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Imagine two 747s colliding in midair every day, killing all 862 passengers each time. If this occurred, the public would be up in arms. But every day 1,350 people die of cancer. We are witnessing a cancer epidemic. One in three Americans will develop cancer at some time in their lives and two thirds of these patients will die within five years. This year close to one million people will develop cancer and a half million Americans will die of the disease.
The War on Cancer — Another Vietnam? In December 1971, President Richard M. Nixon signed the National Cancer Act, officially launching a "war on cancer." Since then, despite the government's expenditure of $1.4 billion every year to the National Cancer Institute (NCI), cancer survival rates have not changed significantly from those of the 1950s.In response to these depressing statistics, the NCI, which must sell its program to Congress, announces at regular intervals that more patients with cancer are surviving more than five years.
But in the early 1980s, members of the cancer establishment began to question the NCI's interpretation of cancer survival statistics. In a 1983 scientific article, a Yale researcher, Dr. Alvan R. Feinstein, stated that cancer survival may be no better today than it was two decades ago. The following year, Dr. Haydn Bush of the London (Ontario) Regional Cancer Center pointed out why the NCI's cancer survival statistics look better than they are. Survival rates are improving not so much because of better treatment, butowing to earlier diagnosis, which simply starts the five-year survival clock sooner, he said. In 1984 Drs. Robert K. Oye and Martin F Shapiro from the UCLA School of Medicine in Los Angeles joined the growing number of NCI critics. In a scientific journal, they questioned whether chemotherapy helps people live longer.
The blast came in May 1986 with publication of an article coauthored by a leading cancer researcher from the Harvard School of Public Health, John C. Bailor, in America's most prestigious medical journal, the New England Journal of Medicine. The authors concluded that "some 35 years of intense effort focused largely on improving treatment must be judged a qualified failure." Their statement "We are losing the war against cancer" made national headlines.
The following year, a congressional investigation conducted by the General Accounting Office (GAO) concluded that gains in treating cancer over the last three decades had been small and overstated by federal health officials.
If you have been diagnosed with cancer, the information in this chapter will help you assess your doctor's recommendations. If you have cancer and have already embarked on standard treatment, this information will help you assess your original decision.
If a biopsy or another procedure shows that a tumor is malignant, the patient undergoes various tests to determine the extent to which a cancer has spread — that is, the stage to which the disease has progressed. This part of the diagnostic process is called "staging." A localized tumor (or what appears to be one) is classified as Stage 1; the most advanced cancer is Stage IV. Based on the stage of a cancer, the oncologist determines what type of treatment is needed. Staging is generally a uniform or standardized procedure, but treatment varies from hospital to hospital. As you'll see, recommendations for treating Stage I breast cancer patients did a 180-degree turn in May 1988.
Standard cancer treatment consists of surgery, radiation, chemotherapy (including hormonal treatment), and immunology. These four types of treatment are used either singly or, more frequently, combined.
What It Is. As described by the American Cancer Society, "Cancer is most often treated by surgery....When dealing with cancer, a surgeon not only removes the malignant tumor or organ, but also a wide margin of normal tissue and, in some cases, the nearby lymph nodes to halt further spread."
Looking Back. Today, surgeons are aware that by the time a lump in the breast (or another type of tumor) is detected, the cancer may have already spread to other parts of the body. But prior to the 1970s, the prevailing belief was that cancer started as a local disease and was surgically "curable" until that unknown moment when distant metastases occurred.As a result, many surgeons believed that cure could only be achieved by the most "aggressive" surgery. For example, the Halsted radical mastectomy, popularized in the 1890s, involves removal of breast tissue, underlying muscle, and an lymph nodes in the armpit. (Removing nodes in the armpit causes the arm to swell in many patients; removing the muscle gives a sunken look to the chest and makes it difficult to raise the arm.) According to Dr. George Crile, Jr., a former Cleveland Clinic surgeon and early critic of the mastectomy, "[it] seems to have been designed to inflict the maximal possible deformity, disfiguration and disability" on women.
As surgeons in Europe and Canada challenged the rationale for extensive surgery, a more limited form of mastectomy called a modified radical mastectomy (removing the breast and lymph nodes) came into use. A ten-year study of women with early breast cancers (New England Journal of Medicine, March 14, 1985) showed that the modified mastectomy achieved the same results as the radical in terms of recurrence of tumor and survival. In the same issue of the journal, a national five-year study of women with small tumors detected early showed even more clearly that less may be as good as more in breast surgery. This study compared, three treatments: modified mastectomy, lumpectomy plus radiation, and lumpectomy alone. (A lumpectomy is removal of the tumor and a margin of tissue around it.) The five-year results showed no difference in survival between a lumpectomy plus radiation and mastectomy.