The system designed to study, diagnose, and treat cancer in the United States is fatally flawed.
We would like to think that we have the tools to detect cancer early enough to cure it and that our treatments are safe and effective. We hope people who have dedicated their lives to cancer—scientists in the public and private sectors, oncologists, and advocacy groups—are sharing ideas and data. We assume that the vast network of government-funded research encourages bold and imaginative new ideas. We trust that compassion, not the quest for professional advancement and profits, is the primary driver of the cancer establishment. Sometimes, all of that is true. Too often, it is not.
For years, I have been observing our “cancer culture” and I have become convinced that it is not structured to do what we most need: to determine how to prevent cancer, and then implement our discoveries. Despite decades of promises and a vast amount of funding, the current model of research has failed us. We no longer expect to cure cancer and now talk mostly about living longer with the disease. We are not doing enough to pursue promising new approaches to prevention, and we are not dedicating sufficient energy to applying the strategies that already work.
The good news is that it doesn’t have to be this way.
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In 1992, I was a young doctor working as a diagnostic radiologist in the outpatient mammography division of a leading teaching hospital. There was always an undercurrent of anxiety in our department, even among the women who were just getting their annual test. Understandably, women who had already been treated for breast cancer were the most apprehensive. We were looking for any sign to suggest that the disease had returned, and their fear was almost palpable.
That was the situation of a 48-year-old woman I’ll call Mrs. Thomson. Two years earlier, she had undergone surgery and chemotherapy for cancer in her left breast. The following year, she received the grim news that the cancer had recurred, and she underwent another operation. Now, six months post-treatment, she had come for a follow-up mammogram. Her husband accompanied her, and from the moment I met them, I could sense their worry. Mr. Thomson, especially, was tense and belligerent. Almost immediately after we introduced ourselves, he told me that his wife had “been through the mill” and that they had “had just about enough” of visits to doctors’ offices.
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An abnormality on a mammogram can turn a woman’s life upside down, even if no cancer is ultimately found. At the very least, she will have to undergo more tests, usually with a biopsy as a first step. The procedure takes its toll in time and money and even more so in the stress it introduces into a woman’s life. If the pathology report says the cell sample is benign, she will likely breathe a sigh of relief, while recognizing the likely need for more vigilant follow-up. Afterward, her anxiety will linger.
A biopsy result that shows cancer has far greater consequences, of course. At the same moment a woman receives that diagnosis—perhaps the most terrifying moment of her life—she must also make difficult decisions.
Knowing that Mrs. Thomson had been through all this and more, I was especially patient and attentive as I examined her breasts. As always, I looked for lumps, skin thickening, or nipple changes, any of which would be important clues to her breast health. With the utmost sensitivity, Maureen, the mammography technologist, positioned her in front of the mammography x-ray unit and tried to be as supportive as possible as she took the four standard x-ray films of each breast.
Mrs. Thomson and her husband waited as the films were developed and brought to me for review. I stood in a darkroom, secured the films to a light box, and began to examine them. My years of training had taught me to be methodical and careful.
Starting at the armpit and slowly moving to the inner portion of each breast, near the sternum or breastbone, I searched each image for signs of masses, skin thickening, nipple retraction, or other abnormalities. Then I used a magnifying glass to search for “microcalcifications,” tiny white specks that signal calcium deposits in the breast. When they are large, coarse, round, smooth-bordered, and scattered within breast tissue, they are almost always benign. Calcifications that are tiny, tightly clustered, and shaped like commas or flames are more ominous, often representing a malignancy.
I saw that Mrs. Thomson’s right breast was free of any abnormal findings. I hoped—and prayed—that the left breast would be equally unremarkable. But as I viewed the outer top part of the left breast, where she had previously had surgery, my heart began to race. I identified a small cluster of irregularly shaped calcifications. Immediately, I compared this area with the mammogram that had been taken before Mrs. Thomson’s most recent surgery, and I saw some of the same calcifications. That was a red flag suggesting either that not all of the cancer had been removed or that the cancer had recurred at the same site. I needed a more focused, “coned down” view of the left breast.
When I received the second set of views, I examined them carefully with the magnifying glass. Again, I compared the new views with those taken previously. My preliminary impression was confirmed. I entered the room where the Thomsons were waiting. Mr. Thomson stood with his arms folded across his chest. His wife remained seated. Calmly and slowly, I explained what I had found on the mammogram and what it meant—Mrs. Thomson would have to pay another visit to her surgeon.
What happened next is something I will never forget.
Mr. Thomson leaped toward me and pinned me against the wall. His lips, eyes, and jaw held an extraordinary mix of fury, fear, and pain as he shouted directly into my face. “My wife has been through two operations! We were told that it was all out! How could you see more cancer?”
Trying to keep my composure, I said quietly, “I understand that you’re very upset and that this is not the news you were expecting.” Mrs. Thomson spoke up, pleading with her husband, “Stop, it’s not her fault!” Mr. Thomson withdrew to his wife’s side, but his anguish and rage were undiminished. I sensed, above all, his feeling of hopelessness. ++++++++++++++ The events of that day were unusual only in the degree of raw emotion that was exposed. Everyone who is diagnosed and treated with cancer has a unique story. Yet their journeys are also alike in many ways, with a painful and arduous course of treatment almost guaranteed. Together, we can change that, but only if we can first agree not to be shackled by the status quo. In 1971, when President Richard Nixon signed the National Cancer Act, America declared a war on cancer, and for more than four decades we have continued to wage that war. Think of it: 40 years battling a disease, with billions of dollars spent to conduct research, build new cancer centers, and develop new drugs and new medical technologies. Still, victory eludes us. In 2012, according to our best estimates, some 1.6 million new cases of cancer will be diagnosed and about 577,000 people will die of the disease. Why have we settled for a medical system that allows cancer to be recast as a chronic and tolerable disease rather than one we should try to prevent? Why do so many scientists at the nation’s drug companies and universities turn their backs on the possibility of prevention? How can we transform the agenda? Dozens of conversations with some of the nation’s most accomplished and respected physicians and cancer researchers have confirmed my belief that while we may never be able to cure most cancers once they take hold, we can find ways to prevent cancer altogether, to eradicate it just as we have virtually wiped out devastating diseases like smallpox and polio. Reinvigorating our commitment means enlisting the best scientific and medical minds around the world. It means ending the competitive model of cancer research—where investigators hold their findings close to the vest, hoping to publish elegant papers and generate revenue—and replacing it with a commitment to a team science that’s dedicated to saving human lives. It means elevating the priority we assign to better nutrition, a healthier environment, walkable communities, and increased physical activity. With leadership at the federal, state, and local levels of government and a commitment from American people from every walk of life and every part of our nation, we can begin to create a world without cancer. Reprinted from “A World Without Cancer: The Making of a New Cure and the Real Promise of Prevention” by Margaret I. Cuomo, MD. Copyright (c) 2012 by Margaret I. Cuomo, MD. By permission of Rodale, Inc. Available wherever books are sold.
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