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kottke.org posts about Emperor of All Maladies

Beating cancer is a team sport

posted by Jason Kottke   Jul 20, 2017

Senator John McCain has been diagnosed with a particularly aggressive form of brain cancer. The tumor has been removed and McCain is recovering at home with his family. I wish Senator McCain well and hope for a speedy recovery.

In the wake of his diagnosis, many of those expressing support for McCain reference his considerable personal strength in his fight against cancer. President Obama said:

John McCain is an American hero & one of the bravest fighters I’ve ever known. Cancer doesn’t know what it’s up against. Give it hell, John.

McCain’s daughter Meghan references his toughness and fearlessness in a statement released yesterday. Vice-President Joe Biden expressed similar sentiments on Twitter:

John and I have been friends for 40 years. He’s gotten through so much difficulty with so much grace. He is strong — and he will beat this.

This is the right thing to say to those going through something like this, and hearing this encouragement and having the will & energy to meet this challenge will undoubtably increase McCain’s chances of survival. But what Biden said next is perhaps more relevant:

Incredible progress in cancer research and treatment in just the last year offers new promise and new hope. You can win this fight, John.

As with polio, smallpox, measles, and countless other diseases before it, beating cancer is not something an individual can do. Being afflicted with cancer is the individual’s burden to bear but society’s responsibility to cure. In his excellent biography of cancer from 2011, The Emperor of All Maladies, Siddhartha Mukherjee talks about the progress we’ve made on cancer:

Incremental advances can add up to transformative changes. In 2005, an avalanche of papers cascading through the scientific literature converged on a remarkably consistent message — the national physiognomy of cancer had subtly but fundamentally changed. The mortality for nearly every major form of cancer — lung, breast, colon, and prostate — had continuously dropped for fifteen straight years. There had been no single, drastic turn but rather a steady and powerful attrition: mortality had declined by about 1 percent every year. The rate might sound modest, but its cumulative effect was remarkable: between 1990 and 2005, the cancer-specific death rate had dropped nearly 15 percent, a decline unprecedented in the history of the disease. The empire of cancer was still indubitably vast — more than half a million American men and women died of cancer in 2005 — but it was losing power, fraying at its borders.

What precipitated this steady decline? There was no single answer but rather a multitude. For lung cancer, the driver of decline was primarily prevention — a slow attrition in smoking sparked off by the Doll-Hill and Wynder-Graham studies, fueled by the surgeon general’s report, and brought to its full boil by a combination of political activism (the FTC action on warning labels), inventive litigation (the Banzhaf and Cipollone cases), medical advocacy, and countermarketing (the antitobacco advertisements). For colon and cervical cancer, the declines were almost certainly due to the successes of secondary prevention — cancer screening. Colon cancers were detected at earlier and earlier stages in their evolution, often in the premalignant state, and treated with relatively minor surgeries. Cervical cancer screening using Papanicolaou’s smearing technique was being offered at primary-care centers throughout the nation, and as with colon cancer, premalignant lesions were excised using relatively minor surgeries. For leukemia, lymphoma, and testicular cancer, in contrast, the declining numbers reflected the successes of chemotherapeutic treatment. In childhood ALL, cure rates of 80 percent were routinely being achieved. Hodgkin’s disease was similarly curable, and so, too, were some large-cell aggressive lymphomas. Indeed, for Hodgkin’s disease, testicular cancer, and childhood leukemias, the burning question was not how much chemotherapy was curative, but how little: trials were addressing whether milder and less toxic doses of drugs, scaled back from the original protocols, could achieve equivalent cure rates.

Perhaps most symbolically, the decline in breast cancer mortality epitomized the cumulative and collaborative nature of these victories — and the importance of attacking cancer using multiple independent prongs. Between 1990 and 2005, breast cancer mortality had dwindled an unprecedented 24 percent. Three interventions had potentially driven down the breast cancer death rate-mammography (screening to catch early breast cancer and thereby prevent invasive breast cancer), surgery, and adjuvant chemotherapy (chemotherapy after surgery to remove remnant cancer cells).

Understanding how to defeat cancer is an instance where America’s fierce insistence on individualism does us a disservice. Individuals with freedom to pursue their own goals are capable of a great deal, but some problems require massive collective coordination and effort. Beating cancer is a team sport; it can only be defeated by a diverse collection of people and institutions working hard toward the same goal. It will take government-funded research, privately funded research, a strong educational system, philanthropy, and government agencies from around the world working together. This effort also requires a system of healthcare that’s available to everybody, not just to those who can afford it. Although cancer is not a contagious disease like measles or smallpox, the diagnosis and treatment of each and every case brings us closer to understanding how to defeat it. We make this effort together, we spend this time, energy, and money, so that 10, 20, or 30 years from now, our children and grandchildren won’t have to suffer like our friends and family do now.