Will there ever be a cure for cancer?

 I was going to write another post about the rona, to close the whole thing out, and focus on the Press and their role in stoking panic (the title of the post was going to be "The Devils"), but I just can't bring myself to do it.  It's probably not good for my soul to focus so much energy detailing to evil done throughout 2020 and 2021 (and to a large extent even now in 2023 though the populace seems to have lost interest).  They worship different a different god than I do.

Instead I thought I'd start on a few thoughts about my recent battle with Bladder Cancer.  I capitalized that because Cancer dominates your life in a way that I hadn't thought it would.  

In the early 2000s, probably 2000 or 2001, I saw a panel discussion on CNBC moderated by Maria Bartiromo (now with Fox Business) with a couple cancer researchers and a director of some large Cancer treatment center (like Memorial Sloan Kettering or MD Anderson).  Early on in the discussion, Ms Bartiromo asked if there would ever be a cure for cancer, or if they were close to a cure for cancer and one of the researchers shrugged and said "probably not". In fact, no one on the panel even gave the idea much credence.  That kind of surprised Bartiromo.  But it was explained that if you look at leading causes of death in 1900, people still get those illnesses, but they just don't die from them.

I was surprised by that, so I looked it up (and let me just say here that it was easier to find this data in 2000 than it is in 2023, interestingly).  Here's the table I'm using for this discussion.

https://www.cdc.gov/nchs/data/dvs/lead1900_98.pdf

In 1900, the top 5 causes of death were Pneumonia, Tuberculosis, Diarrhea, Heart Disease and "Intracranial lesions of vascular nature" (stroke?).  By 1920 that list was Pneumonia, Heart Disease, TB, Intracranial Lesions and Nephritis.  Already it looks like TB is being defeated.  In 1950 the list was Heart Disease, "Malignant Neoplasms" (cancer), "Vascular Lesions affecting central nervous system", accidents and "Certain illnesses of early infancy".  I actually don't know what most of those things are, but none of them are TB and Cancer is on the list. TB is actually #7 on this list but Heart Disease is more than twice the next highest.  In 2000, when the roundtable was aired, the list was Heart Disease, Cancer, Stroke, Respiratory diseases and accidents.

https://www.cdc.gov/nchs/data/nvsr/nvsr50/nvsr50_16.pdf

The latest table I could find on the CDC's website (and, really, I doubt they could make it harder to look up this information) has the top 5 as Heart Disease, Cancer, Accidents, "Chronic Lower Respiratory disease" and "Cerebrovascular Disease" (stroke?).  Pneumonia is #9 on the list and TB is not listed in the top 10.

https://www.cdc.gov/nchs/data/nvsr/nvsr70/nvsr70-09-508.pdf

So to be pendantic, people may still get TB and diarrhea but they don't die from them at nearly the same rate.  Heart disease and Stroke are still in the top 5 and Heart Disease and Cancer have gotten much worse (it's unclear how accurately Cancer was diagnosed in an age before X Rays and MRIs).  And it's actually somewhat better than that.  The age-adjusted death rate is lower for many categories in 2018 than in 1900, but not cancer.

https://www.cdc.gov/nchs/data-visualization/mortality-trends/index.htm

Looking at the graph above, and especially since I'm focused on Cancer, you can see that the death rate for Cancer has decreased a bit from the 1990s.  The national cancer institute has a program called SEER to visualize the data and their graph from 2000 shows a steady decline.

https://seer.cancer.gov/statistics-network/explorer/application.html?site=1&data_type=2&graph_type=2&compareBy=sex&chk_sex_1=1&race=1&age_range=1&advopt_precision=1&advopt_show_ci=on&hdn_view=0&advopt_show_apc=on&advopt_display=2#graphArea

That seems unambiguously positive: fewer people dying from cancer.  Yet the reduction is mostly due to lower incidence.  The survival rate (what you'd consider a "cure") is basically flat since 2000.

Now I'm not one to be churlish: I'm very happy that fewer people are getting cancer, but I can't help but think that the glass is half empty when it comes to cancer care.

Of course, things are even more complicated than that.  Specific cancers like Leukemia have seen impressive increases in survivability.

The graphs for Lung cancer are still distressingly low, but looking at the 3-year and 1-year survival rates (which automatically are more up-to-date than the 5-year numbers) a large improvement is visible.  Fully 30% of lung cancer cases have specific genetic mutations that allow targetted therapies and those are simply miracle drugs that not only extend life but preserve quality of life.

In fact, almost half of the decrease in cancer mortality is due to a decrease in lung cancer mortality, both due to reduced incidence and improved treatment.

One the other hand, specific cancers are relatively survivable.  Prostate cancer has about a 95% 5-year survival, though distressingly that has gone down a little recently.  Breast cancer has a 90% 5-year survival rate, and is very slightly increasing.

It's a good thing to be alive five years after cancer diagnosis, but to get there people have to go through the wringer: surgeries, chemotherapy, immunotherapy, radiation, loss of hair, loss of taste (and consequently loss of appetite), loss of strength and fitness, mental issues (commonly called "chemo-brain"), loss of organs that are currently providing a useful service or contribute to a person's sense of self, and in some cases, loss of friends as they don't know how to relate to the patient any more.  Then there's the emotional toll: the fear of death, fear of being unable to care for your loved ones, guilt that you can't take care of the day to day things that your family depend on, survivors guilt if you survive, and the constant questions like "Why me?" or "What do I do with my life now?".  And that's for something that's 70% survivable.  Even 90% survivable isn't quite good enough.  Would you get on a plane if you were told there was a 10% chance it would crash?  What about a 5% chance?

So to be even more pedantic, there may never be a cure for "cancer" but specific cancers may indeed lose the stigma as a death sentence.  I hope and pray that there are people alive today who won't need to fear a cancer diagnosis.

While people on the TV show were dismissive of curing cancer, they were enthusiastic about increasing access to cancer treatment, and that is definitely a point to discuss.  People who live in rural areas will obviously have a harder time getting even the current standard of care compared to people who live in large metropolitan areas.  Cancer is disruptive in the best of situations, but especially when you have to arrange for someone to drive you an hour or two to the nearest major cancer hospital for whatever treatment you need.  I used to work with a guy whose sister needed to travel from Waxahachie to Dallas every week for chemo.  That's kind of hard to imagine, though the simple fact is that DFW is a big place with bad traffic and the same problem could arise if you live in one of the outer suburbs and have to travel to downtown for your chemo or checkups.

Even in a major metropolitan area, the burden one caregivers is great, but it seems like it would be even greater for those in rural areas.  In my case, I was treated with BCG at my local urologist, who is 5 minutes or so from my house.  But in my hometown, that'd be 20 or 30 minutes.  The BCG treatment involves laying on your back/front and each side to expose the entire bladder to the BCG and that doesn't seem compatible with sitting in a car for 30 minutes.  In that case, it might be necessary to STAY at the urologist while you complete each treatment.  And, I assure you, you do not want to be 20 to 30 minutes away from a toilet after the treatment is done.  So now you're looking at further nuisance and possibly a longer stay at the urologists office.  But I haven't been put in that position, so maybe it's not a big deal: you just do the best you can.  But it's one more thing to worry about.

And what if you don't have insurance?  You might not even get diagnosed with cancer until it's too late if you don't have regular access to a doctor.  And survival decreases dramatically if the cancer has spread.

Better access to care means more local access to care.  That means that Waxahachie and Plano and Lewisville and Red Oak all need quality local cancer treatment locations.  Or that there needs to be hassle-free travel for all of those locations to the care that people need.  That's a tall order and it's hard to imagine how it will be met.  I can imagine a local treatment and diagnostic care location with online access to doctors where you can get your xrays and possibly MRIs and treatment while talking to the experts in more centralized locations.  But we're not there now.

So will there be a cure for cancer?  It seems the answer is still "no".  There's a frustrating lack of progress on overall survival and even on the more treatable cancers, it seems like there's an upper limit of 90% to 95% survivable.  We just made it through two years of hell because of a world-wide pandemic that was 98-99% survivable.  It's hard to imagine people would consider 90% survivability to be a cure when they shut down society for a 98% survivable virus.  A lot of progress has been made on avoiding cancer but most of that came from lower rates of smoking, and smoking rates are hardly going to get much lower.  Targeted therapies for lung cancer really are miraculous, but there aren't many more candidates for those therapies, though there are more options for the existing genetic targets that are coming.

The current state-of-the-art is immunotherapy.  Checkpoint inhibitors have shown decent success in blood cancers but are only effective on 20%-30% of solid tumors.  Current encouraging drugs like Opdivo and Yervoy have increases survival times that are measured in months.  CAR-T therapies are also promising, but the cost is astronomical: tens of thousands of dollars and weeks or months spent in the hospital, since the immune system has to completely destroyed and rebuilt as part of the therapy.  Immunotherapy is, on the whole, "promising" but nowhere near a "cure". 

And mental health care is not quite up to snuff yet, either.  Both patients and caregivers need to know how to navigate the emotional pitfalls that they don't even know exist when the diagnosis comes down.  You may need help transferring responsibilities to another person (ex, all the logins and passwords and apps needed for banking, credit cards, utilities and the like).  By definition, removing a tumor results in removing part or all of an organ, muscle or bone that used to be healthy.  That's a kind of death, if you believe in the dignity and unity of a human body.  Even if you were to recover, there's a part of you that's not you anymore, and that can affect a person in a way that his family and friends don't get.  ("You're alive, what's the big deal?")

It's a cliché to say that cancer sucks, but it really does. I had a relatively easy cancer with a relatively easy treatment and I'm sure there are people who wouldn't even consider me to be a cancer survivor since I never had chemo or lost my hair, but it I'm still not quite over the shock.