summarize this "Steve Rosenberg was still a young resident when he encountered
the patient who would determine the course of his career—and, possibly, of
cancer treatment in general. He was on a rotation at a VA hospital in
Massachusetts in 1968 when a man in his sixties came in needing a relatively
simple gallbladder operation. The man, whose name was James DeAngelo,
already had a large scar across his abdomen, which he said was from a longago operation to remove a stomach tumor. He had also had metastatic tumors
that had spread to his liver, he added, but the surgeons had not touched those.
Rosenberg was sure that his patient was confused. It would have been a
miracle if he had survived even six months with metastatic stomach cancer.
But according to DeAngelo’s hospital records, that was exactly what had
happened. Twelve years earlier, he had walked into the same hospital
complaining of malaise and low energy. At the time, his chart noted, he was
drinking his way through three or four bottles of whiskey per week and
smoking a pack or two of cigarettes every day. Surgeons had discovered a
fist-sized tumor in his stomach and smaller metastatic tumors in his liver.
They removed the stomach tumor, along with half of his stomach, but they
left the liver tumors alone, deciding that it was too risky to try to remove
them at the same time. And then they had sewn him up and sent him home to
die, which he had obviously failed to do.
Rosenberg went ahead with the gallbladder operation, and while he was in
there he decided to take a look around in DeAngelo’s abdomen. He felt
behind the liver, gingerly working his way under its soft purple lobes,
expecting to feel lumps of remnant tumors—an unmistakable feeling, hard
and round, almost alien-like—but he found absolutely no trace of any
growths. “This man had had a virulent and untreatable cancer that should
have killed him quickly,” Rosenberg wrote in his 1992 book The
Transformed Cell. “He had received no treatment whatsoever for his disease
from us or from anyone else. And he had been cured.”
How could this be? In all the medical literature, Rosenberg could find
only four instances of complete and spontaneous remission of metastatic
stomach cancer. He was mystified. But he eventually came up with a
hypothesis: he believed that DeAngelo’s own immune system had fought off
the cancer and killed the remaining tumors in his liver, the way you or I might
shake off a cold. His own body had cured his cancer. Somehow.
At the time, this notion was well out of the mainstream of cancer
research. But Rosenberg suspected that he was onto something important.
The Transformed Cell told the story of Rosenberg’s quest to harness the
immune system to fight cancer. Despite small successes peppered here and
there, however, whatever phenomenon had erased James DeAngelo’s tumors
proved to be elusive; for the first ten years, not a single one of Rosenberg’s
patients had survived. Not one. But still he kept at it.
He was doing better as a cancer surgeon than a cancer researcher: he
operated on President Ronald Reagan in 1985, removing cancerous polyps
from his colon, and that had gone fine. But Rosenberg’s goal was to eliminate
the need for cancer surgeries, period. Finally, in the mid-1980s, he had a
glimmer of success—just enough to keep him going.
—
As soon as I read The Transformed Cell, as a medical student, I knew that I
wanted to be a surgical oncologist and that I had to work with Steve
Rosenberg. Cancer had been on my mind since before I had even applied to
medical school. During my postbac year, while taking med school
prerequisite courses, I volunteered on the pediatric cancer ward of Kingston
General Hospital in Ontario, spending time with kids who were undergoing
cancer treatment. Thankfully, childhood leukemia is one area where
Medicine 2.0 has made real progress. But not all the kids survived, and the
bravery of these children, the pain that they and their parents endured, and
the compassion of their medical teams moved me more deeply than any
engineering or mathematical problem. It confirmed my decision to switch
from engineering to medicine.
In my third year of medical school, I got the opportunity to spend four
months in Rosenberg’s lab, at the epicenter of American cancer research. By
the time I arrived, it had been nearly three decades since Richard Nixon had
declared a national War on Cancer in 1971. Initially, the hope was that cancer
would be “cured” within five years, in time for the Bicentennial. Yet it
remained stubbornly undefeated in 1976, and still by the time I finished
medical school in 2001. And today, for all intents and purposes.
Source: National Cancer Institute (2021).
Despite well over $100 billion spent on research via the National Cancer
Institute, plus many billions more from private industry and public charities—
despite all the pink ribbons and yellow bracelets, and literally millions of
published papers on the PubMed database—cancer is the second leading
cause of death in the United States, right behind heart disease. Together,
these two conditions account for almost one in every two American deaths.
The difference is that we understand the genesis and progression of heart
disease fairly well, and we have some effective tools with which to prevent
and treat it. As a result, mortality rates from cardiovascular disease and
cerebrovascular disease have dropped by two-thirds since the middle of the
twentieth century. But cancer still kills Americans at almost exactly the same
rate as it did fifty years ago.
We have made some progress against a few specific cancers, notably
leukemia (especially childhood leukemia, as I noted earlier). For adults with
leukemia, ten-year survival rates nearly doubled between 1975 and 2000,
leaping from 23 percent to 44 percent. Survival rates for Hodgkin’s and nonHodgkin’s lymphomas have increased as well, especially the former. Yet these
represent relatively small victories in a “war” that has not gone particularly
well.
Like heart disease, cancer is a disease of aging. That is, it becomes
exponentially more prevalent with each decade of life, as figure 6 shows. But
it can be deadly at almost any age, especially middle age. The median age of
a cancer diagnosis is sixty-six, but in 2017 there were more cancer deaths
among people between forty-five and sixty-four than from heart disease, liver
disease, and stroke combined. This year, if recent trends continue, that same
age group will also account for nearly 40 percent of the estimated 1.7 million
new cases of cancer that are likely to be diagnosed in the United States,
according to the National Cancer Institute. By the time cancer is detected,
however, it has probably already been progressing for years and possibly
decades. As I write these words, I reflect sadly on three of my friends from
high school who died of cancer in the past ten years, all younger than fortyfive. I was able to say goodbye to only one of them before she died. Everyone
reading this book probably has a few similar stories.
The problem we face is that once cancer is established, we lack highly
effective treatments for it. Our toolbox is limited. Many (though not all) solid
tumors can be removed surgically, a tactic that dates back to ancient Egypt.
Combining surgery and radiation therapy is pretty effective against most local,
solid-tumor cancers. But while we’ve gotten fairly good at this approach, we
have essentially maxed out our ability to treat cancers this way. We are not
getting any more juice from the squeeze. And surgery is of limited value
when cancer has metastasized, or spread. Metastatic cancers can be slowed by
chemotherapy, but they virtually always come back, often more resistant to
treatment than ever. Our benchmark for success in a patient, or remission, is
typically five-year survival, nothing more. We don’t dare utter the word cure.
The second problem is that our ability to detect cancer at an early stage
remains very weak. Far too often, we discover tumors only when they cause
other symptoms, by which point they are often too locally advanced to be
removed—or worse, the cancer has already spread to other parts of the body.
I saw this happen many times during my training: we would remove a
patient’s tumor (or tumors), only to have them die a year later because that
same cancer had taken hold elsewhere, like their liver or their lungs."