By CHADI NABHAN MD, MBA, FACP
Some books draw you in based on a catchy title, a provocative book jacket, or familiarity with the author. For me, recollections of medical school primers written by the renowned lymphoma pioneer Vincent DeVita Jr. and my own path as an oncologist immediately attracted me to “The Death of Cancer.” I felt a connection to this book before even reading it and prepped myself for an optimistic message about how the cancer field is moving forward. Did I get what I bargained for?
Co-authored with his daughter, Elizabeth DeVita-Raeburn, DeVita brings us back decades ago to when he had just started at the National Cancer Institute (NCI) under the wings of Jay Freireich and Tom Frei. At the time, he was a clinical associate and a “chemotherapist”; the field was ultimately renamed and defined as medical oncology. (Note to self: I am ecstatic the field was renamed; I would prefer to be called a medical oncologist anytime than a chemotherapist, but that’s just me). He recounts how chemotherapy was frowned upon in favor of the two preferable ways to treat cancer at the time: surgery and radiotherapy. DeVita eloquently describes how his mentors were ridiculed when they announced their pursuit to cure childhood leukemia using combination chemotherapy; their approach and determination provided him with inspiration to push his research further. He goes on to describe in a fascinating manner the way he designed the MOPP regimen, which cured many patients with Hodgkin lymphoma. He recounts events when he presented his own MOPP data, and how he was verbally attacked by radiotherapists who claimed his data were insufficient and attempts to drive them “out of business”. Even in 2018, my radiation oncology colleagues protest when medical oncologists challenge the role of radiation therapy in Hodgkin lymphoma. I have actually grown tired of attending debates between any two prominent lymphoma figures discussing whether to use radiation or not in such setting; there are better topics to argue about, like who might win the Super Bowl.
As I continued reading the book, many stories and events resonated with me, not because I am a cancer and a lymphoma specialist, but because much of the interactions, politics, and challenges remain similar and relevant decades later. When DeVitap101 described how Paul Carbone, his superior at the time, forced his name as a co-author on the MOPP abstract back in 1969, it reminded me of many current senior investigators who do the same. DeVita doesn’t shy from saying, “Carbone’s tendency to add his name to papers wasn’t unknown.” We all know a Carbone-like physician and scientist and this behavior, sadly, is likely to continue. DeVita courageously suggests that clinical trials are occasionally designed for economic incentives and that some of the debates on how best to manage patients are driven by economics and politics. He recalls that one of his colleagues, a leader of the largest Hodgkin disease clinical trials group, told him privately that he had to include radiotherapy in each group of patients with an early disease if he wanted to enroll patientsp107. Any investigator in today’s world will tell you that similar scenarios still happen. I was told to not open a study at an institution because it might upset a famous faculty member’s approach to how “a cancer” is treated. I am not sure if I felt reassured or disappointed that what took place several decades ago occurs often.
DeVita’s journey is inspiring and spans years of changes in political and scientific environments. He became the NCI Director and was exposed to Washington politics; Physician-in-Chief at Memorial Sloan Kettering Cancer Center where he was eventually asked to resign; and the Yale Cancer Center Director. As he recounts interesting details of his career, he is not afraid to describe characters the way he had viewed them, whether they were drunk at work or arrogant when dealing with others. I specifically enjoyed his recollection of meetings with Senator Ted Kennedy, and how they clearly disliked each other. DeVita was no fan of Jim Watson, a Noble Prize winner, stating that Watson was rude and disrespectful to committee members he was serving with; Watson was asked to no longer serve on that committee.p159
Perhaps the subject that surprised me to a level of disappointment was that DeVita mentioned opposing randomized controlled trials (RCTs). Hearing this from a pioneer researcher was astonishing. Devita said, “Today we seem to be mindlessly wedded to the use of RCTs……But RCTs can be unethical”.p196 This is disturbing. In his book, DeVita challenges the FDA and suggests that their regulations are too restrictive. He seems opposed to overall survival as an endpoint for all cancer trials, and while he provides his reasoning, it was not convincing to this reader. DeVita mentions few situations where complete responses do correlate with outcomes, but he conveniently selects successful stories, refusing to concede that some regulatory safeguards are essential to protect patients from getting unnecessary treatments. Throughout his discussion of clinical trials, he seems to correlate “thinking outside the box” with oncologists treating patients with whatever they “believe” is the right approach. In my opinion, this is a slippery slope. I have witnessed some patients suffering consequences of therapies that were not validated and simply thought to be effective by some. Not long ago, some physicians advocated high-dose therapy and stem cell transplant as a curative option for advanced breast cancer. We learned later that this was incorrect and many women were subjected to this wrong approach. The field of oncology is filled with similar lessons, but DeVita does not mention any. He is persistent in suggesting that we should always continue to try treatments, and nowhere in his 300-page book discusses palliative care, how aggressive therapies can jeopardize the quality of life, and when physicians go too far.
There is a warm and sad personal angle in the book when DeVita discusses his son’s diagnosis with aplastic anemia, and how he died at the age of 17. DeVita’s portrait was taken at the end of his tenure at the NCI and was in front of the building of his son’s hospital. DeVita himself was diagnosed with prostate cancer. In recounting his diagnosis and treatment, he is humble and a clear patient advocate, but once again, suggests that he is doing well 8 years later because he chose an “aggressive” route of treatment and sought an “aggressive” physician. You might have guessed my opinion on that.
DeVita ends his book with a chapter that summarizes why he believes that we are winning the “war” on cancer, a metaphor that he claimed he once hated, but continued to use throughout his book. He is optimistic and brings up very valid points when he explains to readers how cancers evolve and metastasize. He is optimistic where we’re heading, and readers are likely to share his enthusiasm.
Despite my disappointment in how DeVita challenges the FDA regulations and how he appears not in favor of RCTs, or survival as an endpoint for many studies, I find the book compelling, captivating, and written in a way that will resonate with you, whether you are a healthcare provider or a patient. I did get what I bargained for and recommend this book.
Chadi Nabhan is an oncologist in Chicago. His interests include strategy and business of healthcare. He’s a prolific speaker and occasional tweeter. He can be reached @chadinabhan