A disturbing report from the front lines of the war on cancer.
“The Death of Cancer” is an angry book, in which one of the critical figures in twentieth-century oncology unloads a lifetime of frustration with the obduracy and closed-mindedness of his profession. DeVita concludes, “There are incredibly promising therapies out there. If used to their fullest potential for all patients, I believe we could cure an additional 100,000 patients a year.”
.. Baffled, he asked one of the hospital’s leading oncologists, Barney Clarkson, to explain exactly how he was administering the MOPP protocol. Clarkson answered that he and his colleagues had decided to swap the nitrogen mustard in DeVita’s formula for a drug called thiotepa. This was a compound they had developed in-house at Memorial Sloan Kettering and felt partial to. So MOPPwas now TOPP.
.. “Why in God’s name have you done this?” he asked.
A voice piped up from the audience. “Well, Vince, most of our patients come to us on the subway, and we don’t want them to vomit on the way home.”
Here were physicians at one of the world’s greatest cancer hospitals denying their patients a potentially life-saving treatment because their way felt better. Stories like this are why DeVita believes that a hundred thousand cancer patients in the United States die needlessly every year.
.. The angriest chapter of “The Death of Cancer” is devoted to the Food and Drug Administration, because DeVita believes that it has fundamentally misunderstood the trade-off between diffusion and innovation. The agency wants all new drugs to be shown to be safe and efficacious, to be as good as or better than existing therapies (or a placebo) in a randomized experiment involving the largest possible number of patients. For example, the F.D.A. might ask that patients getting an experimental treatment have better long-term survival rates than those receiving drug treatments already in use. The F.D.A. is the country’s diffusion gatekeeper: its primary goal is to make sure that good drugs get a gold star and bad drugs never make it to market.
.. A given tumor, for instance, can rarely be stopped with a single drug. Cancer is like a door with three locks, each of which requires a different key. Suppose you came up with a drug that painlessly opened the first of those three locks. That drug would be a breakthrough. But it can’t cure anything on its own. So how do you get it through a trial that requires proof of efficacy—especially if you don’t yet know what the right keys for the two remaining locks are?
.. Drugs are now approved not for a specific cancer or for general use in a variety of cancers but for a specific stage of a specific cancer and specifically after and only after patients have had all current treatments, which are listed drug by drug, and the treatments have all failed. Doctors risk F.D.A. censure if they use an approved drug under any other circumstances, and patients are penalized because insurance companies won’t pay for treatments not approved by the F.D.A.
The vital insight gained by using an approved drug in a different way for a different tumor has been lost.