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Cancer: Malignant Maneuvers

When President Richard Nixon signed the US National Cancer Act into law on December 23, 1971, he declared, “I hope that in the years ahead that we may look back on this day and this action as being the most significant action taken during this Administration.” Nixon killed his hope with bewildering hubris. But his call for a war on cancer remains the most astonishingly ambitious, and ultimately flawed, political commitment to a disease in the history of humankind.1 With the joy of hindsight, one cannot help viewing Nixon’s juxtaposition of cancer next to man’s successful efforts to split the atom and walk on the moon with admiration mixed with incredulity. It is morbidly ironic that Nixon’s wife, Pat, died from lung cancer in 1993.

Today, cancer is an undefeated epidemic in all industrialized Western societies. Among American women, for example, lung, breast, and colorectal cancers remain some of the leading causes of death. Among American men, the prostate and liver replace the breast as organs of major malignant importance. There are also disturbing disparities: death rates from cancer are highest among African-Americans. Yet despite enormous investments in research, diagnosis, and treatment, one in two men and one in three women will die of cancer. Moreover, once a cancer has spread, or metastasized, the chances of stopping it by radiation or chemotherapy for more than a short period are usually very small. One American dies from malignant disease every minute. By any common-sense measure, the war on cancer has been lost.

The current leaders of that war take a very different view. They point out that in 1978 there were three million cancer survivors in the US. By 2005, that figure had swelled to ten million. They list a plethora of task forces, initiatives, programs, and studies that signify phenomenal activity. They speak of a long list of accomplishments, unprecedented opportunities, a new age of scientific discovery, and their strong sense of mission.2 The National Cancer Institute (NCI) is the world’s most influential cancer research organization. Its leaders have supported the work of at least twenty Nobel laureates.

To be sure, there have been impressive signs of progress. The year 2003 saw a decline in the number of women diagnosed with breast cancer. The mass abandoning of hormone replacement therapy—an important cause of invasive breast cancer—from 61 million prescriptions in 2001 to 21 million in 2004 is one likely explanation. And new classes of treatment for some of the most intractable types of cancer, such as monoclonal antibodies for colorectal cancer, are prolonging lives.

But these isolated instances of success belie larger failures. Writing twenty-five years after Nixon launched his campaign, the respected cancer scientist Michael Sporn argued that the critical obstacle to large reductions in mortality was a misplaced emphasis on treatment over prevention. Playing catch-up with surgery, radiation, and toxic drugs once cancer has taken hold reflected an inappropriate obsession with the concept of cure. According to Sporn,

We must develop new approaches to control this plague of deaths, adopting an ethic of prevention, based on a more sophisticated understanding of the process of carcinogenesis and the potential to prevent disease before it becomes invasive and metastatic.3

Sporn’s words have not been heeded, prompting some observers to call the so-called war simply “futile.”4 Joining this increasingly fractious debate with devastating force, Devra Davis, director of the Center for Environmental Oncology at the University of Pittsburgh Cancer Institute, claims that the war “has been fighting many of the wrong battles with the wrong weapons and the wrong leaders.” She calculates that these “fundamental misdirections” have thrown away well over a million American lives. Her aim in The Secret History of the War on Cancer is to deliver nothing less than a “reckoning” of this terrible toll.

1.

Davis’s main charge against the cancer establishment is that it has ignored accumulating evidence pointing to environmental hazards as a—perhaps the—major preventable cause of malignant disease. Through an utterly disingenuous strategy of “doubt promotion,” cancer scientists have poured scorn on what could be the key to controlling this most resistant of modern scourges. Evidence from animal-based research indicates clear risks from environmental chemicals, argues Davis. Yet while cancer physicians accept data about potentially effective new drugs from animal experiments, they reject animal research as the basis on which to estimate risks from environmental toxins and pollutants.

This irrational double standard has fostered an “arrogance” among today’s leaders of the war on cancer. They have chosen to ignore sixty years of what Davis sees as convincing science. Why? Partly, she claims, because of “the revolving door of cancer researchers in and out of cancer-causing industries,” among them the tobacco and cosmetics industries. The result of this indolence and self-interest is that “we are treating people like experimental animals in a vast and largely uncontrolled study.” The field of oncology has become a business. One consequence is that the Food and Drug Administration (FDA), fearful of incurring the political wrath of Congress, is soft on businesses that promote possible cancer-causing chemicals in an array of drugs, lotions, and creams.

One example Davis cites is Ritalin. As many as one in ten American children take this drug at some time in their young lives. Evidence from animal research suggests that Ritalin may cause liver tumors. Studies in children point to possible genetic damage. Davis concludes that Ritalin “may pose extraordinary risks to our genetic makeup.” Despite protests, the FDA has taken no action.

Her sharp critique goes well beyond the FDA. Early in its history, the NCI delayed and ultimately barred efforts by one of its most distinguished scientists—Wilhelm Hueper—to publish an uncompromising report on environmental carcinogenesis. His work showed how frequently used substances—asbestos, benzene, chromates, amines, together with assorted oils and dyes—were readily avoidable causes of cancer. Their elimination from industrial, civilian, and military use as “the dominant cause of human cancers” was, he said, a public health imperative. Yet in the 1950s his work was deemed anti-business and pro-Communist.

The American Cancer Society, whose leadership once included a tobacco magnate, was fifteen years late in advocating the Pap smear as a means to prevent cervical cancer. The society considered anti-cancer clinics to be “socialistic.” And it has adopted a skeptical attitude toward the value of research, betraying Mary Lasker (of Lasker Award fame), whose original and ardent support of the society was, Davis reminds us, based upon extracting a commitment from its leaders to invest generously in science. For every $4 raised, the American Cancer Society promised to spend $1 on research; it now invests only a tenth of its resources in research, an unacceptably small sum, Davis suggests.

The American Medical Association has a similar record of obfuscation. The US surgeon general’s report on smoking and health was published in 1964. Three months after its release, cigarette consumption in America had fallen by 20 percent. Yet it took a further fifteen years before the American Medical Association publicly accepted that tobacco smoke was harmful to the lungs. Even then, Davis emphasizes, this leading professional voice of American medicine had nothing to say about smoking and cancer.

One institution that should have made a muscular response to these manifest environmental dangers—the Occupational Health and Safety Administration (OHSA)—was nothing more than a “paper tiger,” according to Davis. Over a twenty-five-year period, OHSA has, on average, set environmental standards for only one human carcinogen each year, a pitifully poor record. Davis alleges that OHSA works too closely and comfortably with the industry trade association, the American Chemistry Council.

Her critical eye also takes in the International Agency for Research on Cancer (IARC) for, she claims, delaying work on the safety of mobile telephones and accepting funding from industry. She describes how the agency bullied and intimidated one of its former directors when he inquired about the status of this important research concerning a potentially common cancer-causing environmental hazard.

There are individual as well as institutional villains in Davis’s account. Robert Kehoe was the founder of American industrial hygiene. He discovered the connection between bladder cancer and benzidine in German factory workers. But from the 1930s to the 1960s Kehoe conducted secret contract research for companies, such as General Motors and Monsanto, while working at the University of Cincinnati. From that highly compromised position—posing as an independent scientist, while all the time working for the same industry he was supposed to be scrutinizing—he defended the increasingly preposterous argument that lead was a natural and unavoidable environmental contaminant.

In the 1920s, Clarence Little led a successful campaign to make the public more aware of cancer. He mobilized women into a field army to educate more women about the widespread existence of cancer. Because of his energetic efforts to persuade a largely unaware population to seek early diagnosis and treatment, Little was appointed the first director of the NCI in 1940. But he soon became part of a clandestine operation spreading doubt about the environmental causes of malignant disease. He was a founder of the Tobacco Industry Research Council, a group that aimed to deflect concerns about smoking as a cause of cancer by proposing alternative causes (air pollution), by criticizing animal research (unreliable), and by sowing public and political seeds of uncertainty (tobacco as a cancer-causing agent was merely a theory). Davis describes how Little spent the final decades of his life miserably “masterminding ways to magnify uncertainties about tobacco products.”

But these attacks are mild by comparison with her extraordinary onslaught against the aristocracy of modern cancer research. Davis’s principal target for criticism is Sir Richard Doll.

2.

For half a century, the British epidemiologist Richard Doll was one of the world’s leading cancer researchers. Beginning with his report proving once and for all that smoking was a cause of lung cancers,5 his work inspired generations of young scientists to study the causes of human disease. For most researchers who investigate cancer in human populations (rather than in the laboratory), Doll is a revered figure. He is spoken of with respect and admiration to this day (he died in July 2005, aged ninety-two). But for Davis, Doll is an example of a scientific egotist who sold out his discipline and his colleagues.

The quantity of vitriol and innuendo that Davis pours on Doll’s reputation is unusual for one scientist writing about another. He “maneuvered and failed,” she writes, to get the Nobel Prize for his discovery of the link between tobacco and lung cancer.6 His behavior was “less than gallant.” Among Davis’s more serious charges, she claims that Doll failed to acknowledge earlier German research linking smoking to lung cancer. Although she concedes that Doll’s work had a “radical impact” and that he did, indeed, cite one piece of German research from 1939, she implies that he deliberately obscured the work of others—he refused to acknowledge “critically important precedents” for his own findings—in order to advance his own fame.

  1. 1

    The World Health Organization’s smallpox eradication program was a bold and dramatic success, but this virus was a far more circumscribed threat and realistic target than cancer.

  2. 2

    See John E. Niederhuber’s 2006 address to the American Association for Cancer Research at www.cancer.gov/aacr2006/directoraddress. Niederhuber is the director of the National Cancer Institute.

  3. 3

    See Michael B. Sporn, “The War on Cancer,” The Lancet, May 18, 1996.

  4. 4

    See Ralph Moss, “Our Futile War on Cancer,” New Scientist, December 16, 2006.

  5. 5

    See Richard Doll and A. Bradford Hill, “Smoking and Carcinoma of the Lung,” British Medical Journal, September 30, 1950.

  6. 6

    As far as I am aware, it was not Doll who maneuvered for a Nobel Prize, but his colleagues who maneuvered for him. For example, I received several letters from his associates encouraging me to support Doll’s nomination for a Nobel Prize, which I was happy to do. Our collective lobbying failed. I once asked a member of the Nobel committee why Doll had never become a laureate. The answer was that the Swedish Academy did not deem him to have made a truly original and individual discovery. Given the huge impact of his work, this always seemed a rather harsh judgment to me.

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