cal of a mam­mog­ra­phy screen­ing pro­gram be­ing spon­sored by his own agency, the NCI, along with the ACS.

He ar­gued that the value of mam­mog­ra­phy had not been shown, es­pe­cially for women un­der 50, and the risks of ra­di­a­tion “may be greater than com­monly un­der­stood.” In other words, ear­lier was not nec­es­sar­ily bet­ter.

Bailar even­tu­ally coau­thored two im­por­tant pieces for the New Eng­land Jour­nal of Medicine, one in 1986 ti­tled “Progress against Can­cer?” and another in 1997 called “Can­cer Un­de­feated.” He ar­gued that a quar­ter-cen­tury af­ter Nixon de­clared war on can­cer, the United States was los­ing badly and that mor­tal­ity rates had not budged. Bailar also be­lieved that can­cer pre­ven­tion, a much more promis­ing ap­proach, had been ig­nored.

But haven’t we made some progress against can­cer since the early 1970s?

Yes, since 1971, the can­cer mor­tal­ity rate has gone down about 5 to 10 per­cent. Much of this, how­ever, is due to the de­cline in smok­ing, although there have also been modest de­clines in mor­tal­ity from breast and prostate can­cer. Un­for­tu­nately, pan­cre­atic, liver, kid­ney and other can­cers are ac­tu­ally in­creas­ing, de­spite the War on Can­cer and $100 bil­lion hav­ing been put into it.

What do you think about us­ing the moon­shot anal­ogy, as Vice Pres­i­dent Bi­den has done, in talk­ing about can­cer?

The moon­shot metaphor is not any more sub­tle than the War on Can­cer, and when you use that kind of lan­guage, it’s easy to over­sell things.

But at least Bi­den is ac­knowl­edg­ing the lim­its of the moon­shot, such as the no­tion that cer­tain ther­a­pies might be used to con­trol — as op­posed to cure — can­cer.

Af­ter Nixon signed the War on Can­cer leg­is­la­tion, one can­cer spe­cial­ist at the time was so ex­cited that he pre­dicted that can­cer would be wiped out by the 1976 Amer­i­can Bi­cen­ten­nial. Well, not ex­actly. This story re­minds us to be modest about what we can hope to achieve in the next 10 to 20 years.

Can we de­velop meth­ods to con­trol can­cer if it can­not be de­feated?

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