November 4, 2021
A half century since the National Cancer Act passed, understanding of the disease has deepened but challenges remain
Vincent DeVita Jr., M.D., was the medical branch chief of the National Cancer Institute (NCI) when Richard Nixon launched the “war on cancer” in December 1971. “[T]he same kind of concentrated effort that split the atom and took man to the moon should be turned toward conquering this dread disease,” the president told a national TV audience, calling for an intensive $100 million quest for a cure that would be sparked by new legislation known as the National Cancer Act of 1971.
DeVita, who was 36 at the time, was skeptical. He has since changed his mind. “Money does buy ideas when you put brilliant scientists to work,” says the oncologist and researcher, who became director of the NCI from 1980 to 1988 and later director of the Yale Cancer Center. Today — 50 years and over $100 billion later — he believes that “we are not only winning the war on cancer, but the death of cancer is inevitable.”
Successes and challenges
Decisive victories abound. Since 1971, the cancer death rate is down more than 25 percent. Between 1975 and 2016, the five-year survival rate increased 36 percent. The arsenal of anticancer therapies has expanded more than tenfold. Mammograms, colonoscopies and other screenings are finding common cancers in early stages more often, when survival odds are as high as 99 percent.
Yet cancer remains the number 1 killer of Hispanic and Asian Americans, of women in their 50s and of everyone ages 60 to 80. Your lifetime risk for invasive cancer: a stunning 1 in 2 for men, 1 in 3 for women. And while it can strike at any time in our lives, cancer is now understood to be primarily a disease of aging, one that has proven more complicated than we ever imagined. While the root issue in all cancers is cells that mutate and grow uncontrollably, how this happens, the effects it has and how to treat it vary enormously, based on where in the body these cancerous cells occur.
“When the war on cancer started, somehow people thought we could do it in 10 years,” says oncologist Ezekiel Emanuel, M.D., vice provost for global initiatives at the University of Pennsylvania. “But going to the moon was easier. It takes a long time to understand complicated diseases.”
Here’s a look at where we stand.
Cancer, then and now
If you were diagnosed with cancer in the early 1970s, there was just a 50-50 chance you would survive the next five years. Your body — cancerous and healthy cells alike — would be bombarded with radiation, sliced apart in major and sometimes disfiguring surgeries and deluged with megadoses of highly toxic chemotherapy. And that’s if you were lucky. People considered “elderly” often got no treatment at all. Cancer was shrouded in terror and myth.
“People would whisper the word or call it the ‘Big C,’ like John Wayne did when he had lung cancer,” says Susan Leigh, an oncology nurse and a founding member of the National Coalition for Cancer Survivorship (NCCS). “People would spray desks at work with Lysol because they thought that cancer was contagious. Families made a loved one with cancer use paper plates and plastic utensils.”
Plenty has changed, but plenty more needs to. Consider Leigh. Now 73, she’s a beneficiary of the war on cancer’s victories and has also weathered its shortcomings. A U.S. Army nurse who served in Vietnam, she was diagnosed with Hodgkin’s lymphoma in 1972. If untreated, her life expectancy was just three to five years. But radiation and a revolutionary multi-drug chemotherapy regimen called MOPP, developed by DeVita and considered one of the war on cancer’s earliest successes, put Leigh’s cancer in remission. The experience inspired her to become an advocate for cancer survivors.
“When I think back now on the war on cancer, the most important thing is that it increased funding for research,” she says. “But we thought in simplistic terms. Over 50 years, we’ve discovered cancer is not one but many, many hundreds of diseases. We’ll be looking for treatments for years.” Indeed, years after her early success, Leigh battled breast, lung and bladder cancer, as well as heart damage and weakened bones, issues that are often long-term side effects of both radiation and chemotherapy.
Among the most notable wins from the early days of the war is the establishment of NCI-designated cancer centers across the country that, for the first time, tied scientific discoveries more closely to bedside cancer care. Today, there are 71 centers in 36 states and the District of Columbia. Studies show they often deliver better cancer survival and recovery rates than other hospitals.
The war also cracked open the hidden universe of cancer genetics. In 1979, the most commonly mutated gene in human cancer was discovered. By 2018, the Cancer Genome Atlas had enough DNA data to fill 530,000 DVDs. “It took billions [of dollars] to sequence the first cancer genome,” DeVita says. The pace of discovery for treatments has accelerated as well. Between 1941 and 1970, the FDA approved 16 cancer drugs.
Between 1971 and 2020, it OK’d more than 160. Many are brand-new types that cancer specialists call the “fourth and fifth dimensions” of cancer treatment. (Chemotherapy, surgery and radiation are the original three.) It’s a powerful advance.
“Ten years ago, chemotherapy was the only treatment for most patients with advanced cancer,” says oncologist Ravi Parikh, M.D., an assistant professor of health policy and medicine at the University of Pennsylvania. “Now there’s been a revolution in cancer treatment. Immunotherapies and targeted therapies are not chemotherapy. They work in completely different ways,” Parikh says.
Immunotherapies harness the immune system to fight cancer. Targeted therapies zero in on molecules in a cancer, often stalling growth. These breakthroughs extend life and can turn killer cancers into chronic diseases managed with a daily pill. “They aren’t cures,” Emanuel notes. “But giving people many years of normal life beyond what we could do at the start of the war on cancer, that’s truly remarkable.”
Yet not every new treatment has lived up to its early promise. In 2019, a study published in JAMA Internal Medicine found that only 19 of 93 cancer drugs fast-tracked through the U.S. Food and Drug Administration’s accelerated approval process actually extended life. Underperforming drugs might shrink or stall tumors but didn’t improve survival or quality of life for people with cancer. Immunotherapies work in less than 20 percent of patients — and experts often can’t predict who will be helped.
DeVita says it’s shortsighted to rely on any single drug therapy on its own. “If you want to cure advanced cancer, you need to combine three to four drugs that are individually effective to some degree,” he says. “Cancer cells are very flexible; they adjust quickly.” Combinations, like the four-drug MOPP treatment DeVita developed and that vanquished Leigh’s cancer, are effective because they attack cancer cells on several vulnerable fronts at once.
Often, chemotherapy remains the best option — another area where the war on cancer is helping. “People fear chemotherapy,” says Parikh. “A lot have visions of losing their hair, being over the toilet and vomiting all the time. But our methods of controlling your chemotherapy side effects are a lot better than 10 to 15 years ago. It’s one of the untold successes of the war on cancer.”
Prevention and detection In dozens of laboratory freezers at Columbia University in New York City, 60,000 cancer specimens await testing that oncologist Azra Raza, M.D., anticipates will find “cancer’s first cell” — the earliest mutated cell that will eventually multiply to become a cancer — and lead to treatments that knock the disease out before it grows. The blood and bone marrow samples come from nearly every one of her patients of 35 years, provided as they moved through cancer treatment.
“We have not won the war on cancer,” says Raza, a professor of medicine and director of the MDS Center at Columbia. “Understanding cancer will take 1,000 years. It is too evolved,” she says. “Instead, we have to find the first cell and eliminate it.”
Raza’s $15 million project, with input from a think tank of researchers from eight major cancer centers, aims to collect 50,000 tissue samples from another group: people who do not have cancer — yet. Intensive analysis, she says, can find tiny trouble cells, then examine how genetic changes and everyday exposures lead to cancer. Raza envisions developing an early-alert system by placing a microchip under the skin that will make avoiding cancer as commonplace as avoiding heart disease: You take care of the warning signs, and the risk diminishes.
Finding cancer before it starts is a powerful prevention strategy. An estimated 20 to 40 percent of cancer cases and half of all cancer deaths could be eliminated with familiar steps like not smoking, exercising, avoiding too much alcohol and maintaining a healthy body weight, a 2016 study says. And Americans are catching on, in some ways. Since the start of the war on cancer, smoking rates are down 63 percent, a major contribution to the overall drop in cancer deaths.
But the epidemic of obesity, which increases risk for 13 types of cancer, according to the National Cancer Institute, could soon overtake smoking as a major cancer trigger. Currently, obesity is responsible for at least 40 percent of U.S. cancers — and two-thirds of cancers in people ages 50 to 74 — and rates are rising, even as the number of smoking-related cancers declines.
More funding for prevention might prod Americans to take the practical, everyday steps that keep cancer at bay and reduce cancer deaths at any age. Among them, according to the American Institute for Cancer Research: eating plenty of produce, whole grains and beans; limiting red and processed meat, sugary drinks, junk food and alcohol; avoiding tobacco and excessive sun exposure; and getting recommended screenings.
Meanwhile, a cancer-avoidance strategy called “secondary prevention” — where cancer is found at its earliest, most treatable stages and eliminated — is also getting a boost on another front. Right now, for most people, secondary prevention means getting recommended mammograms, colonoscopies or other colorectal cancer screenings, lung scans for smokers, Pap smears for women and prostate cancer checks for some men. In the future, it could start with a single blood test that looks for floating traces of protein and DNA from a wide range of cancers. Detection at the earliest stages makes halting the cancer’s progress far easier.
“The best way to decrease cancer’s lethality is by not getting it at all,” says Nickolas Papadopoulos, professor of oncology and pathology at the Johns Hopkins University School of Medicine.
Papadopoulos studies cancer biology and genetics. He discovered genes behind the most common type of inherited colon cancer. More recently, he led development of an experimental blood test called CancerSEEK that found 26 undiagnosed cases of cancer in a 2020 study of 10,006 women who thought they were cancer-free. These included nine lung cancers, two colon cancers and — especially notable — six cases of ovarian cancer, which is difficult to detect in early stages and for which there is no screening test. After a positive test, women saw their doctors for further testing and treatment if needed. Papadopoulos says the test, called a liquid biopsy, can be used to look for a wide variety of cancers. Someday it may be part of your annual wellness checkup with your primary care doctor.
“Even drugs we now have to treat advanced cancers appear to work better when cancers are early,” Papadopoulos explains. That kind of prevention could boost survival greatly, creating new hope for hard-to-spot cancers that could be treated effectively if caught early. Most ovarian cancer, for example, is found at advanced stages, when the chance of survival with treatment is about 15 percent, he says. In contrast, “only 15 percent is found at stage 1, when survival with treatment is 95 percent.”
Left out: older adults
Aging boosts cancer risk. Rogue cells with potentially risky gene mutations build up over the decades, and an aging immune system may be less aggressive at killing them off. That’s why the average American who has just been told “you have cancer” is 66 years old. But despite the tidal wave of research bankrolled by the war on cancer, cancer doctors don’t always have great data to draw on when treating their largest group of patients. The reason: For much of the past five decades, older adults were frequently shut out of cancer studies.
Just this year, researchers from the City of Hope, a cancer research and treatment center near Los Angeles, sounded the alarm: While 42 percent of people with cancer are age 70 and older, they represent just 10 to 24 percent of trial participants. The gap, they note, means older people are more likely to get suboptimal cancer care. They’re often undertreated with smaller doses, milder drugs or no drugs at all. Or they’re overtreated with doses tested in healthier, stronger, younger people — and they experience side effects. “We often err in those directions because we don’t know what to do without age-specific data,” says William Dale, M.D., director of the Center for Cancer and Aging at City of Hope.
Researchers are looking at new and better study designs that will include more older adults, allow for their other commonly coinciding health issues, and make it easier for them to participate. “The biggest influence on whether you enroll in a clinical trial is whether your doctor asks,” DeVita says. “Doctors don’t ask older patients, on the assumption they won’t want to be in a clinical trial. But you should ask. You’d be surprised how much older people want to contribute to science.”
Meanwhile, doctors could better tailor cancer treatments by using a new research-based assessment of their older cancer patients. Called the geriatric assessment, it was developed by Dale and a team of top oncologists and looks at the all-around physical, emotional, cognitive and social health of older adults (generally age 65 and up) to help guide cancer treatment choices, including doses of chemotherapy. When the assessment is used, “survival rates are just as good, but drug doses could be lower, the chances of toxicity from chemotherapy are lower, and the chance you’ll finish your [treatment] is higher,” he and other City of Hope researchers noted in a 2020 study.
But don’t assume you’ll automatically get this kind of personalized health review. Dale and his colleagues surveyed 1,227 cancer providers and found that 57 percent rarely or never used these special assessments. Some relied on their own judgment, which Dale calls “eyeballing,” and others did little or nothing. Dale says older cancer patients looking for optimal health outcomes can ask for an assessment, or look for an oncologist who uses the tool, when they need cancer care.
Gaining attention: care after cancer
Here’s another big cancer number: 15 million. Of the nation’s 17 million cancer survivors, that’s roughly how many are 50 or older, according to the American Cancer Society report.
Early in the war on cancer, survivors were on their own when it came to anticipating and recognizing the long-term effects of cancer and cancer treatment on their physical and emotional health. “I asked questions all the time. ‘How do I know the cancer is cured?’ ” recalls Leigh of the NCCS. Back then there were no support groups and little medical data about what to expect.
Survivorship is another emerging facet of cancer care in which things are better than they were in 1971 — but could be even better. The NCI established the Office of Cancer Survivorship in 1996, bringing new awareness and new research to what had been a grassroots issue, Leigh says. But 15 years after the Institute of Medicine cautioned that survivors too often got “lost in transition,” not all cancer patients receive valuable survivorship information recommended by the American College of Surgeons’ Commission on Cancer.
Leigh says survivors and their family doctors need to understand cancer’s long-term effects and what to watch out for over the increasingly long years after cancer treatment. Survivors, she says, can help, too. “There are so many things that doctors who are not used to older oncology survivors don’t know,” she says. “They need to listen to us because we have a lot to teach them.”