"One may hope that in another 10 to 15 years medical progress will make this edition of the Manual of Oncologic Therapeutics read like an archaic document for the Middle Ages." --NCI oncologist Robert E. Wittes, M.D., Manual of Oncologic Therapeutics (1991)
I began my career as a science writer at Memorial Sloan-Kettering Cancer Center (MSKCC) in the spring of 1974. I started out as an enthusiastic believer in chemotherapy. An older relative had inspired me with the progress he himself had witnessed during his own medical career. He had "rotated through" Memorial when he was a doctor in training. In the early 1960s, he recalled, New York City's famous cancer hospital had to offer interns and residents lobster dinners just to get them to serve.
By the mid-70s, when he came to visit me at my new job, chemo-therapy had made significant advances against some forms of childhood and adolescent cancer, and doctors no longer looked on childhood leukemia or a dozen other rare types of cancer as a death sentence. It was indeed a time of great hope.
The implication of all that I heard and read was that adult cancers would be the next to fall before this chemical assault. I considered myself a rationalist, and chemotherapy was "rational therapeutics" par excellence (66). At MSKCC I thought I had a ringside seat on the impending cure for cancer and looked forward to doing my own small bit in helping to bring it about.
As part of my job in the Public Affairs department, I wrote monthly articles on cancer science for MSKCC's in-house newsletter, Center News. For this, I interviewed many oncologists, often passing through the hospital's Outpatient Department. I was repeatedly startled by the sound of unearthly retching coming from the partitioned cubicles.
At first, guided by what these doctors told me, I wrote glowingly about their triumphs over such rare malignancies as osteogenic sarcoma (bone cancer) and Hodgkin's disease (lymphoma). But I soon learned about grave reservations that lurked behind even their most sanguine public pronouncements. Some of the scientists and administrators I encountered intimatedstrictly off the record, of coursethat finding cures for the common solid tumors of adults, such as breast, colon, and lung, would be an order of magnitude more difficult than treating the unusual pediatric malignancies. In a memorable phrase, one of them told me it would be like trying to dissolve a person's left ear while leaving the right one intact.
I was beginning to feel a vague uneasiness about my role as an ardent promoter of these doctors and their treatments. At the same time, I was proud of my position at MSKCC and determined to do my job well. I had no idea where these vague doubts would eventually lead me.
Some months after I was hired, our department moved from its temporary quarters on East 62nd Street to what was then called the "new hospital" at 68th Street and York Avenue. As part of that move, my boss discarded a collection of handsome departmental scrapbooks that had been gathering dust in a back room. I asked if I could take the binders home to my children, seeing them as ideal for their school reports.
As I began to clean out yellowing newspaper and magazine clippings from the binders, my eye was caught first by one, then another startling story. That summer, almost every evening, I stayed late, systematically reading and saving choice bits of the historical record of Memorial Sloan-Kettering's publicity efforts. I began to augment this with visits to the MSKCC Archives in the hospital basement and to a college library down the block.
A public relations strategy
What I eventually discovered was this: I had been hired to help publicize the latest breakthroughs in the "war on cancer." But publicizing the imminent cure for cancer was nothing new. Rather, for decades it had been the stock-in-trade of newspaper writers, public relations flacks, and "development" (i.e., fund-raising) strategists at Memorial and other medical centers.
At Sloan-Kettering Institute, despite the obligatory lip service to humanitarianism, the focus of some researchers seemed to be a high-paced game of new drug development. The patient, for some of them, was a pawn in the process of discovering and testing new agents that would boost their own careers, and the profits of drug companies.
Money for research was (and continues to be) scarce, no matter how much was pumped into the war on cancer. Scientists therefore sought out pharmaceutical or venture-capital financing. This created an inevitable tendency to try to please their research sponsors.
This impression has been confirmed by a more rigorous survey of clinical trials published in a medical journal. While 61 percent of drug studies in general reported results favorable to a new treatment, for studies supported by pharmaceutical companies the number soared to 89 percent (91). In other words, when the drug company is paying, nine out of ten times scientists find something positive to say, or say nothing at all.
As time went by, I learned that pharmaceutical companies active in the cancer field had assumed positions of great influence on the Board of Overseers (the directorship) of Memorial Sloan-Kettering and its subsidiary corporations. Overseers with fortunes from other sources went into the drug business and became even wealthier. It was a tightening noose.
Bright new minds
The director of Sloan-Kettering, Robert A. Good, M.D., Ph.D. was famous for his speeches extolling the need for fundamental discoveries from "bright new minds." But often the best that profit-oriented scientists at his Institute could come up with were minor modifications of formulas whose patents were running out. This led to boring, incremental change, masquerading as progress. Other scientists were indeed seeking ways to understand the chemical environment of the body (cytokine research, for example). But the practical upshot turned out to be drugs like filgrastim (Neupogen), which enabled clinicians to give increasing amounts of standard toxic chemotherapy to their patients, usually with no appreciable improvement in survival. Cancer was once seen as a dead end in medicine, and smart doctors hesitated to go into this specialty. But with the creation of the war on cancer, hundreds of millions of dollars were suddenly up for grabs. At around the time that I joined Memorial, cancer research became a smart career move, bringing high salaries, academic prestige, and peer recognition. For a lucky few, it meant really big bucks in the biotech field. Cancer had become big business.
Those vague doubts that I experienced more than 20 years ago have now crystallized into the book you hold in your hands. To my knowledge, this is the first book in any language written for the general public that is about the failures as well as the successes of chemotherapy. But it is certainly not the first time trenchant criticisms have emerged. From time to time, researchers have voiced similar reservations within the pages of medical books and journals; but almost never have their qualms been brought to the attention of the general public.
Why such hesitancy? Perhaps it is a fear of damaging long-nurtured careers by appearing disloyal to the cancer establishment. Cancer specialists also sometimes justify their reticence by claiming that a book such as this might discourage people from getting proper medical attention for life-threatening conditions. I doubt that will happen, but let me make my position clear from the start. Namely, there are situations where chemotherapy can be a rational and life-saving course. These include most cases of Hodgkin's disease, acute lymphocytic leukemia (ALL), and testicular cancer, as well as certain rare cancers, such as Burkitt's lymphoma, choriocarcinoma, and lymphosarcoma.
It also plays a part, with surgery, in the successful treatment of Wilms' tumor, Ewing's sarcoma, rhabdomyosarcoma, and retinoblastoma.Among the more common adenocarcinomas, chemotherapy appears to extend survival in many cases of ovarian cancer. In small-cell lung cancer (SCLC) there seems to be a survival gain of several months.
Its possible value as an adjuvant treatment in breast cancer patients after potentially curative surgery is discussed at some length below. Basically, some chemotherapy has its uses; this message will be repeated throughout the text. However, even for the above cancers, chemotherapy remains an often grueling optionmedieval, by many doctors' own admission. Even for these kinds of cancer, effective, less-toxic substitutes are therefore still desperately needed.
A reasonable prospect
My point of view in this regard is essentially the same as that of New York cancer specialist, Albert Braverman, M.D., writing in the British medical journal, The Lancet:
"Chemotherapy should be prescribed only when there is a reasonable prospect either of cure or of benefit in quantity and quality of life. Oncology trainees should be taught that chemotherapy is not part of the management of every cancer patient..." (48).
As I shall explain, for solid tumors of adults, such benefit has rarely been proven and consequently chemotherapy should just as rarely be given.
For reasons of space, our focus shall be only on those drugs that have been approved by the U.S. Food and Drug Administration (FDA), used either singly or in combinations of what are rather flippantly called "chemo cocktails."
Naturally, this book deals with chemotherapy's record up to this point. Although I personally doubt that cytotoxic drugs (i.e., those that are detrimental or destructive to cells) are about to make any big breakthroughs, admittedly I cannot predict the future. Every new treatment idea certainly deserves to be considered on its own merits, and not rejected because of other drugs' failures.
I am also aware that some doctors use chemotherapy in innovative ways. For example, some doctors use drugs unapproved in their own countries. Others use standard drugs "off-label," for purposes or in dosages that have not been approved by the FDA. This may involve massive doses of conventional drugs. Some patient advocates, desperate for cures, encourage doctors to pursue even seemingly remote possibilities, such as administering chemotherapy in situations that are unjustified by any scientific results. Even ardent enthusiasts must admit that there is no way to know if such unapproved treatments are really effective. And usually, one doctor's or clinic's astonishing claims of success evaporate when their results are subjected to larger, multi-center studies.
But if such treatments are not subjected to more definitive trials, then these "successes" remain essentially in the realm of anecdote.
It amazes me how much of what passes for knowledge in cancer therapy turns out to be incomplete, inadequate, and anecdotal.
A bitter pill
Early successes with Hodgkin's disease and childhood leukemia stirred up great hopes. As Dr. Braverman points out, some chemotherapists now find it hard to accept the fact that their even greater dreams of curing the common forms of cancer have not come true, and probably never will. That must be a bitter pill indeed. Patients are angry and doctors are defensive; tempers are bound to flair in such a situation. I disagree with almost all the current dogmas of oncology, but do not need to personally attack my opponents in order to build up my own position. Those looking for ad hominem attacks will have to look elsewhere.
Chemotherapy's use is now rampant not just in the United States, where it began, but in Canada, Chile, Denmark, France, Germany, Italy, South Africaactually throughout most of the industrialized, and some of the developing, world. In fact, in Great Britain, 60 different cytotoxic drugsmore than in the United Statesare now licensed for use in cancer therapy (61).
With Questioning Chemotherapy, I hope to spark an international debate on the value of toxic drugs in the treatment of cancer.
There is much discussion of the meaning of the word "epidemic" in relation to cancer. However, consider this: in 1962, 278,000 Americans died of cancer. By 1982 that figure had risen to over 433,000. By 1995, cancer deaths were estimated at 547,000. Certainly, part of this increase is due to the growth and aging of the population. But even when one adjusts for these, the overall U.S. mortality rate had increased by 10.1 percent from 1950 to 1991 (323). Incidence during that time had increased 49.3 percent. While the occurrence of some cancers declined, many of them were on the rise, sometimes dramatically:
A sweeping reform of the "war on cancer" is needed, with new leadership focused on prevention, non-invasive forms of early diagnosis, and the exploration of non-toxic and substantially less toxic treatments. A discussion of 102 such approaches is given in my book, Cancer Therapy (271).
For the 1.2 million Americans and the 9 million people worldwide (192) who will develop cancer this year, such a reform cannot come too soon.
--Ralph W. Moss, Ph.D.
Ralph W. Moss, Ph.D. is the author of eight books and three documentaries on cancer-related topics. He is an advisor on alternative cancer treatments to the National Institutes of Health, Columbia University, and the University of Texas. He researches and writes individualized "Healing Choices" reports for people with cancer. For information on Healing Choices, you can contact coordinator Anne Beattie @ 144 St. John's Place, Brooklyn, NY 11217; Phone 718-636-4433; Fax 718-636-0186.
Web site: www.ralphmoss.com.