The 40th Anniversary of the National Cancer Act

The 40th Anniversary of the National Cancer Act

Michael Paul Link, MD, FASCO

Dec 13, 2011

This month we will celebrate the 40th anniversary of the signing of the National Cancer Act—the initial declaration of our country’s so-called “war on cancer.” Some have found the symbolic war metaphor distasteful, suggesting that progress against cancer is more akin to problem solving than to winning a war. Nevertheless, the war metaphor does provide some convenient descriptors of our “enemy” and the strategies and technologies that have been employed to vanquish it. Few would argue that many of the successful therapies involve the mobilization of overwhelming force and bear close resemblance to “firebombing” of enemy cities (and even the use of “nuclear” technology) at the cost of serious collateral damage to the host and the killing and maiming of innocent bystander tissues. Victory in individual battles comes at a high cost, the need to rebuild the damage done to the host by a sort of Marshall Plan, and the acknowledgement that some of the damage cannot be undone. The enemy has proven to be devious and unashamed to recruit the help of collaborators and turncoats in the host to facilitate its invasion of friendly shores.

Although cancer has proven to be a formidable enemy, there are many reasons to rejoice at the progress achieved. Despite the view of naysayers, there is ample evidence that we have won some important battles and skirmishes: from 1990 to 2007, the death rate from all cancers combined declined by 22% for men and 14% for women, resulting in 900,000 fewer deaths during that time; certain cancers that were uniformly fatal only 40 years ago have yielded significant ground; almost 80% of children with cancer can now be cured; and close to 90% of children with acute lymphoblastic leukemia (the most common form of childhood cancer) become long-term survivors. Young men with testicular cancer have a realistic chance of cure (even those presenting with metastatic disease), and patients with Hodgkin disease and non-Hodgkin lymphoma are approached with curative intent. Additionally, significant progress has been made in the management of key solid tumors, promising prolonged survival and improved quality of life for many patients. Even the most difficult to treat cancers—non-small cell lung cancer and melanoma—have given ground, and we have established a beachhead in our battle against them.

We now have the “luxury” of worrying about the long-term consequences of our therapies as young patients survive for decades. More than 12 million individuals living in the United States are cancer survivors. Further, we have uncovered clues to carcinogenesis and thus some strategies for prevention. Smoking is the leading cause of preventable cancer death. Some successes in blunting the impact of smoking have been achieved, but the political reality may prove to be a daunting challenge, especially in the developing world. Infection-associated cancers are a leading cause of death worldwide, and here, vaccination strategies are certain to lower the incidence of several difficult cancers, including hepatitis B-associated hepatocellular carcinoma and HPV-associated cervical cancer (and head and neck cancer). H. pylori eradication might help prevent gastric cancer, and the prospect of vaccines against EBV and hepatitis C would likely translate into further effective prevention. Understanding the molecular mechanisms that characterize the progression from benign polyp to fully malignant bowel cancer provides the rationale for screening endoscopy to save lives. Although the benefits of other screening strategies are more controversial, further refinements will likely confirm the utility of screening for other cancers as well. These advances, based on basic and clinical research, could benefit millions of people worldwide. However, we will only be able to deliver on these discoveries if we have the will to overcome the political, economic, and administrative challenges to their widespread application.

So where are we now 40 years after the first declaration of war on cancer with the signing of the National Cancer Act? As in all wars, progress is painfully slow with maddening setbacks and unforeseen obstacles; Americans are notoriously impatient with unachieved goals. But cancer has proven to be a complex collection of diseases, with the capacity to evolve, mutate, and develop drug resistance. We have made striking progress on some fronts, but frustratingly little on many others. However, we should take heart from another war analogy: breaking the enemy’s code was a major advance in World War II, leading to advanced notice of enemy movements resulting in innumerable lives saved. Similarly, advances in biology are providing great breakthroughs in decoding the molecular programs that drive cancers, allowing us to understand the heterogeneity within cancer subtypes, predict their behavior, and detect potential vulnerabilities to target. The success of highly targeted molecules derived from basic research and translated to the clinic is a hopeful glimpse of the future.

Delivering on these results remains challenging. Unhealthy lifestyle choices leading to obesity, sedentary lifestyle, and tobacco addiction increase the risk of preventable cancers, while failure of uptake of proven preventive measures leads to needless cancer deaths. Poverty and health care disparities that are magnified by an inefficient, indefensible health care system stand in the way of delivering on what we already know. The state of our economy and our unwillingness or inability to invest substantially in medical research threatens to slow the pace of progress. Nor can we ignore the looming burden of cancer in the developing world which threatens to overtake the available health care systems of resource-poor countries.

Future progress will depend on continuing to collaborate with one another and partnering with our patients in their battle. The willingness of our patients to participate in clinical trials and to donate their tissues for laboratory research has powered the progress that we have made to date; partnering with them is more important than ever as we continue the struggle in the genomics era. We are a long way from declaring victory in this war on cancer. But we should not be deterred. Rather, we should examine the great progress that has been made with some satisfaction. We are, perhaps, at the “end of the beginning.”


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