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226  Cancer `Cure' Has Limitations
     The Washington Post  February 14, 1971

     "Cure-cancer!," a crusade now well-launched with President
Nixon's acclaim, has come under skeptical fire. The slogan does warrant
careful analysis.  Like all war cries, it is an oversimplification,
and it has some potential for backfiring if unachievable hopes are
aroused.

     It is also a subject on which honest men may disagree; but with
so much at stake, the public interest might be well served by 
encouraging the most optimistic in each facet of the cancer problem to
prove that his is the true solution.  If any one is successful, we 
will all benefit.

     We should not dismiss the fact that some $2 billion has already
been invested in cancer research in the last 20 years.  What is the
outcome?

     Earlier diagnosis of certain cancers, and new treatments by  
surgery, radiation and drugs, have reduced the inevitability of dying
from cancer, once found.  More than two million citizens who have had
cancer would not be alive today had they been left untreated.

     Nevertheless, the aggregate rate of death from cancer is still
rising, mainly because of lung cancer cases attributable to cigarette
smoking and air pollution.  Can more money spent on research give us a
realistic hope of outpacing these statistics?

     There is certainly need for wider availability of the measures
already available at the best-staffed centers, but we simply do not
have the basic knowledge to do more than gain time with many cancers 
after they have reached a certain state of development.  At the
present time, about one person in six dies of cancer; the best avail-
able (and costly) treatments probably could not improve that figure
below one in ten.  This would be a notable accomplishment, but it
would buy fewer lives per dollar spent than many other unmet 
opportunities.  

     Some specific exceptions should not be forgotten.  They include
vigorous treatment of some leukemias with new drugs, and the 
sophisticated use of new forms of radiation for the eradication of 
Hodgkin's disease.  They also include some mass screening programs for 
the early detection of cancer of the cervix and the breast, which verge
on other measures for prevention rather than cure.

     Broader Attack

     The dissemination of existing modes of treatment has another
payoff besides giving every cancer patient a chance to get the best 
in available therapy.  It would broaden the base of research on human
cancer, for the improvement of the methods and the testing of totally
new concepts.  Given a cost-effective balance between more care and 
more knowledge, many of the proposed new cancer centers may be 
effective investments.

     The greatest promise, of course, comes from the great leaps in
basic biological knowledge of the last decade, many of them in the
related areas of DNA and viruses.  These have so far given only a few
answers centrally connected with human cancer, but we are now able to
formulate sensible questions about the nature of the cancer cell and
the origin of its deadly differences from the normal.

     These were only dimly perceived before now, were far beyond the
reach of our experimental tools.  Within the last few months, however,
we have learned that tumor viruses in animals produce a remarkable
enzyme that codes DNA from RNA, the reverse of the process by which
the genes control normal development.

     Furthermore, this special enzyme has also been found in cells of
human leukemia, previously suspected, but not otherwise proven, to be
caused by a virus. (These viruses may be harboured by most normal 
individuals;we are not speaking of a contagious disease like influenza.)
Naturally, many investigators are probing the properties of this
enzyme in search of approaches to block its activity, say with a
specific drug or with some competing viruses otherwise harmless.

     Despite these leads, I believe that "Cure Cancer" is a misleading
slogan, but only because cancer prevention is a far more promising   
approach than the cure of the disease once established.  Prevention
also offers the most incisive channels for exploiting basic molecular
and cell biology.

     It is not as glamorous as cure by surgery or radiation, and a
citizen who may balk at another dollar's outlay for preventive public
health will spend a fortune to root out his own cancer after the fact.
Human nature, however, still does not exclude the eventual use of
rational intelligence to help decide among policy alternatives.

     The very facts of changes in cancer incidence in different eras,
and in different occupations and geographical areas, give the strongest
hopes for preventive measures.  For they speak to the importance
of specific environmental factors rather than letting us acquiesce 
ignorantly to cancer as an inevitable lightning bolt.

     Many forms of cancer are related to known environmental hazards:
asbestos and uranium for lung cancers of different kinds; certain
dyestuffs for bladder cancer.  Chemists are subject to an increased
risk of cancers of the pancreas and lymphoid tissues.  Learning the
environmental factors responsible here might benefit housewives and
amateur photographers even more than the professional laboratory 
workers, who give crisper data for statistical analysis.

     The effective pursuit of these leads will, however, require the
linking of various statistics, for example, Social Security data on
occupational histories with recorded causes of death. This is now
obstructed by a legal impasse over safeguards of privacy and 
confidentiality.

     Cigarette smoking is, of course, the best known of the environ-
mental factors in the United States.  Nevertheless, the surge in lung
cancer has not been halted, partly on account of the momentum of
decades of innocence; partly on account of psychosocial stupidity in
the face of overwhelming evidence, and to a large degree because of
unanswered technical questions.

     When we learned just how the cigarette works, we might persuade a
few more scoffers; more important we could surely devise a smoke that
still satisfied while lacking the naughty thrill implied by the old
cliche "coffin nail."  Individuals may also differ in their inherent
sensitivity to the active ingredients of tobacco.  Biochemical tests
might then identify the high-risk citizens who should be most 
energetically dissuaded from smoking, or warned to have their lungs 
checked as often as they lubricate their cars.

     An Inherent Safeguard

     Recent work has also thrown light on the role of the immune
system, hitherto thought of mainly in connection with infectious
diseases like smallpox, polio or diphtheria.  We now theorize that many
incipient cancers are normally eliminated in the healthy body.  How-
ever, a weakening of the immune mechanism may allow a potential cancer
seed to escape this surveillance and grow to unmanageable size and
virulence.

     Some drugs used to suppress the immune reaction against organ
grafts have been associated with a visibly higher incidence of cancer.
Research would aid prevention here by providing the tools to evaluate
widely used drugs, for we do not know how to test them properly at
this time.  It could also establish the role of genetic factors or of
other disease conditions in weakening the immune response.

     Thus Burkitt's lymphoma, a leukemia-like disease found across
Africa, is connected with the coincidence of malaria and infection
with a virus related to mononucleosis.  Both of these diseases have
profound effects on the immune system; neither alone, in all
likelihood, will cause the cancer.

     When the immune factor in cancer is clarified, we might 
eventually develop specific vaccines.  (In my own view, we are more 
likely to learn how to tend to the health of the immune system as a 
bulwark against cancer.)

     Another line of action is already well-founded in basic work.
This is the evaluation of the direct cancer potential of chemicals
used as food additives or drugs or otherwise added to the human 
environment.  Existing methods are costly, and not always foolproof.  
Perhaps the anticipated shock of discovering how many of our synthetic
additives, and perhaps some natural foods as well, have a cancer
potential is a greater deterrent than the expense of deeper reliance
on these tests.

     We know the appropriate directions needed to improve cancer tests.
We also know how to set up preliminary  screens with much cheaper
laboratory models of cancer than colonies of mice, like mutation in
bacteria and chemical changes in DNA.  We can also tackle the difficult
and subtle problems of more accurately translating the results of
laboratory tests into quantitative measures of human hazard.  This
area, more than any other, needs only money to give prompt returns in
reducing environmental cancer.

     A Social Factor 

     Chemical technology is not the only change in modern life style
that may be influencing cancer rates.  Epidemiological surveys made
over a period of many decades suggest that breast cancer occurs most
often in women with fewer or no children, or who started childbearing
later in life.

     A modern social motif that now encourages these trends must also
bear the burden of accounting for this subtle side-effect on normal
variations in the hormone balance of the body.  Present methods of
assessing the role of natural hormones, and related synthetic drugs,
in animals are all too crude for any reliable use, except to arouse
suspicions if cancer-promoting effects are found.

     The problems of testing potential cancer-preventing agents in
this field are technically formidable.  They would involve clinical
testing on large numbers of healthy women for the sake of preventing a
disease that will eventually attack only about one in 1500.  The 
problem of justifying and financing such kinds of testing has become
insuperable for a profit-oriented system of drug development.

     To protect the public interest, the drug industry must be policed
by the Food and Drug Administration in a way that objectively assumes
the utmost venality  and unreliability of any member.  When profits
are involved, the remotest doubts about the safety of a clinical test
would have to be resolved against a company.  Investment in innovative
areas is, however, so discouraged by this philosophy that it will 
wither away if left to free enterprise.

     The answer is not to relax regulatory vigilance but to establish
a new system for the development of such preventive measures under
direct government control and sponsorship.  This is a mandate to
undertake drug development as a positive responsibility to balance the
regulatory inhibition of private enterprise in this field.  The 
fulfillment of such a mandate, with its attendant legal and political
problems, would be enough justification for the National Cancer 
Authority that has been advocated to establish a "cure" for cancer as a 
national goal.

     Whatever administrative machinery is established to achieve this
goal, it must fix a consistency of purpose for health research that
has been flawed for the past several years.  The rapid changes in our 
outlook on federal responsibilities for health have outpaced the
financing and administrative capacity of the Department of Health,
Education, and Welfare.  For example, consistent underestimates of
the costs of medical care programs, and confusions about the means
needed to bolster the supply of health services, have generated
predictable budgetary crises.  In the struggle for disposable funds,
research was bound to be the most vulnerable target for lack of a
well-defined political constituency.  The new presidential
initiatives, coupled with vigorous pressure from the Congress, will
happily put the lie to a cynical pessimism about the future of
of bio-medical research like that expressed in my own writings
heretofore.
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