Make no mistake about it, cancer is a scary disease—and that reputation is well-deserved. Forty- three percent of all Americans alive today will have a serious malignancy With current treatments, about half of those diagnosed die of their disease. And this says nothing about the suffering that patients and their loved ones must endure. Nor does it speak to the economic impact of the premature loss of productive members of society.
Frightening as this information is, it is even more unacceptable because of the fact that the numbers do not need to be this bad. No, we obviously don't have cures for all patients. But the good news is that for the first time for many types of cancer, we actually know the specific causes. In an astounding series of discoveries in the past decade, the genes specifically causing many human cancers have been identified. In some cases, those altered genes are inherited, causing familial cancers, and in other cases sporadically mutated as we go through life exposed to carcinogens.
A great deal is known about the exact function of many of these genes. It seems intuitive that knowing the exact causes of diseases ought to lead to very specific treatments that might reduce their impact or prevent their occurrence entirely. And now, over and over again in many laboratories, this intuition has been borne out. Amazing as it may seem, it is actually a students' experiment to cause a cancer in an otherwise normal human cell by transferring to it a single mutated cancer gene or to revert a cancer cell to normal by "knocking out" a single cancer gene or its protein product.
The cruel irony is that in many cases, these proven and successful preclinical research approaches are languishing badly. We are in an era in which what we now know about cancer and what we could almost certainly learn in the next five years with appropriate research efforts could dramatically change the way we diagnose, treat and control the disease. But a series of critical supports that would allow this to go forward have been removed from the enterprise. This is nothing short of a calamity.
First and foremost is the fact that numerous research initiatives are simply not being moved to human clinical settings because of the lack of money. These initiatives are based on fundamentally sound molecular and biochemical principles and have already demonstrated their ability to cure human cancers growing in experimental animals.
Funding by the federal government for cancer research has remained largely flat in real dollars for many years—ironically, at a time when we almost certainly know some things we could do better. The actual cost of doing this research has obviously increased. Tragically, while many of the right directions have been identified, these efforts are stuck short of the clinic.
There is an explanation. An incredibly large incremental expense is involved in moving experiments from test tubes and mice to human beings. In our own institution alone, I can identify at least a half-dozen strategies whose success in curing animals with human cancer would justify clinical trials. For each of these strategies, something in the range of $1 million to $2 million would be required to get them from the lab to a clinical trial for human beings. Other cancer centers could make similar claims. But the money just isn't there. And so discoveries of great potential languish, as do our patients.
The second critical development in the past few years is that in many cases the patients aren't the there either. Every day, patients who have exhausted "standard therapies' (or for whom no standard therapies have ever existed in the first place) are refused coverage by their 'managed care' organizations (increasingly a* oxymoron) for new and exciting trials of experimental therapies. It is a sad reality that patients can receive reimbursement for care known to have response rates that are abysmally low but be refused access to some of the most new and exciting possibilities for treatment.
In less than five years, managed care (including Medicare) has taken over at least 75 percent of the Washington market. Thus, most, Washingtonians have their health care controlled by groups that in many cases report to their stockholders and their excessively rewarded management rather than to patients and the institutions upon whose discoveries they depend. Thus, not only are there no money and no patients, but in many cases, it is rapidly becoming the case that there are no institutions cor physicians to give this highly specialized experimental care either.
In the "good old days, academic hospitals were profitable enough to take care of the poor and put a great deal of their money into the development of research initiatives and the training of the next, generation of physicians. That was then. In our own city, George Washington University Hospital is likely to become a for-profit institution in which it is hard to believe that research will be given a significant priority. My own institution, also beset by financial concerns, has been forced to divest itself of almost all responsibility for training of new faculty and research develop ment, leaving this to often-generous but inadequate philanthropic funds.
It should be obvious, but it somehow isn't, that the academic health centers essential to any hope for the future are never going to compete perfectly with "for-profits," given the additional and appropriate burdens that they must carry: research and education, not to mention the poor.
So what can we do? Let me suggest several things that can help:
- Support the research activity that has brought us so close to success. Clearly, the federal governments which spends less than the cost of one Stealth bomber on all cancer research in the country, needs a wake-up call. Sen. Connie Mack, a cancer survivor himself (as is his wife), recently asked the Senate to express itself on whether the funding for NIH should be doubled. The Senate said yes, 98-0. Now we need to translate that sentiment into real money.
- Launch a grass-roots offensive &owing upon every American's concern with cancer deaths. There are tens of millions of cancer survivors out there who, together with their families and friends, need to demand support for cancer programs at every level.
- Become involved with your local comprehensive cancer center. Many of the programs they maintain that can prevent cancer, such as smoking cessation initiatives, dietary intervention, etc. are both non-reirnbursable by insurers and managed care and unsupported to any significant extent by district, state or federal dollars.
- Learn what managed care is doing to American academic medicine. Whatever the need for cost containment, we must realize that we are gutting the institutions that are our total future for cancer research, and are actively and cruelly denying legitimate experimental treatments for cancer sufferers every day.
The bad news about cancer is that too many people are dying and suffering unnecessarily. The good news is that defeating the, disease is a matter largely of will-personal will (chiefly, avoiding tobacco) and societal will—for cancer will surely yield to increased investment in research. With half a million Americans dying every year, now is the time to act.
The writer is director of the Lombardi Cancer Center at the Georgetown University Medical Center.
Material presented on this home page constitutes opinion of the author.
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