The book “The Death of Cancer” by Dr. Vince DeVita really struck my prevailing pessimism towards late-stage cancer and further solidified my interest in cancer. As I read the book, I felt that there were too many good quotes that just had to be quoted here. Dr. DeVita is one of the authors of the world’s most credible textbook on Oncology and is internationally renowned for his contribution on the treatment of Hodgkin’s lymphoma.
Below is the interview wherein Dr. DeVita discusses his book.
Without further ado, here are the quotable quotes:
“Many people will tell you that treating patients with advanced cancer is not worth it. That’s baloney. When a doctor says that, what he usually means is that it would not be worth it for him. Doctors often have trouble walking in the shoes of their patients. If a patient is functional and there is a reasonable chance of a useful response, I believe that it is worth trying one or two cycles of treatment. That can take a month to a month and a half.” – Vince DeVita, MD (The Death of Cancer)
“I could have told you a story with a happy ending. I instead chose to tell you one that could have had a happy ending because it illustrates what has been, for me, a source of perennial frustration: at this date, we are not limited by the science; we are limited by our ability to make good use of the information and treatments we already have. Too often, lives are tragically ended not by cancer but by the bureaucracy that came with the nation’s investment in the war on cancer, by review boards, by the FDA, and by doctors who won’t stand by their patients or who are afraid to take a chance.” – Vince DeVita, MD (The Death of Cancer)
“As early as 1907, Paul Erhlich, the great German chemist, had begun to use rabbits with syphilis to test the efficacy of certain chemicals to fight infectious diseases. He thought about doing the same for cancer but was so pessimistic about the likelihood of success that he hung a sign over the door leading to the cancer lab. It read, “Give up all hope oh ye who enter.” Other doctors had tried a solution of arsenic, called Fowler’s solution, to treat leukemias and lymphomas, with no success.” – Vince DeVita, MD (The Death of Cancer)
“Halsted’s procedure lived up to its name. It was radical. It left a woman with only a thin skin graft covering the chest wall, through which her rib cage was clearly visible. Removing this much tissue also tended to cut off the drainage path for lymph channels—small, almost invisible vessels that drain excess fluid from organs, strain it through lymph nodes, and then deliver it back to the bloodstream. This blockage resulted in the additional disfigurement of a swollen arm.
Because Halsted was a surgeon of such renown, removing tumors en bloc became the standard for all cancer surgery. In fact, surgeons referred to it as “the cancer operation.
Applied to head and neck cancers by the famous head and neck surgeon Hayes Martin, it became the commando procedure, in which surgeons took the tumor, the lymph nodes, the strap muscles of the neck and the jawbone (which make it possible to speak, chew, and swallow), and even the tongue, if necessary. It was the most disfiguring operation ever invented. Patients wore special veils across their faces to hide their disfigurement.
Applied to colon and rectal cancers, it meant permanent colostomy. Applied to tumors on the extremities, such as bone cancers affecting the leg, it meant radical amputations, sometimes removing the entire femur bone from the hip on the affected side or taking off half the pelvis, too. Applied to pancreatic cancer, it became the Whipple procedure, which involved the removal of the pancreas, stomach, duodenum, spleen, and surrounding lymph glands.
Applied to cervical cancer, it became the Wertheim procedure, in which the surgeon totally excavated a woman’s pelvis, resulting in not only a colostomy but also the redirection of urine flow.” – Vince DeVita, MD (The Death of Cancer)
“Gilman and Goodman gave nitrogen mustard to rabbits and noted that the cells within the rabbits’ bone marrow and lymph nodes disappeared. It occurred to them that this might be a positive when it came to certain types of cancers, such as lymphomas, which inhabit the lymph nodes. When they tried nitrogen mustard on mice in which tumors had been transplanted, the cancer went away. The idea of giving nitrogen mustard to an actual person was a tantalizing next step.
The doctors couldn’t specify the drug, nitrogen mustard—similar to mustard gas—because it was being studied in secret as part of the war effort. But that’s what they were referring to.” – Vince DeVita, MD (The Death of Cancer)
“The ultimate outcome, in all cases, was the same. The children died. Leukemia was a death sentence, a torment to the children who had it, their parents, “and the doctors who had to stand by, knowing full well they were doing things that would not work, while the children slipped away.
It was in this atmosphere that Frei and Freireich announced that they planned to use chemotherapy to cure childhood leukemia, which elicited ridicule because everyone knew it was impossible. And then they’d come up with an even more radical idea than giving toxic drugs to children who were, quite literally, on their deathbeds. They decided to give the drugs in combination—two or more at a time. The medical community was scandalized. Using more than one drug at a time to treat something was, as a general rule, considered sloppy medicine. Using more than one highly toxic drug, in children, no less, and in children who were already suffering, was unfathomable.” – Vince DeVita, MD (The Death of Cancer)
“I wasn’t sure if these scientists were maniacs or geniuses. But most of the senior doctors at other NIH institutes had long since decided on the former. “Every Wednesday, in the NCI solarium, there were grand rounds for the entire hospital, where scientists would stand at the podium and discuss their work while their peers listened and, perhaps, gave helpful feedback. Whenever Frei and Freireich were featured, it was a verbal bloodbath.
Some of the doctors in the audience would scream out interjections while Frei and Freireich talked. “This is a meat market! What a butcher shop!” I saw it happen many times. Frei and Freireich ignored them, but it was embarrassing and shocking to watch. Never had I seen doctors behave this way toward other doctors. And it made us clinical associates question what we were doing. Were we doing the right thing? Were we accessories to what other doctors were portraying as unethical behavior? How could we know? And what was our recourse?” – Vince DeVita, MD (The Death of Cancer)
“One of the main obstacles to treating leukemia patients with chemotherapy, for instance, was that they often succumbed to infection before we could even try to treat them with drugs. They were uniquely vulnerable to infection because cancer cells crowded out their infection-fighting white cells and lymphocytes, which control the immune system. One infection they commonly fell prey to was pseudomonas meningitis, which was quickly fatal once it set in. There was no IV antibiotic known to be able to cross the blood-brain barrier, a blockade made mostly of complex lipids that few drugs seemed able to penetrate, in order to get to the bacteria.
Freireich instructed us to get around that problem by injecting an antibiotic called polymyxin B directly into the spinal fluid intrathecally—that is, via a lumbar puncture in the lower back. This was something the label on the drug vial expressly instructed you not to do. The first time Freireich told me to do it, I held up the vial and showed him the label, thinking that he’d possibly missed something. “It says right on there, ‘Do not use intrathecally,’” I said. Freireich glowered at me and pointed a long bony finger in my face. “Do it!” he barked. I did it, though I was terrified. But it worked every time.
When pseudomonas causes an infection in a normal patient, it creates an abscess, a pus-filled mass made up of millions of white blood cells. Leukemic patients didn’t get abscesses, Freireich said, because they didn’t have enough normal white cells to form one. If you saw a kid with a fever, you couldn’t rule out pseudomonas aeruginosa in less than a couple of days. And once pseudomonas was in the bloodstream, it was usually fatal in leukemic kids in twenty-four to forty-eight hours. Freireich wanted us to treat it as soon as we suspected it was what we might be looking at. And, because we couldn’t be sure what bacteria was responsible, he insisted we use several antibiotics at a time, to cover all possible bases.
In medical school and during our early training, we’d been taught to culture the blood for bacteria, find the exact bacterial culprit, and, only then, treat the specific cause of the infection with the right antibiotic. Treating with more than one drug, without identifying a specific cause, was not standard practice. But Freireich insisted on it. The problem, Freireich said, was that as in the case of pseudomonas aeruginosa, it took days for bacteria cultures to grow, and we didn’t have the luxury of time with our leukemic patients, who had few or no white blood cells and could die within hours from an untreated infection. “We can always back away later,” he said.” – Vince DeVita, MD (The Death of Cancer)
“Until the turn of the twentieth century, the assumption was that Hodgkin’s was a form of tuberculosis. It wasn’t an unreasonable assumption. One subtle aspect of Hodgkin’s is that even patients with early-stage disease are susceptible to infections, particularly tuberculosis and fungal infections. Ergo many patients with Hodgkin’s also had tuberculosis, which was nearly epidemic in the early nineteenth century. One well-known pathology textbook dating to 1919 said, “Tuberculosis follows Hodgkin’s disease like a shadow.”
It wasn’t until 1902 that Drs. Dorothy Reed and Carl Sternberg at Johns Hopkins University, aided by microscopes, were able to look at cells that came from the lymph nodes of people with Hodgkin’s. Most cells, even cancer cells, have just one nucleus. Reed and Sternberg saw something unusual—a cell with two, looking back at them like the eyes of an owl.
It was Reed and Sternberg who reclassified Hodgkin’s as cancer. The owlish-looking cell came to be known as the Reed-Sternberg cell. (In medicine, first spotters get naming rights. The disease was named after Hodgkin, but Reed and Sternberg had been the first to spot the cell.) Not all malignant cells in Hodgkin’s look like Reed-Sternberg cells. But in order for a lymphoma to be classified as Hodgkin’s, they have to be there.” – Vince DeVita, MD (The Death of Cancer)
“Medical school doesn’t prepare you to speak with patients about their impending deaths. And even though I was now compelled to deal with death quite a lot, I hadn’t gotten past my discomfort.” – Vince DeVita, MD (The Death of Cancer)
“I’d learned that in order to do anything outside the mores of medicine, you needed someone in a high place, or at least high enough, to run interference.” – Vince DeVita, MD (The Death of Cancer)
“A new pair of eyes often sees something obvious that the primary doctor, staring at the chart and the patient every day, has missed.” – Vince DeVita, MD (The Death of Cancer)
“Radiotherapists began to lose referrals as the management of the disease shifted to medical oncologists. As a result, many began to refuse to cooperate in large studies of early-stage patients unless radiotherapy was included in every group of each study, which meant that you could no longer gauge the outcomes with and without radiotherapy.
One colleague, the leader of the largest Hodgkin’s disease clinical trials group in the world, told me privately that he had to include radiotherapy in each group of patients with early disease if he wanted to accrue patients. He needed the cooperation of radiotherapists who often saw these patients first. Ergo, many patients were receiving radiotherapy—needlessly.
This assured that no matter the outcome, radiotherapists would always have a role in the care of patients with Hodgkin’s disease—even though our data already indicated that it wasn’t necessary and there was reason to believe that exposure to radiation could put patients at risk of future cancers down the road.” – Vince DeVita, MD (The Death of Cancer)
“A good cancer doctor never wants to be too far from his pathologist.” – Vince DeVita, MD (The Death of Cancer)
“In 1946, the microbiologist Selman Waksman published a paper on streptomycin, a new class of antibiotic that appeared to be effective against certain microbes that were not vulnerable to penicillin. Mary, who was not a scientist, pointed out to Waksman that the drug had had some effect against tuberculosis. There were no useful drugs for the disease at the time, and Waksman himself, along with most of organized medicine, initially thought the results not promising enough to pursue. Mary’s instincts said otherwise. She persuaded Waksman and the Merck pharmaceutical company to support tests of streptomycin against TB. By 1952, the widespread use of streptomycin resulted in cutting mortality from TB in half—only a few years after the drug’s discovery. You might say she helped him win the Nobel Prize, which he received that same year for developing the tuberculosis cure.” – Vince DeVita, MD (The Death of Cancer)
“Her mantra was that Congress wouldn’t be generous in funding a concept—something like “biological research.” But propose funding for an institute named after a feared disease, and you’d make progress.” – Vince DeVita, MD (The Death of Cancer)
“What separates great doctors from mediocre doctors is the ability to integrate all the information they see in their patients, on the wards, on a day-to-day basis and understand it.” – Vince DeVita, MD (The Death of Cancer)
“All researchers can use another pair of eyes—or a dozen pairs—to make sure they stay on the right track.” – Vince DeVita, MD (The Death of Cancer)
“Not all stories had happy endings, but it was still a privilege to be a part of them. […] But they meant something, these moments. They not only taught you what it means to be a doctor, and a human being, but gave you opportunities to step up and be one.” – Vince DeVita, MD (The Death of Cancer)
“Jim Watson, of double helix fame, had been appointed to the NCAB because he was a brilliant scientist. But he also hated the concept of the war on cancer and was purposefully rude at board meetings to show his contempt. The board chair couldn’t control him. Watson was, after all, a Nobel laureate. He liked to lean back and put his feet up on the table and read The New York Times, lowering the paper only to interject a derogatory comment here and there. Schmidt patiently waited for the board chair to say something, but he didn’t. On one occasion, when the board was discussing the newly formed Cancer Centers Program, Watson lowered the paper and said, “This is a pile of shit.”
Benno asked for the floor and said, “I have the budget of the centers program here.” He then noted that one of the largest grants went to “Dr. Watson at Cold Spring Harbor.” “Are you part of the pile of shit, Dr. Watson?” A stunned Jim Watson put the paper and his feet down and remained silent. His bluff had been called. Then Schmidt got in his limo and went to the White House and asked that a disruptive Jim Watson be removed from the board. Watson’s six-year appointment was terminated after two years. You didn’t want to mess with Benno Schmidt, even if you had a Nobel Prize. In 2009, Jim wrote an editorial in The New York Times claiming that he had been booted because “the NCI went clinical,” which wasn’t even close to being true. Then and now, about 85 percent of the NCI’s budget went to supporting basic research.” – Vince DeVita, MD (The Death of Cancer)
“Bernie’s study was controversial, because breast surgeons made their living doing radical or total mastectomies, and they did not want to hear that that was no longer necessary. […] Not because the science was bad, but because they didn’t want to give up the more extensive surgery that created 90 percent of their income. It was economics. […] Most surgeons and radiotherapists would never admit that they opposed Fisher’s findings because they threatened the doctors’ incomes. Instead, they questioned his integrity.” – Vince DeVita, MD (The Death of Cancer)
“It is unrealistic to use survival as an end point. Consider the number of cancer cells a drug has to kill to be effective. The average patient with advanced cancer has more than a kilogram of tumor on board. That’s many billions of cancer cells, because a lump about one centimeter across contains roughly one billion cells. Even after surgery, when a primary cancer has been removed and no errant cells can be detected, a patient can have more than a billion cancer cells circulating around the body.
To see a complete response to treatment, a drug has to kill 99.99 percent of the cancer cells. And then a very curious thing happens.
The time it takes for the surviving tumor cells to grow back to their pretreatment levels varies depending on the number of cells that have survived the treatment. Smaller populations grow back faster than larger populations. It seems counterintuitive, but it’s true. The net effect is that if you have two treatments—one that reduces the cancer cell population in a patient to just a few cells, and one that reduces the population to one billion cells—neither patient will have visible tumor masses at that point. But after five years, both will have the same number of cancer cells present, as the rapidly growing smaller population catches up. The five-year survival rates will be the same. But the treatment that reduced the population to a few cells is the one you want to go forward with. But which one is that? You cannot tell by using five-year survival rates as an end point.
This is called the Norton-Simon effect, named after two of my colleagues who discovered it. This alone should lead to the reconsideration of the use of survival rates in advanced cancer patients as a requirement for approval of a new drug.” – Vince DeVita, MD (The Death of Cancer)
“Cancer is the most curable chronic disease. But it is more often fatal as well.” – Vince DeVita, MD (The Death of Cancer)
“So when I say we want to convert most cancers into chronic diseases, I mean we want cancer patients we can’t cure to more closely resemble those with diabetes or arthritis—to live out a normal or near-normal life span while managing the condition. Immortality is not our goal here, just a normal life, free from the gnawing worry that a premature death is lurking just around the corner.” – Vince DeVita, MD (The Death of Cancer)
“As a result of the war on cancer, the cancer cell is no longer a black box; it’s a blueprint. And we can read blueprints. We understand the cancer cell’s stages, how it thinks, what drives it. And we have the tools to attack each of the steps on the way to malignancy. There isn’t a question about cancer we can’t address, at this point, without the expectation of a usable answer.” – Vince DeVita, MD (The Death of Cancer)
“As optimistic as I am, I don’t think there will ever be a world in which cancer doesn’t occur. It’s in our biology. In the millions of cell divisions that take place in our bodies every day, there are too many opportunities for mistakes. And some of those mistakes will activate a cancer hallmark and give rise to cancer.
We can prevent it, to some extent, by avoiding the things that make those mistakes more prone to happen, like smoking. And we can take advantage of medication that seems, in some cases, to prevent those mistakes.” – Vince DeVita, MD (The Death of Cancer)
“It is now clear that the cancer cell is recapitulating developmental biology. In plainer terms, it thinks it’s a fertilized egg on its way to becoming an embryo, and it uses the powerful growth machinery of the early embryo, normally shut down in adulthood, to fire its growth and development. You can look at cancer, then, as a failure in the control of the delicate cellular machinery that evolved to prevent embryos from becoming monsters. This sounds fantastic, I know, but it’s true. There are cancers that, when removed, are found to have hair and teeth and other tissues. They’re called teratomas, from the Greek word teras—meaning monster.” – Vince DeVita, MD (The Death of Cancer)
“The real toxicity of low-dose chemotherapy is premature death. If your doctor recommends it, head for the nearest exit.” – Vince DeVita, MD (The Death of Cancer)
“Frank Schabel, who worked at the Southern Research Institute in Birmingham, Alabama, with Howard Skipper, did a set of experiments that were very telling about the effect of full doses of chemotherapy on the ability to cure a metastatic tumor. He implanted mouse sarcomas into groups of mice and watched the sarcomas grow until the mice had lots of measurable tumors in their lungs. Then he treated them with combinations of cancer drugs. At full doses, all of the mice went into complete remission. That is, all of their measurable tumors disappeared. Then he stopped treatment and followed the mice. Within months, about half of the mice developed recurrences and died. The remainder were cured.
So he had a 100 percent complete remission rate and a 50 percent cure rate. Then he began to reduce the doses of the drugs. He found that if he reduced the doses of the drugs by 20 percent, he still got a 100 percent complete remission rate. But he got only a 25 percent cure rate.” – Vince DeVita, MD (The Death of Cancer)
“Dr. Stanley Cohen at Vanderbilt University was a basic scientist interested in cell growth. In the course of his experiments, he had injected newborn mice with extracts from salivary glands. He was surprised when the newborn mice prematurely opened their eyes and erupted teeth. Something in the salivary extracts was speeding cell growth.
Ultimately, Cohen figured out that the material he was purifying was accelerating the growth and separation of epithelial cells that sealed the mouse eyelids and caused teeth to sprout. He discovered, isolated, purified, and sequenced a material he called epidermal growth factor (EGF), a protein that stimulates the growth of epithelial and other cells and enhances certain developmental growth.
He was also able to identify the target receptor for EGF and the mechanism of its action, providing a breakthrough in understanding how signals from outside a cell reach the inside of a cell, how cells talk to one another.
This turned out to be one of the most important discoveries of the twentieth century. It has had an important impact not only on the understanding of how cancers grow but also on cancer treatment. The discovery enabled scientists to further explore the cell growth process set in motion by EGF stimulation and to develop drugs to block the individual steps. The EGF receptor is expressed in virtually every cell in the body, and it is often over-expressed in cancer cells. This realization led to a huge increase in research on targeted therapies. In 1986, Cohen and Levi-Montalcini shared the Nobel Prize for identifying the first growth factors.
The biotech firm ImClone was one of the companies to take up the challenge of finding drugs to block EGF. I’m quite familiar with this work, because I was on the company’s board when this research was being done. Researchers identified four EGF receptors—labeled EGF-1 through EGF-4. ImClone developed an antibody, called Erbitux, to block the EGF-1 receptor, the most common variety. The drug proved to be useful in prolonging survival in both colon and lung cancer patients. And its side effects on normal cells were trivial: a rash around hair follicles. (Oddly enough, people who got a rash responded to the drug more often than those who didn’t.) Others discovered that EGF-2, also known as HER2, is over-expressed in about a third of patients with breast cancer. And it is not commonly expressed in normal cells. Another drug, Herceptin, which blocks the HER2 receptor, is a mainstay of the treatment of breast cancer.” – Vince DeVita, MD (The Death of Cancer)
“The death of cancer is inevitable. It is a question not of if but of when.” – Vince DeVita, MD (The Death of Cancer)
“The rate-limiting step in eradicating cancer today is not the science but the regulatory environment we work in.” – Vince DeVita, MD (The Death of Cancer)
Incognito 