The Emperor of All Maladies

Never have I seen such complete outpouring of interest in cancer research than I did last week when the Ken Burns’ special of Siddhartha Mukherjee’s The Emperor of all Maladies aired on PBS. Patients were mesmerized by it, coworkers and colleagues were touched by it, and the twitterverse was all aflutter with #CancerFilm.

Perhaps more than anything, the documentary told our story . . . and what a story it has been. When one actually ponders how far we’ve come in our understanding of how cancer works, and where we are going in terms of unlocking the continual mysteries of the disease, it truly is remarkable.

This was the story of cancer discovery—the debates between Halsted and Fisher, the search for "magic bullets,” and the dawn of the era of immunotherapy which promises to unleash the power of the immune system on cancer.

It was the story of great institutions, like the American Cancer Society, the NCI, and the Jimmy Fund, that emerged out of an obstinate desire to make a difference and move the field of cancer research forward.

Perhaps, more importantly, however, it was the story of how cancer affects people, and the ongoing crusade of physicians and scientists to end suffering due to this disease. We remembered the many patients who participated in clinical trials that resulted in advances; and while many perished in spite of their efforts, future generations can now avail themselves of better therapies because of them.

Sadly, it also told the story of stagnant funding—a tragedy, when one considers that we are on the brink of great discoveries—and of the financial toxicity faced by patients who encounter ever-increasing medical costs. It is clear that financial distress is a leading indicator of poor quality of life for our patients, and that medical bills are a driver of bankruptcy.

Yet, costs continue to spiral out of control. This week in JAMA Oncology, there was a paper that found no correlation between the costs of drugs and their efficacy in improving progression-free or overall survival; and there are a myriad of studies that have found that physicians order unnecessary tests simply for fear of liability.

We’ve come a long way when it comes to the translational science that is leading to precision medicine and personalized care; but it seems we still have a long way to go. As I think about what story the sequel to The Emperor of all Maladies might tell, I imagine that interspersed between discoveries in immunotherapies and more targeted approaches that will revolutionize cancer care will be the underlying theme of fiscal restraint.

The challenge of the past was to understand how cancer works and to stop it at any cost; the challenge of the future will be to think more innovatively about cancer and to stop it at lower cost.


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