The Death of Cancer By
Vincent T. DeVita Jr, MD and Elizabeth DeVita-Raeburn

By

Leonard Zwelling

On
page 248 of this extraordinary memoir-battle story, Dr. DeVita lists the eight
attributes of cancer cells as first delineated by Weinberg and Hanahan:

1. Sustained proliferative signaling

2. Evasion of growth suppressors

3. Resistance to cell death

4. Avoidance of immune destruction

5. Ability to induce angiogenesis

6. Deregulation of cellular energetics

7. Ability to enable replicative immortality

8. Activation of invasion and metastases

         This is an excellent list, but it
leaves out the single most important aspect of cancer and this omission is the
reason that Dr. DeVita and I differ on where cancer research is today.

         Nowhere in this excellent text is the
work of Josh Fidler and Margaret Kripke cited. In the late 1970’s, these two
former chairs of basic science at MD Anderson elucidated the most important
principle of all of cancer biology and surely the most salient observation in
cancer research of the 20th century. Cancers are genetically
unstable, intrinsically heterogeneous and always changing. Thus, any given
human malignancy does not represent one target, but millions, all different,
all in metamorphosis, all the time.

         If this is taken as a first principle,
then the job of curing cancer becomes more daunting and not quite as “around
the corner” as Dr. DeVita’s book might have a layperson believe.

         That being said, this is still a superb
description of 50 years on the front lines of the war on cancer and how often
do you get a description from the front lines by a general? Rarely.

         First a bit of a disclaimer. Vince
DeVita is my friend, my mentor and my boss at the NCI for most of the time I
was there, 1975-1984. He is a fearless warrior, ardent patient advocate and a
real bedside doc. It is often forgotten that Dr. DeVita personally cared for
every single one of those 43 patients with Hodgkin’s Disease who were treated
on the MOPP study that completely changed the way oncology dealt with solid
malignancies. This is no small accomplishment. He used the principles first
elucidated by Freireich and Frei in the treatment of childhood leukemia with
cytotoxic drug combinations and devised a regimen called MOPP that cured some
people with a formerly fatal lymphoma. This gave birth to a revolution in the
use of chemotherapy in the treatment of solid tumors that I was fortunate
enough to be caught in the middle of. It changed who I was and what I believed
was possible. I was particularly pleased that Dr. DeVita tickled my Duke
professor in his book, the late, great Dr. Wayne Rundles, who was very
skeptical about combination chemotherapy and whose skepticism was one of the
reasons I left Duke to get trained at the NCI where the pervading outlook was
far less pessimistic for cancer patients than the one at Duke in 1975.

         Dr. DeVita saves his harshest criticism
for the FDA. Me, too.  Chapter 8 of his
book lambasts the FDA as following the Frances Kelsey Syndrome of saving
America from thalidomide for the next 50 years and thus slowing progress in the
approval of needed cancer drugs. This syndrome persists at the FDA to this day.
As someone who had to sit between aggressive investigators like Dr. DeVita and
equally aggressive regulators in the federal government when I was an Anderson
VP, I can assure you there may be no less comfortable place to be. Over the
years, I have become more encamped with the investigators and less with the
regulators. I now believe that the system of clinical trials in cancer needs a
complete overhaul as it will never be able to keep up with the latest progress
in genomics that is revealing that each cancer may constitute a study group
with an N of 1, a fact Dr. DeVita covers quite well toward the end of his book.

         Finally, just so that no one thinks
this is solely a science or biomedical text, the heart of this book is the
patients that Dr. VeVita cared for or knew and his mentors who taught him how
to do the clinical research that has so benefitted mankind. Personality number
one is Jay Freireich and well he should be. I know him too and he, like Dr.
DeVita, is one of a kind. And like Dr. DeVita, that there is only one Jay
Freireich is probably a good thing as the world could not handle more than
that.

         It is very difficult to imagine a world
before combination chemotherapy, but I lived in it during my training at Duke.
I still remember pushing a new drug called cis-platinum into the veins of a
young man with testicular cancer at the Durham VA as he wretched his guts out
and his kidneys were damaged. But we learned how to give it safely and Lance
Armstrong and many others were cured.

         I believe that I am the luckiest
observer in the history of biomedical science. I was blessed with the wisdom of
Freireich. I was doubly blessed with the perseverance and clinical brilliance
of DeVita and then triply blessed to be married to a woman who has also cured
quite a few young cancer victims who had been given up for dead. I have
witnessed three generations of pioneers in the treatment of human cancer. If
you can’t do it yourself, at least be there at the moment when history is being
made.

         I was. I am. If you want to get a
really good view of where we have been, where we are and where we are going,
read this book!

         I, like Dr. DeVita, get regular calls
from all over the country for help from patients with cancer. I use all the
connections in my power to get that patient to the right doctor, just as Dr.
DeVita does and did, when he himself was the cancer patient. Despite all the
progress we have made, it is still too hard for most people with cancer to get
the best care that modern medicine has to offer for a host of reasons that Dr.
DeVita describes well. Yes, it is critical that we make inroads in our scientific
understanding of cancer, but it is equally important that we get the regulatory
bureaucracy and moneymakers out of the way of the patients so they may have
access to physicians who actually know what they are doing because they do it
every day in cancer centers. Both the molecular and the bureaucratic are
jungles requiring continuing work—preferably with machetes.

         Cancer is not nice and those of us who
fight it shouldn’t be either. However, Dr. DeVita’s call for a Cancer Czar
makes me a bit queasy. After living under two of them at MD Anderson (‘Raising
the Bar’ and ‘Moon Shots For All’), I find a more democratic approach might be
more compatible with progress.

         I might acquiesce to a Cancer Czar if
one of the three people I mention above, Freireich, DeVita or Kleinerman got
the job. Otherwise, I am a bit put off by the concept of a Czar. The last few
haven’t performed all that well, in the US or Russia.

Leonard Zwelling