Siddhartha Mukherjee: The former NCI director, Dr. Andrew von Eschenbach established an ambitious goal of eliminating the suffering and death due to cancer by 2015. Dr. Varmus will this happen?
Harold Varmus: You’re putting me in a different position. Politically, I don’t want to bash a previous director, but I will because this was a claim that just has no reality. The argument was we’re going to banish death and suffering from cancer, not that we were going to abolish cancer, but that is just not going to happen in such a short timescale, and it creates first of all, a false aspiration, one that we clearly cannot succeed in achieving and secondly, it provides too much optimism in a setting that is—as you’ve heard around this table—a very complicated set of diseases and we are not going to conquer all those diseases and prevent death from them in such a short timescale.
Lewis Cantley: Yeah, I completely agree and I would add that I'm optimistic because I think with these target approaches and as we break cancer into more and more sub fractions we figure out how to cure the sub fractions. Every year we’re going to see another few percent get if not cured, at least have treatments that allow people to live without extensive chemotherapy approaches and so if you do that, if you project it and say we’re only going to cure 2% this year, well if we started curing 2% in 1970 today we’d be almost finished because in 50 years at 2% we could get them all.
Siddhartha Mukherjee: I'm reminded of the advertisement that came out in 1969 which said, “Mr. Nixon, you can cure cancer”, in the New York Times and the Washington Post and of course the advertisement says you can cure cancer as if it was one disease and of course the word cure. And in fact, the goal was set at that point of time by 1981, and 1981 has long passed as you know.
Harold Varmus: Yeah, I think the discussion though needs to be enlarged slightly so we remind ourselves that while it’s attractive to think about curing an advanced cancer with drugs that there are many other things we can do to reduce the burden of cancer. One of course is to prevent it and we’ve had some brief discussions about that, but we can make great- in fact, most of the reduction in mortality from cancer in this country is due to smoking cessation. Secondly, I would point out that drugs are only one of many things we do to treat cancer and perhaps the most effective thing we can do is remove a cancer, so surgery is a very important tool here, surgical methods, not much talked about, have improved. When we detect cancer early before it has spread we can cure it more frequently, so early detection, prevention and conventional therapy used early on are very important steps.
The other thing I would go back to is Dr. Von Eschenbach’s term suffering. We tend to forget that while cancer is still a terrible disease we have reduced suffering from cancer already dramatically, much better pain control, control of nausea and vomiting. Chemotherapy has gotten more tolerable. We can restore bone marrow function fairly quickly with really very superb science using hormones to stimulate the way the marrow functions after chemotherapy. These are major changes.
Deborah Schrag: And the fact that it’s no longer something that people need to keep a secret, the fact that there are many public figures who have cancer who are open about their cancer diagnoses and the numerous strategies people use to cope.
Doug Schwartzentruber: I think our strategy somewhat has changed. Yes, we continue to search for a cure, but the other C word, control and so many of our trials right now that are publishing results talk about cancer control as opposed to the term cure and getting that disease to stabilize and not progress and if we can do that it becomes an elegist to some of our other chronic diseases.
Siddhartha Mukherjee: Dr. Schrag, can lifestyle choices alone prevent cancer?
Dr. Deborah Schrag: Lifestyle choices alone can’t prevent all cancers, but they can enormously decrease the incidence, particularly of some cancers, so lung cancer would be the best example. Some of the things Harold was talking about, getting vaccinated for hepatitis B, getting vaccinated for the human papillomavirus, getting 11 year-old girls- we could probably eradicate or come close to eradicating cervical cancer. The challenge is here we’ve got a cancer that is caused by a virus and we know that just as our genes are changing and evolving so are the genes of viruses, so right now we have a vaccine that seems to work against most strains, but is it possible that we’ll have new viral strains that this vaccine will no longer work? Absolutely, that's possible, so this is going to be an ongoing process.