Learning to Expect Less From the War on Cancer

By George Johnson | September 22, 2013 7:41 pm

When the American Association for Cancer Research released its 2013 progress report last week, it was faced with a familiar dilemma: how to emphasize the good news and the bad news both at the same time. To keep government funding flowing in, the leaders of the research establishment bring out statistics suggesting that tax money isn’t being wasted — that progress is really being made. But lest we become too complacent they are ready with numbers emphasizing how badly we are losing the fight. Sometimes they want to assuage and sometimes they want to frighten, and so they keep two sets of books.

According to ledger number 1, we are winning or at least keeping up. The overall likelihood of an individual getting cancer and dying from it has been holding steady and even decreasing a little every year. But ledger number 2 clearly shows that more people than ever are dying of the disease.

The reason for the discrepancy, of course, is the expanding size of the population and the famous demographic bulge — the greater proportion of older people alive each year. With tragic exceptions, cancer is a condition of aging and entropy — a matter of cells wearing out. Adjust for that inevitability and the numbers for incidence and mortality (the percentage of people getting cancer and the percentage succumbing to it) are not increasing. But remove the statistical filters and out comes the raw truth: the sheer number of cases — and the burden on the clinics and hospitals — is rising with no prospect of letting up.

The dueling statistics can be seen every year in the National Cancer Institute’s Annual Report to the Nation and in publications of the American Cancer Society and other advocacy groups. The AACR’s new assessment is just the most recent example.

We start off reading about “amazing progress” and “remarkable advances.” And then in the third paragraph comes the shock: Despite the gains in knowledge, “580,350 Americans will die from one of the more than 200 types of cancer in 2013.” Because of the growing, graying population that is more than ever before.

After the report was released at a press conference in Washington, news stories focused on one of the AACR’s cheerier-sounding statistics: “the number of cancer survivors living today in the United States is estimated to be more than 13.7 million” — and that too is more than ever before.

So we have a record number of deaths and a record number of survivors. You have to reach pretty deep into the report and read between the lines to be reminded that “survival” is defined as still being alive five years after diagnosis. If you die in year six you go into the records as a survivor and as a fatality.

Survival rates are also artificially inflated because of improvements in scanning technologies. The earlier your cancer is detected, the longer you will be said to have survived it — even if the treatment had no effect.

For all of that there have been genuine improvements. But these are almost always for tumors that have not metastasized. For a few of these primary cancers, like cervical and colorectal, early detection has allowed for the safe removal of dysplasias — messed up cells that may sometimes become malignant. Screening for breast cancer and prostate cancer presents more of a dilemma, saving some lives but also leading to harmful and unnecessary treatments.

Whether you look at the incidence, mortality, or survivability of cancer, most of the real progress has come from simpler solutions: smoking prevention, pap smears, HPV vaccines. The high-tech approaches — the targeted drugs like Herceptin, Perjeta, Kadcyla, and the experimental immunotherapies so much in the news — have yet to offer more than modest improvements, particularly with metastatic cancer, which accounts for almost all cancer deaths. (For two great articles on cancer immunotherapy see Dan Engber’s “Is the Cure for Cancer Inside You?” in the New York Times Magazine and Jerome Groopman’s “The T-Cell Army” in The New Yorker.)

No matter how effective any of the new therapies or their successors might turn out to be, there is not going to be a complete victory in the war on cancer. We have to die of something. For every success in combatting other diseases, more people will be left to ultimately succumb to the breakdown of cellular functions that we call cancer. That is a number that can still be reduced but only somewhat.

Maybe we need to lower the bar on what counts as a success. Victory would mean preventing and successfully treating more cancers that strike the young and even the middle aged — and improving hospice care for the aged, who have managed to survive everything else.


For a preview of my book The Cancer Chronicles, including the table of contents and index, please see the book’s website.


CATEGORIZED UNDER: Cancer, select, top-posts
  • Ismur

    Apart from a few singular exceptions, the war on cancer has been a complete failure. If you recognize that strong evidence documented that the main cause of cancer (especially breast cancer) is medical x-rays (read the book “The Mammogram Myth: The Independent Investigation Of Mammography The Medical Profession Doesn’t Want You To Know About” by Rolf Hefti) and that the magnitude of x-ray use has been increasing drastically over the last 30 years, it all starts to make sense…

  • Jim

    John Goffman made those claims in the late 80s and early 90s when CT diagnostic machines were still in infancy. The number of CT scans and medical X-rays rose sharply from that point onward and yet the rate of breast cancer incidence, adjusted for population growth, has remained stable. So Goffman was clearly wrong. He was a brilliant scientist but in his later years his strong stance against the nuclear industry caused him to look for things that weren’t there. The truth is, some of the most common types of cancer are going down in incidence. How could that be possible if CT scan usage is going up? Smoking is known to cause 1/3 of all cancers. And you know what else. 12 percent of breast cancers are estimated to be caused by alcohol consumption. Not just heavy consumption, but casual weekly drinking of wine. The ethanol in alcohol is converted by the body into acetylaldehyde, which is a carcinogen. It disrupts DNA repair and blocks the absorption of folic acid.
    Diet is also a major cause. The western diet leads to obesity. 2/3 of all Americans are overweight. 1/3 are considered obesity. Obesity is a risk factor for several different kinds of cancer because the fatty adipose tissue that most obese people possess produces estrogen. Estrogen, although a vital hormone, is a known cancer-promoter. It helps in the proliferation of cancer cells. Diabetes is also a risk factor for some cancers. In summary, there are a lot of things that I would chalk up as major causes of cancer before even considering the effects of medical radiation. However, I am in favor of the linear-no-threshold theory and I do believe in the ALARA philosophy. As Low As Reasonably Achievable. Scientists and radiologists and engineers are working to make CT radiation doses smaller. They’re also working on making MRI machines faster and they’re working on combining the two modalities to make an even better imaging machine. We need to focus on eradicating tobacco usage in this country and around the world. We need to stop promoting regular alcohol consumption and binge drinking in our films and television shows. We need to change our diets. You will see big gains made that way. Although, as the article states, people have to die from something. We make major gains against non-malignant diseases such as heart and kidney disease because they’re not complex. So if less and less people die from heart attacks, strokes, and renal failure, what will they die from? They’ll live long enough to get cancer. So let’s not treat the depressing figures as a failure. Our goal is to treat cancer successfully in both the young and the old, and our success with the young has been tremendous. We have made huge strides in childhood cancer. In the 70s, the survival rate for childhood leukemia was 5 percent; now it’s 96 percent. Who would dare to scoff at that? Only a pessimist.

    • jaia

      Actually, a large decrease in smoking and hormone replacement therapy could hide a small or moderate cancer increase due to x-ray exposure.

      • Jim

        The risk of getting cancer from a CT scan is 1 in 2000 to 1 in 3000, and that’s a conservative estimate based on the LNT model. If a large decrease in smoking and hormone replacement therapy can hide the small increase in cancer due to x-ray exposure, that just further proves my point. Epidemiological studies on X-ray and Gamma radiation show that below 50 mSv of acute exposure, the risks of getting cancer are so small as to be undetectable or non-existent. Further studies on cancer patients who received radiotherapy show that despite large doses of radiation that scatter to nearby tissue, the occurrence of secondary cancers was very small. To try and pin the blame on medical diagnostic tools – which have without a doubt saved hundreds of millions of more lives than they’ve harmed – when there are so many obvious causes to address is ludicrous. Recently, the AMA and recommended that long-term smokers get yearly CT scans to check for lung cancer. If one of them gets lung cancer after a CT scan, what is to blame? The CT scan or the 40 year smoking habit?

        In any case, CT scan doses are being lowered and physicians are now advised to keep track of how many scans people have had to be as conservative with the machines as possible.

        • jaia

          Is that a lifetime risk or a per-scan risk? And do they include the ages at which people get scanned? If yes, it’s pretty large, especially on a population level. If Americans average one CT scan in a lifetime, you’re looking at 300,000,000*(1/3000)=100,000 excess cancers in the US alone. I’m not saying that’s what’s actually happening (I’m not in medicine or epidemiology), but those are the consequences of the numbers you provided.

          • Jim

            Lifetime risk. If it happens, it usually takes 20 or 30 years.

            If a person has a genetic defect like Lynch syndrome, a CT scan will accelerate the growth of cancer cells.

  • Matthew Slyfield

    How about we stop using war as a metaphor for medical research or law enforcement?

  • Gear Mentation

    I think we are headed for a technological singularity. How can I justify that, when we have articles like this one? One way is to note that exponential growth in knowledge and ability, something we’re seeing in the biological sciences, looks like nothing to begin with. But then you get to a point where things shoot through the roof. This article may in fact be written from the standpoint of linear growth in our knowledge and ability to treat cancer. But in fact, our abilities may be growing exponentially.


Discover's Newsletter

Sign up to get the latest science news delivered weekly right to your inbox!

Fire in the Mind

Whether a subtle new pattern shows up in an experiment on the Higgs boson, an epidemiological report about a suspected cancer cluster, or a double-blind trial purporting to demonstrate ESP, it can be maddeningly difficult to distinguish between what we see and what we think we see. "Fire in the Mind" takes a look at the big questions behind today’s science news.

About George Johnson

George Johnson writes about science for the New York Times, National Geographic Magazine, Slate, and other publications. His nine books include The Cancer Chronicles: Unlocking Medicine's Deepest Mystery (August 2013), The Ten Most Beautiful Experiments, A Shortcut Through Time, and Fire in the Mind. He is a winner of the AAAS Science Journalism Award and has twice been a finalist for the Royal Society science book prize. Co-founder and director of the Santa Fe Science Writing Workshop, he can be found on the Web at talaya.net. Twitter @byGeorgeJohnson.


See More


@byGeorgeJohson onTwitter

Collapse bottom bar