On February 12, I gave a talk at Stevens on the gap between the grim reality of cancer medicine and upbeat claims made by the cancer industry and its media enablers. Below is the first half my talk, which I also posted on my Scientific American blog “Cross-check.” I will publish Part II of my talk next week. —John Horgan, Director, Center for Science Writings
BIG PROBLEM, BIG BUSINESS, BIG HYPE
First, some basic facts to convey the scale of the problem. Cancer is the second most lethal disease in the U.S., behind only heart disease. More than 1.7 million Americans were diagnosed with cancer in 2018, and more than 600,000 died. Over 15 million American cancer survivors are alive today, according to the National Cancer Institute.
Cancer has spawned a huge industrial complex involving government agencies, pharmaceutical and biomedical firms, hospitals and clinics, universities, professional societies, nonprofit foundations, and media. The costs of cancer care have surged 40% in last decade, from $125 billion in 2010 to $175 billion in 2020 (projected).
Research funding has also surged. The budget of the National Cancer Institute, a federal agency founded in 1937, now totals over $6 billion per year. That is a fraction of the total spent on research by nonprofit foundations ($6 billion a year, according to 2019 study), private firms, and other government agencies. Total research spending since Richard Nixon declared a “war on cancer” in 1971 exceeds a quarter trillion dollars, according to a 2016 estimate.
Cancer-industry boosters claim that investments in research, testing, and treatment have led to “incredible progress” and millions of “cancer deaths averted,” as the homepage of the American Cancer Society, a nonprofit that receives money from biomedical firms, puts it. A 2016 study found that cancer experts and the media often describe new treatments with terms such as “breakthrough,” “game changer,” “miracle,” “cure,” “home run,” “revolutionary,” “transformative,” “life saver,” “groundbreaking,” and “marvel.”
There are more than 1,200 accredited cancer centers in the U.S. They spent $173 million on ads directed at the public in 2014, according to a 2018 study, and 43 of the 48 top spenders “deceptively promot[ed] atypical patient experiences through the use of powerful testimonials.” A 2014 study concluded that cancer centers “frequently promote cancer therapy with emotional appeals that evoke hope and fear while rarely providing information about risks, benefits, costs, or insurance availability.”
LITTLE NET PROGRESS BESIDES ANTI-SMOKING EFFORTS
What’s the reality behind the hype? “No one is winning the war on cancer,” oncologist Azra Raza asserts in her 2019 book The First Cell: And the Costs of Pursuing Cancer to the Last. Claims of progress are “mostly hype, the same rhetoric from the same self-important voices for the past half century.” Trials have yielded improved treatments for childhood cancers and specific cancers of the blood, bone-marrow, and lymph systems, Raza says, but these successes, which involve uncommon cancers, are exceptions among a “litany of failures.”
The best way to measure progress against cancer is to look at mortality rates, the number of people who succumb to cancer per unit of population per year. The risk of cancer grows with age. (Although childhood cancer gets a lot of attention, Americans less than 20 years old account for less than 0.3% of all U.S. cancer deaths.) Hence as the average life span of a population grows (because of advances against heart and respiratory disorders, infectious disease, and so on), so does the cancer mortality rate. To calculate mortality trends over time, therefore, researchers adjust for the aging of the population.
With this adjustment—which, keep in mind, presents cancer medicine in a more favorable light—mortality rates have declined almost 30% since 1991. This trend, according to cancer-industry boosters, shows that investments in research, tests, and treatments have paid off. What boosters often fail to mention is that recent declines in cancer mortality follow at least 60 years of increases. The current age-adjusted mortality rate for all cancers in the U.S. is just under what it was in 1930, according to a recent analysis.
The rise and fall of cancer deaths track the rise and fall of smoking, with a lag of a couple of decades. Cigarette consumption in the U.S. more than doubled between 1930 and the early 1970s and has fallen steadily since then, according to the nonprofit site Our World in Data. Smoking raises the risk of many cancers but especially of lung cancer, which is by far the biggest killer, accounting for more deaths than colon, breast, and prostate cancer combined. A 2006 analysis concluded that “without reductions in smoking, there would have been virtually no reduction in overall cancer mortality in either men or women since the early 1990s.”
NEW TREATMENTS YIELD SMALL BENEFITS, BIG COSTS
Research has linked cancer to many internal and external factors, notably oncogenes, hormones, viruses, carcinogens (such as those in cigarettes), and random cellular replication errors, or “bad luck.” But with the notable exception of the smoking/cancer link, which led to effective anti-smoking measures, that knowledge has not translated into significantly improved preventive measures or treatments. Clinical cancer trials “have the highest failure rate compared with other therapeutic areas,” according to a 2012 paper.
Pharmaceutical companies keep bringing new drugs to market. But one study found that 72 new anticancer drugs approved by the FDA between 2004 and 2014 prolonged survival for an average of 2.1 months. A 2017 report concluded that “most cancer drug approvals have not been shown to, or do not, improve clinically relevant end points,” including survival and quality of life. The authors worried that “the FDA may be approving many costly, toxic drugs that do not improve overall survival.”
Costs of cancer treatments have vastly outpaced inflation, and new drugs are estimated to cost on average more than $100,000 per year. Patients end up bearing a significant proportion of costs. More than 40% of people diagnosed with cancer lose their life savings within 2 years, according to one estimate.
Immune therapies, which seek to stimulate immune responses to cancer, have generated enormous excitement. But a 2017 analysis estimated that fewer than 10% of cancer patients can benefit from immune therapies. The therapies can trigger severe side effects, and costs can exceed one million dollars, oncologist Siddhartha Mukherjee reported in The New Yorker last year. If widely prescribed, he warns, immune therapies “could bankrupt the American health-care system.”
Part II will cover screening, overdiagnosis, and other issues.
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