Pioneering Cancer Doc Foresees ‘The Death of Cancer’

IRA FLATOW: This is Science Friday, I’m Ira Flatow.

In his State of the Union address, President Obama called for a moonshot to cure cancer, in the war that has cost over $100 billion since 1971, when we officially declared war on cancer. And, despite the drumbeat in the media that we are losing the war on cancer, my next guest says that he can lay out a blueprint for winning the war in his new book, “The Death of Cancer.”

A cancer survivor himself, Doctor Vincent DeVita Jr. and co-author Elizabeth DeVita Rayburn talk about the history of cancer research and new treatments that are, not only hopeful, but are turning cancer into a chronic, treatable disease. Dr. DeVita is author of “The Death of Cancer,” and professor of medicine at the Yale Cancer Center in New Haven, Connecticut.

Welcome to Science Friday.

VINCENT DEVITA: Well, thank you. Thank you for having me.

IRA FLATOW: It’s been many years since we’ve chatted.

VINCENT DEVITA: Yes.

IRA FLATOW: Let’s go right to the President’s moonshot. Do you think he was correct in calling for that now?

VINCENT DEVITA: Well, I think the field is a really starving for resources. So any infusion of money would be very well appreciated, and I think well used. I think the worrisome thing is not to make the mistake that was made in 1971, with the passage of the first cancer act, and try to put a date certain on it, because biology is way too uncertain for that.

IRA FLATOW: Hmm. Our number, 844-724-8255. You can also tweet us, @scifri. I was quoting from your book at the beginning there, where you write, “If you believe the drumbeat in the media, we have spent more than $100 billion on cancer research, and we’re losing the war on cancer.” And you think that totally misses the point of what’s really happening.

VINCENT DEVITA: Yeah. I mean, the mandate of the cancer act was to support research and the application of the results of research, to reduce the incidents, morbidity and mortality from cancer. It didn’t say in 10 years, or in 20 years. And the support for research, 2/3 of that $100 billion went to support research. The application side is what’s suffered. It’s very difficult to have the flexibility that you need to apply the results of research these days. But the incidents of cancer has come down since 1991 for some cancers. And the mortality rate has come down, overall, 25%, and for some major cancers, even more. And the morbidity is much less.

I mean, if you look at cancers like breast cancer, how it’s treated now, compared to how it was treated in the 1970s, it’s a completely different animal. So I think it’s fulfilled its mandate. It took a long time. And the payoff in the biology is enormous. We know things now we never would have dreamed about.

IRA FLATOW: Let’s go back to those early days a little bit. I know you were highly involved in it, as you can see in the book. You write, “There was a time when chemotherapy was a dirty word. There were shouting matches, and insults would break out at cancer meetings over these new treatments.”

VINCENT DEVITA: Yeah, it was not an easy time. I had it just a touch easier than the people who came before me, but I do remember meetings where people would get up in the audience and shout insults that I would’ve thought were unimaginable at a University. But they did it. There were very strong feelings about it. Just somehow, if you mentioned that you could cure cancer with drugs, it was considered slightly the other side of sanity.

IRA FLATOW: We’ve heard that, over the years, as journalists and people who cover medicine a lot, we’ve heard so many times there’s no such thing as cancer, because there are a hundred different types of cancer. But you say that now you can narrow down multiple hallmarks, as you call them, that are shared by all cancers, that require complex clinical trials of a new kind. Tell us about what you mean by narrowing down to those multiple hallmarks, and why that offers us new opportunities we didn’t have before.

VINCENT DEVITA: There was a landmark paper published 10 years ago, and then a repeat just recently, by Hanahan and Weinberg called “The Hallmarks of Cancer.” And what they point out, is there are certain characteristics, acquired characteristics, that a cancer cell has to have to become malignant, to grow, then to make its own blood supply, to evade the immune system, and to metastasize.

And all cancers need to require, more or less, the hallmark. Some depend more on one than another. So instead of focusing on 100 different cancers, you can attack the hallmarks. In fact, the cancer therapies that work have been, though they weren’t designed that way, have been inadvertently attacking the hallmarks. Most of them attacked the hallmark of uncontrolled growth, for example.

But, recently, we’ve now begun to unravel the immune system problem that we had faced before. That’s another hallmark, immune surveillance of cancer. So I think we could narrow our focus. But these require very complicated clinical trials. You’re going to be looking at one drug to attack one hallmark, another drug to attack another hallmark, and that requires a certain degree of flexibility that we don’t have at the moment.

IRA FLATOW: Talk about that a little bit more. You say that it’s impossible under current government regulations to carry out what you’re saying are truly needed kinds of research.

VINCENT DEVITA: It takes too long. And my own view was, although we need the FDA, I’m not really proposing that we do away with the FDA, but the FDA, I think, is approving drugs based on the last century criteria. We really, basically, should approve cancer drugs based on their safety, in the context of a cancer patient who’s dying of cancer, and the ability to hit a known biological target. And then let the investigators at cancer centers play with the drugs that we have, in the post marketing period so that we can come up with novel ways of attacking all eight hallmarks in cancer.

Sort of like, I’d describe in the early days, what a colleague of mine named, the society of jabbering idiots. Which was like a war room for what we had in those days, which was a very exciting meeting. It was one of the most exciting meetings I’ve ever attended in my life. Where you could take the data that came in on a day-by-day basis and make adjustments in your treatment protocols. We can’t do that now, but there is plenty of data that could be used that way.

For example, if you know the biologic pathways that are abnormal in a cancer cell of a particular type, one can really mix and match with the drugs available to attack those pathways. There are attempts to do that, but they’re really thwarted by the fact that it takes months to get protocols approved. And if you want to adjust a protocol you have to go back to the end of the line and start all over again.

IRA FLATOW: Let me hone in on a couple of cases here that you write about, that illustrate this. You talk about two drugs approved by the FDA for Melanoma, that have not yet been approved for lung cancer. But you write that thousands of patients with lung cancer are being deprived of years of good life right now for no earthly reason. That sounds pretty strong.

VINCENT DEVITA: It is pretty strong. These drugs have now been approved for cancer. But I’ll give you an example. My own sister died of lung cancer in May. She was in a hospital where these drugs were being used. And every cancer doctor I knew of that took care of lung cancer knew, then and now, feel that these are the best drugs that have come along in 40 years for lung cancer. They had been approved in Melanoma, so we knew their safety profile was OK, and the data were really there in the early trials that it was working in lung cancers. But you couldn’t get them.

And the doctors taking care of her could have gone the root of a compassionate IND, but that takes unbelievable amount of time that no functioning physician can actually do. So my sister died without having a chance to get a crack at a drug that had maybe given her a 60% chance of having a decent prolongation of life. And that happens all the time. So I think we need to change how we let patients access experimental drugs. We had a system, I describe it in the book, what we call the Group C system, in the 1970s that actually worked. And when I left the cancer institute, the FDA scotched it.

Anyhow, I think that’s one of the problems are facing today. That falls under the category of the mandate that said the application of the results of research. That was the tricky part of the war on cancer. When the cancer act was passed, the NIH really had no interest in the application of the results of research. So the cancer war broke the ground on the application side.

IRA FLATOW: So what were they doing the research for if they weren’t going to apply it?

VINCENT DEVITA: Well, it’s a very interesting mindset. In those days the people worked to find new knowledge. And they just assume that if it was important enough, that somehow it would find its way into the clinic. Nowadays it’s quite different. Scientists, when they make a discovery, they immediately think of the application of that discovery. But in those days it was just support research. We didn’t, frankly, have a lot of new information at that time.

IRA FLATOW: Is that because drug companies are so much more working in unison with the Universities now, and they can see that there’s a potential moneymaker here?

VINCENT DEVITA: Yeah, I think the fact that years ago the Congress said we could patent biologics, it made a big difference that the people see the opportunity to have an important drug. But I think, still, because there have been successes in drugs that have attacked important targets, that people have the incentive to do that.

IRA FLATOW: You call yourself and, quote, “An aggressive doctor.” And in the book you write that “Regulations and research protocol stood in the way of potential treatments for your friend Lee, who was suffering prostate cancer.” But later in the book you also write “Medicine is, by definition, a conservative field. It should be, in a way. People’s lives depend on it.” So when do you become an aggressive doctor, and when do you become a conservative doctor?

VINCENT DEVITA: I think if there’s a chance that somebody will respond to something, then that’s when you become an aggressive doctor. You shouldn’t really cut off any avenue of hope for a cancer patient. This is misinterpreted to think that I would never let someone die, no matter what stage they’re in, and that’s not true. There are people we really can’t help.

But there are lots of cancers where there’s something you can do, especially today. All these new advances, when they come out, they don’t come out universally across the country. They come out in pockets. They may come out in New York, in a cancer center there, they may come out at Yale, they may come out in California. And so not everybody’s always aware of them. And it makes it a little bit difficult to get at them, but many times, and I think, the new immunotherapy drugs, for example, they’re not universally available. They weren’t universally available just a few months ago. But they are probably the best thing that’s come along for many cancers.

IRA FLATOW: That’s one of the drugs that President Cli–

[LAUGHS]

Clinton– uh, President– I can’t think of his name. He was on immunotherapy.

VINCENT DEVITA: Yeah, Carter.

IRA FLATOW: Carter. Thank you. He was on immunotherapy, and he says he was cancer free. But tell us how promising– you cite work of Stephen Rosenberg, who says we’re finally arrived at the point where immunotherapy has reached its full potential. That sounds very promising.

VINCENT DEVITA: Yeah, well Steve has been a pioneer in developing immunotherapy now, going back when it wasn’t very popular. But the big advance that happened was when Jim Allison, at MD Anderson Hospital, uncovered what we call the checkpoints in lymphocytes. We were always puzzled for many years, why immunotherapy would occasionally work brilliantly, but in most cases it didn’t. And it turned out that the lymphocytes have checkpoints that prevent them from attacking ourselves, so we don’t have more of what we call autoimmune diseases.

And what he did was found the checkpoint, developed antibodies to block them, and it was sort of like the lymphocyte woke up and said, whoa, I can see this cancer, and they can attack it. And the checkpoint inhibitors, I think, are extremely exciting. And almost all cancers where they’re being tested, they’re being tested in virtually every cancer, there’s some degree of response. In some cases more than others, but I think they are the example of how we’re finally unlocking the potential of the immune system.

IRA FLATOW: You know we’re reading more and more about the microbiome and how essential it is for so many things that are going on in the body. Do you think it could also be involved in cancer suppression?

VINCENT DEVITA: We know that, for example, stomach cancer is related to a bacteria call helicobacter and lymphomas of the stomach, related to the same bacteria. And then we know in the very early lymphomas of the stomach, and you treat the bacteria, the lymphoma goes away. So, yeah, we know the microbiome has a role. And I think we’re just learning a lot about how it may play a role in cancer.

My own feeling is that we’ve always been puzzled by these interesting conundrums, in terms of diet and cancer. We know diet’s important because of Migration Studies. When people migrate to and from an area of low cancer, incidents of certain types of breast cancer, and they migrate to the US and the incidents goes up. We’ve never been able to use that information. And, my guess, the microbiome is going to provide some data on that. It’s probably alterations in the microbiome that may be influencing the cancer cell. The other thing that’s happened about the same time, is that we’ve learned that the tumor micro environment, where a cell is sitting in the liver, the environment around it is very important because the normal cells can actually talk to cancer cells. And I think the same thing happens in the microbiome. They can receive signals from bacteria, even though the bacteria are just normal bacteria. So we have a lot to learn there, but I think it’s going to be an exciting phase.

IRA FLATOW: This is Science Friday from PRI, Public Radio International. Talking with Doctor Vincent DeVita Jr, who has a new book, and this is a great read, a highly readable book on cancer. Who of us doesn’t know somebody with cancer, a survivor, or a friend. It’s called “The Death of Cancer.” And I highly suggest it.

I have so many things I want to get to before we get to the break. I want to ask you about this idea of making cancer a chronic disease. Something you might be able to treat. And as new medicines come out, you then extend the life of someone further and further.

VINCENT DEVITA: Well I think the best example of that is the first example of real targeted therapy. That’s where we have a target in the cell, the cancer cell, and we attack that particular target. It’s a disease called Chronic Myleocytic Leukemia. When I was starting out this was a universally fatal disease. They called it chronic because the average survival was about 42 months. And then in 1996 Doctor Brian Druker, from Oregon, reported the results of an attack on the one molecular abnormality in this disease. We call it BCR-ABL, it’s a gene.

And that disease now is a chronic disease. People live virtually a normal life span by taking a pill every day. Now, sometimes they develop resistance to that pill, and the pharmaceutical industry has developed four more that have already been approved. They’re available so they can substitute one pill for another. You can look and you can find the disease in most cases. There are a few cases where it appears to be totally gone. But in most cases it’s still there, but it doesn’t bother the patient because the white cells that are affected function normally. So here you have what was a universally fatal disease, which is now a chronic disease.

And I think maybe as we work and learn how to combine different agents, we’ll eradicate the cells entirely. But until then, these patients are living a, really, very normal life. And I think we’re seeing more of that. Even with the new immunotherapy drugs, where the immune system seems to put the tumor in abeyance and the patients seem to be normal, even though if we look hard we can still find the tumor.

So that’s a new way of thinking about cancer. You cure whatever you can cure, you convert whatever you can convert to a chronic disease with a normal lifespan. But if you don’t do either one, then patients usually diet of it. So that’s why I always say cancer is the most curable chronic disease, but it’s also the most fatal chronic disease.

IRA FLATOW: We’re going to take a break and come back and talk a lot more with Doctor Vincent DeVita Jr, author of “The Death of Cancer.” Our number, if you’d like to call in, 844-724-8255. You can also tweet us, @scifri. We’ll be right back after this break.

You’re listening to Science Friday. I’m Ira Flatow, talking with Doctor Vincent DeVita Jr, who’s the author of “The Death of Cancer.” He is a former head of the National Cancer Institute who worked his whole life in the field of cancer. And a cancer survivor from prostate cancer, which you talk a lot about in your book. You make the case that you’re a doctor, and you hardly knew– the panic was not foreign to you.

But one of the points you make in your book is that you advise people that finding a good cancer doctor is essential, and to be around that, “to be around”, quote unquote, is how you put it. And if you can’t find a good advocate, to keep an eye out there where the action is, one willing to ignore traditional boundaries in medicine. You, who know everybody in the field, how do you find a good cancer doctor and a good place to go?

VINCENT DEVITA: It’s not easy. But I can’t find a good lawyer either.

[LAUGHS]

So you need to ask around. Ask people, use whatever information you can. If you have a great primary care doctor, as I do, that person can usually find somebody for you. But you want a doctor who believes in what he’s doing. I think one of the problems we had early days, and still sometimes now, is cancer doctors who don’t really believe that the therapy they’re giving works that well, or is worth the effort. So I say in the book, if somebody tells you, if you’re newly diagnosed with cancer and they say, there’s nothing I can do for you, then you should find another doctor.

IRA FLATOW: And what do you mean by one willing to ignore traditional boundaries in medicine?

VINCENT DEVITA: Well I touched on it before. I think that if there are drugs out there that we think work, when you hear about these, you go to meetings and hear about them, and your patient might be a candidate for that drug, then can you use it off label, for example. Which is frowned on by the FDA, is frowned on by hospital pharmacies. I have a doctor I mentioned in the book, just one doctor, who seems to be able to do this for everybody. Not only gets access to new treatments, he sometimes gets the insurance companies to pay for them. So it can be done, but it takes a lot of effort. And these kinds of doctors are, when you find them, you should hang onto them.

IRA FLATOW: Let’s go to the phones. Let’s go to Lake Tahoe, to Susan. Hi, welcome to Science Friday. Hi Susan.

SUSAN: Hi, thank you. I have had three cancers. One in 2001, I had LCIS and DCIS. In 2012 I was diagnosed with stage three, 3D colon cancer, and went through the [INAUDIBLE] treatment protocol. And then in 2014 I was diagnosed with cancer and had a thoracotomy. I’m 58 now, and I’m wondering what kind of research is being done with regard to individuals who have multiple cancers, and if you have any advice for someone like me who is, right now, going to CT scans every six months, chest and abdomen, but anything beyond that, that I could do proactively?

VINCENT DEVITA: Certainly you haven’t been lucky in terms of getting cancers, but you seem to be well. You’ve managed to survive three difficult cancers. There are lots of genetic analysis going. And I think if you haven’t seen a genetic counselor, you probably should, to see if there’s some common trait that might be passed on to other members of the family.

SUSAN: I have, and they haven’t seen anything yet.

VINCENT DEVITA: Yeah, OK. Well, then I think what you’re doing is, I can’t argue with its success.

IRA FLATOW: All right, Susan, good luck to you.

Is personalized medicine now moving heavily in cancer therapy?

VINCENT DEVITA: Oh yeah. I think now, with the ability to sequence the genome, we can sequence cancers for the mutations that we know are important and we have drugs that target those mutations. Certainly in lung cancer now you can treat people who have specific mutations with drugs that work only against that particular type. Unfortunately, they’re in the minority of lung cancers, so they hardly ever make up more than 20% of the population.

IRA FLATOW: Hmm. Well, going back to the title of your book, “The Death of Cancer,” and the war on cancer is winnable, and how we can get there. Yet cancer is still the second leading cause of death, killing nearly 600,000 Americans in 2014, just behind heart disease. That must still indicate we have a long way to go, or why is that number still so high?

VINCENT DEVITA: Well a lot of the new things I’m talking about have just not reached the widespread use yet. So I think you’re still in for some very difficult cancers. But I’m encouraged by the fact that a tumor like Melanoma, the malignant mole, which was, really, you either removed it and cured a patient, or they died from it, we had very little therapy that worked, is now teetering on the edge of being one of the curable tumors when they have metastatic disease. This was unheard of a few years ago.

The new target of therapy is called BRAF inhibitors, and the immunotherapies are working very well in these patients. We have patients living for years now. And then lung cancer, which was really a very difficult tumor to treat with chemotherapy, with some benefit, but not a great deal of benefit, is now responding to the immunotherapy drug. So we’re starting to see the common cancers succumb to the new treatments.

IRA FLATOW: I read a research paper on mice recently, that a probiotic, when given with these drugs you’re talking about, actually dramatically increased their survival rate. Why would that be? Do you know what I’m talking about?

VINCENT DEVITA: I’ve seen it, yeah. I mean, I’ve seen reference to them.

IRA FLATOW: What’s your opinion on that? Too early to think about that?

VINCENT DEVITA: [LAUGHS]

No, but as I said before, there’s no question that bacteria are able to send signals. So, obviously, altering the gut bacteria is doing something in those mice. I would hasten to point out that mice are not humans. They often mislead us. But it just signifies that the microbiome is important, and we’re likely to find ways to make it useful in cancer treatment.

IRA FLATOW: How do you kee–

VINCENT DEVITA: But–

IRA FLATOW: No, go ahead.

VINCENT DEVITA: I was going to add that there’s a combination of Chinese herbs that have been used for about 2,000 years, that when you give them along with chemotherapy, also alters the toxicity markedly. My guess is, probably mostly through altering the microbiome. So there’s a lot of people looking at this now, and hopefully we’ll get some usable information.

IRA FLATOW: So your book is very, very hopeful, and it lays out where that hope lies, and giving us case histories of it, instead of just saying we can cure cancer.

VINCENT DEVITA: Yeah, I’m an undeniable optimist. But as I said before, the mandate of the cancer act has really been fulfilled. We’ve reduced the incidents of cancer, we’ve really markedly reduced the morbidity and mortality rates, 25% overall decline in mortality, 25% for breast cancer, all these things are very real, and they’re old data. They’re data that are about five years old. When they finally catch up to 2016, they’ll be even more impressive.

IRA FLATOW: One last question, does it help to just throw more money at it, which is what we do?

VINCENT DEVITA: No. That would be my only warning. I think that if you’re going to put more money into the system, you should revise the system so that you can have more flexibility to use all the new information. In the book I mentioned the fact that we really need, and it’s an unfortunate term, but a cancer czar in the government. Because a lot of money is in the Defense Department for cancer research. The NIH, the CDC, the FDA. You need someone to coordinate this effort, and then coordinate it with the private sector.

Plus, I think we need to alter, as I said before about how we do clinical trials, we should delegate the responsibility for the early stage clinical trials to the cancer centers, and let them do it. The FDA and the NCI can audit them whenever they want to, but it would save an untold number of days, and it would also save money. So I think yes, more money, but give it with more flexibility.

IRA FLATOW: The book is “The Death of Cancer,” written by Doctor Vincent DeVita Jr, and Elizabeth DeVita Rayburn, your daughter. Good luck to you, and thank you. It’s a terrific book, and it’s a primer for anybody who wants to know anything more about cancer. Thank you, and good luck with the book.

VINCENT DEVITA: Oh, thank you. My pleasure.

IRA FLATOW: We have an excerpt of the book up at sciencefriday.com/deathofcancer.

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