Reginald Brill's A Surgical Operation (1934-1935)

Detail of British painter Reginald Brill’s A Surgical Operation (1934–1935). Medicine has changed significantly since the 1930s, with combination-drug therapies designed by Vincent DeVita and colleagues in the 1960s turning untreatable cancers, such as Hodgkin’s lymphoma, into curable diseases.

Wellcome Library

Killing Cancer

Cancer researcher Vincent T. DeVita Jr. casts a critical eye on the battle against cancer.

Vincent T. DeVita Jr. and Elizabeth DeVita-Raeburn. The Death of Cancer. Sarah Crichton Books, 2015. 324 pp. $28.

Cancer has bedeviled humans throughout our existence. As far back as the ancient Egyptians, people have tried to understand this scourge and have sought its remedy, but with little success until the second half of the 20th century. Today tens of thousands of people work in cancer research worldwide and have made immensely more progress than their predecessors. Many of the researchers who read Vincent DeVita’s account of the modern history of the disease, The Death of Cancer, will likely see some of their friends, colleagues, and rivals—perhaps in a new, sometimes unflattering light.

DeVita is well positioned to explore the world of cancer research. He directed the National Cancer Institute, served as physician in chief of the nation’s largest cancer center (Memorial Sloan Kettering), directed the Yale Cancer Center, and served a term as president of the American Cancer Society. In his spare time he wrote more scientific papers than anyone would care to count and coauthored the most authoritative book on cancer medicine, Cancer: Principles and Practice of Oncology, now in its 10th edition. DeVita also suffered his own bout with cancer, thus lending a personal empathy to his discussion of the terrors of the disease and its treatment. The book is coauthored with his daughter, Elizabeth DeVita-Raeburn.

Other recent volumes have covered some of the same ground. These include George Johnson’s The Cancer Chronicles and Siddhartha Mukherjee’s Pulitzer Prize winner, The Emperor of All Maladies. The former is less optimistic than DeVita about a lasting cure for cancer, and the latter treats a wider swath of cancer history, putting more emphasis on basic science than DeVita’s book. Perhaps surprisingly, The Death of Cancer has a peculiarly schizophrenic view of the role of lab-based research in the cancer arena, pairing optimism for the therapies being devised with impatience for the institutional conventions and bureaucratic obstacles DeVita believes delay the therapies’ arrival. For example, he assesses the 1965 meetings of the American Association of Cancer Research by remarking, “Most of the studies presented . . . were lab based and boring.” And one of DeVita’s many criticisms of Sloan Kettering on his arrival in 1988 was the center’s focus on the “long-standing bugaboo that has always dogged cancer—a tendency to value lab research for its own sake.” While such sentiments may betray a clinician’s perspective and are not likely to resonate with the thousands of lab-based scientists who have spent their careers trying to uncover the basic workings of the disease, they also contradict DeVita’s views in other sections of the book. DeVita, for instance, exults in the fact that the cancer cell is no longer a “black box” but a “blueprint” understandable in all its molecular glory. Moreover, the central theme of the book—that the end of cancer as a major disrupter of human existence is just around the corner—is based on the notion that science is not the limiting factor in cancer treatment. Instead, it is the inability to use the treatments we already have that impedes progress, treatments that largely originated in the basic science DeVita decries.

One of the book’s most captivating sections recounts the development of MOPP, an acronym for the four component drugs used to treat Hodgkin’s lymphoma, a tumor of the white blood cells. (Before the introduction of MOPP, being diagnosed with Hodgkin’s disease was a likely death sentence. These days a combination of radiation therapy and chemotherapy cures roughly 85% of cases.) MOPP was developed by DeVita and colleagues at the National Cancer Institute in the 1960s. Many physicians were skeptical, even hostile, to this new approach, but DeVita’s group doggedly based its treatment strategy on an understanding of the biology and natural history of the tumor, as well as the pharmacology of the drugs employed in the course of therapy. Although MOPP has now been surpassed as a primary treatment for lymphoma, its achievement as the first widely successful combination-chemotherapy regimen laid a foundation for other such combinations, which in turn became the mainstay of cancer treatment. While taken for granted today, the use of drug combinations required persistence, a willingness to suffer strong professional criticism, and the ability to grasp insights unrealized by others. In other words, a heroic accomplishment.

Portraying the history of science with the “scientist-as-hero” motif may be inspiring, but it is not usually the favored treatment among professional historians, who tend to a more nuanced approach based in social and cultural studies. The Death of Cancer lies somewhere between the two approaches and often portrays its characters as antiheroes rather than stars. Starting with the beginning of his professional career at the medicine branch of the National Cancer Institute, DeVita envelops himself and favored colleagues (one group is affectionately nicknamed the “gang of five”) in the posture of iconoclasts, bravely battling those with entrenched interests who pursue personal career fortification over developing better treatments for their patients. This characterization initially makes for an exciting tension in the narrative but begins to wear thin when the theme recurs time and again. Thus, as director of the National Cancer Institute, chief of medicine at Sloan Kettering, and director of the Yale Cancer Center, DeVita finds all those around him lacking in the excellence for which only he understands the remedy. It is surely the case that each of these distinguished institutions could have benefited from the administrative and scientific improvements that inspired leadership brings, but DeVita’s colleagues were influential and accomplished in their own right before the arrival of the good doctor.

DeVita’s criticism extends beyond just his employers. Officials at the National Institutes of Health are shown dissembling to Congress when asked if scientists and physicians were working closely together to cure diseases (the two groups often work in their own realms with little interaction); and as DeVita sees it, the national clinical-trials groups, who coordinate experimental therapies across institutions, act “more like competitive sports teams” than organizations meant to help patients. The FDA draws particular ire because it is always in the way of brave research clinicians trying to get new medicines to patients and has succeeded in getting “more and more control over our lives.” No concession to the agency’s protection of safety and welfare here. Patients, at least, are spared the critical firepower and are generally portrayed as brave souls fighting for life, an attitude one hopes to find in a doctor.

Discerning readers may discover facts about the cancer establishment that hinder progress. Most of the nation’s comprehensive cancer centers are located in university medical schools. This arrangement has been a tremendous boon to creative fundamental research but can pre-sent intractable difficulties for clinicians dealing with the complexities of treating cancer patients. The directors of university-based cancer centers have little authority compared with department chairs and hospital administrators; as a result it is much more difficult to mobilize the teams of specialists, sophisticated facilities, and varying treatment modalities required in contemporary cancer medicine. DeVita, to his great credit, is a forceful advocate for cancer centers with more independent leadership, freed from the bureaucracies and fiefdoms of medical schools.

We also learn that different centers have vastly different success rates in dealing with the many types of cancer that afflict human beings. Working doctors, especially those as well connected as DeVita, know who is best for prostate cancer, melanoma, glioma, or any of the myriad types of malignancy. Ordinary folks can’t readily get this information from public sources and so are left to the vagaries of whatever treatment facility they happen to be near. Excellent doctors, like the author, can advocate for their patients and get them to the best possible place to treat their particular disease. In the end this is what we would all seek for ourselves or our loved ones, and DeVita comes across as one of the masters of the art for his own patients.