It is common for me to be asked, “So when are we going to cure cancer already?” If I am at a bar mitzvah, I start to look for the sushi or the bar at this point. A reasonable answer is, as most of my colleagues would concur, that we do cure many cancers already, but unfortunately have limited success with others. I suspect many of you know that, but my goal is to give you a perspective that is different.
The most recent data show that U.S. cancer mortality rates peaked in 1991, 20 years after the signing of the National Cancer Act of 1971 by President Richard Nixon, at 215 per 100,000—we should always use age- and sex-adjusted rates rather than absolute numbers for a variety of reasons—and decreased to 149 per 100,000 in 2018 (the last year for which complete data are available). This represents a 31% decrease over 30 years.
These rates are continuing to decrease steadily and mainly reflect decreases in the major cancers—lung, colorectal, breast, prostate. You may not realize these improvements are occurring because of the remaining large number of deaths, but from a 30,000-foot perspective, things are improving.
Some of this improvement reflects new and important cancer treatments, but I want to highlight what I think are truly important advances over the past few decades, which have not been fully appreciated. Consider this a partial list, since many more things are happening in the world of genetics, genomics, immunology, pediatric oncology, bone marrow transplants, etc:
1. For nonmetastatic solid tumors, cure is dependent on a successful surgical resection; the surgeon’s ability to pull off such an operation is crucial. Luckily, major advances in technology and technique, such as the development of the surgical intensive care unit, have made surgeons able to do much more aggressive surgery than in the past.
A classic example is the famed Whipple procedure, a major surgical procedure for cancers of the pancreas and nearby organs, which can provide a possibility of cure, but entailed a mortality rate greater than 10% in the past, limiting its use. Improved surgical techniques now permit its much more routine use and thus have significantly increased the frequency of its use and at least the possibility of cure for some patients.
Likewise, resection of liver and lung metastases in some patients with colorectal cancer has now become fairly routine, again providing opportunities for cure to many. Similar improvements in surgical success have ameliorated the cancer landscape across oncology.
2. If one considers the causes of death for cancer patients, one of the most common is thromboembolic complications—blood clots usually to the lung, known as pulmonary emboli. Blood clots in the calves and pulmonary emboli can occur in healthy people as well, typically after prolonged immobilization like on a long plane ride. Many cancers secrete chemicals that activate the coagulation system to stimulate clotting and hence inadvertently create blood clots and put the cancer patient at risk for emboli. It is likely that at one time over 10% of cancer deaths were due to this complication.
A major advance in cancer treatment is the development of drugs for anticoagulation, so-called “blood-thinners,” which dramatically reduce this risk. An early drug was warfarin (Coumadin), more recently the injectable enoxaparin (Lovenox), and now a new generation of oral anticoagulant drugs—Xarelto (rivaroxaban), Savaysa (edoxaban) and others.
3. Going back to the 1970s, some of the most effective new chemotherapy agents, like the platinum-containing drugs, were necessarily constrained in their use by severe nausea and vomiting. This side effect is common among many effective and important chemotherapy regimens as well. Thus, it is outstanding that oncology has derived anti-nausea regimens that are now highly efficacious in preventing and reducing the worst of this dreaded side effect—not perfect, but very good. Likewise, other supportive drugs have been devised as well for other important chemotherapy side effects, such as bone marrow stimulating factors to prevent decreased white blood cells, another important chemotherapy complication.
4. In this list, my goal is to describe what has affected cancer mortality. Thus, I necessarily include advances in the use of adjuvant and neoadjuvant therapy, i.e., the addition of chemotherapy, hormonal therapy, or radiotherapy subsequent to curative surgery in an effort to eradicate microscopic tumor cells that may remain and thereby decrease the risk of future recurrence (in contrast to chemotherapy administered for metastatic disease). This is now normative for many (but not all) patients with breast, colorectal, lung, prostate, ovarian, pancreatic, and other malignancies. Likewise, in certain instances the therapy is given pre-surgery, so-called neo-adjuvant therapy.
5. Finally, I would highlight the category of prevention, under which I include early detection and screening. Indeed, most of the reduction in mortality over the past three decades with which we started this discussion can probably be relegated to this category. Many changes have taken place here—it is my intention to devote the next few issues of Thoughts on Cancer to this critically important topic.
Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York.
This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.
