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GUEST EDITORIAL |
C. Everett Koop Institute at Dartmouth, Hanover, NH
Correspondence: C. Everett Koop, M.D., Sc.D., C. Everett Koop Institute at Dartmouth, 7025 Strasenburgh, Hanover, NH 03755, USA. Telephone: 603-650-1450; Fax: 603-650-1452; e-mail: Koop.Institute{at}dartmouth.edu
I think you all know me. I imagine most of you know me as your former Surgeon General, a position I held for eight years; an office I used as often as I could to advance our efforts against cancer. Especially the varieties of cancer attributed to tobacco.
But my own professional crusade against cancer goes back decades before my years as your Surgeon General. I've now been a physician for almost 60 years. That's a long time! I must admit that as a newly minted M.D. in June of 1941, I never would have imagined I'd be an active physician in the 21st century.
I, myself, am very much an example of what modern American medicine can do, with my knee implants, coronary stent, and enough drugs a day that it takes my wife and me to make sure we have them all counted out! Every time I speak on a subject in medicine, I have to acknowledge my personal debt to American medicine, first as a physician, then as a patient. And for most of those 60 years in medicine I was a surgeon, a pediatric surgeon who committed himself to cutting back cancer mortality in children long before medicine even knew what an oncologist was.
For years I saw what cancer does to children, and to their parents. We made great strides with children—compared to adults. Mortality when I started was 100%-40%. Now some cure rates are over 95%.
I lost my mother to cancer. And when you get to be my age, you have seen all too many of your friends succumb to cancer. I've even seen some of my former residents retire. That makes you feel old! My residents became surgeons whose skills allowed many youngsters to shake free of cancer. And I've seen their retirement cut short by their own cancer. So, I'm not only professionally committed to our effort against cancer; my commitment is very personal as well.
Now—as I occupy an Endowed Chair of Surgery at the Dartmouth Medical School, where the C. Everett Koop Institute has among its programs a variety of efforts to prevent cancer and to assist people who have survived cancer—I consider myself still very much in the forefront of the campaign against cancer. And I hope that you will forgive me if I add one more credential that encourages me to speak to you today. I am now midway through my ninth decade of life, and along the way I hope I have learned to convert a lot of information into knowledge, and some of that knowledge into wisdom.
We've come a long way. Many years ago, in my first radio discussion about cancer in children, I was instructed by my interviewer not to use the word "cancer," because it would be too disturbing to the radio audience. So, we spoke for 25 minutes about "that dread disease," until just before she turned my microphone off I quickly said, "And in case you don't know what that dread disease is, it is cancer!" That radio station never invited me back.
We've come a long way. The kindergarten kids I speak to about the dangers of smoking know that one of the dangers is cancer. And we all know how much we've gained from the public discussion and advocacy for breast cancer, prostate cancer, colon cancer—cancers that no one talked about even long after lung cancer became part of the public discourse.
But we still have a long way to go. You all know that, as much as you all know me. That's why we are here today. So, I know I am "preaching to the choir." That term is usually used in a semi-derogatory way, but in this case I'm delighted to be preaching to the choir, because I know that you understand the music. Indeed, you'll probably know the tune I'm going to sing when you've heard the first few notes. But since we are here not only to sing a bold new tune, but also to do it in harmony, I think that's okay.
The war on cancer, officially declared in the 1971 National Cancer Act, can now be called the "Second Thirty Years' War," and it may, indeed, become another Hundred Years' War. That means it has become a transgenerational conflict. My generation has long since handed off the responsibility to our children; and now the job is also being taken on by our grandchildren, as I am reminded whenever I speak to my physician-granddaughter.
Since 1971, we have won many battles, but we have still not yet won the war against cancer. We've seen a reduction in the incidence of cancer and in age-adjusted cancer mortality, but we also see more than a million new cases of cancer each year. Our aging population—one of the results of the progress in American medicine, especially in the progress in treating heart disease—means more cancer, because cancer is a disease often associated with aging.
More than 500 Americans will die of cancer during the time of our meeting today, and 30 will die between now and the time I finish these brief remarks. And in spite of all that our research and treatment can offer victims of cancer the words that many Americans fear more than any other are, "You have cancer." That's why, more than ever, we need a bold new national commitment against cancer.
It is often said that political revolutions come, not when a society is down and out, but when a society's aspirations and expectations begin to rise. Let's see if we can use that same dynamic in the contest against cancer. At one time, maybe just 30 years ago, Americans were afraid, discouraged, down and out about cancer. Since 1971, we have accomplished so much that now America's hopes and expectations about victory over cancer have begun to rise. Let's use this revolutionary dynamic to revolutionize our crusade against cancer.
Now, I assume I am speaking not only to people who share my passion, but also to people who know more about cancer than I do. Many of you know more than I, some of you know more than anyone, about the various ways we now have either to diagnose or to treat cancer. And I assume that most of you are familiar with the milestone documents in our war against cancer: Healthy People 2010, The Nation's Investment in Cancer Research, and the President's Cancer Panel's Report to the President from last June. All of these make clear to us the obligation and opportunity we have to continue what was accelerated by The National Cancer Act of 30 years ago.
This is a cause to which, in one way or another, I shall devote whatever time God has still allotted me. Since I resigned as your Surgeon General, I've spent much of my time as a speaker on the national lecture circuit. I've given a lot of speeches in the last 10 years, and yet I would like this to be one of my most effective, this speech in which I call for a bold new venture, for new national commitment, for a revolutionary increase in our determination to defeat cancer.
We can do this as we extend three great new areas of our success in the past 30 years: the prevention of cancer, the early detection of cancer, and the treatment of cancer. The best news is we've learned how much we can save—not only in money but, more important, in lives—if we simply prevent cancer from taking hold in the first place.
You all know how much of my energy I have devoted to fight the power of tobacco in this country, to free Americans from the threat that tobacco use poses to their life and health. Tobacco is the number one killer in this country, and lung cancer is probably our most dangerous cancer. As I often say in my speeches focused on smoking, more than 400,000 Americans die each year from tobacco use, the proverbial equivalent of two jumbo jet crashes each day.
And, while I'm talking about preventable death in this country, I should also mention the second and third causes of preventable death, obesity and alcohol abuse. True, not all these tragic deaths are attributable to cancer, but you will find at least cancers of the breast, colon, and liver linked to obesity and alcohol abuse.
Nearly a million lives are cut short each year by preventable causes. That statistic is a national tragedy, but it is also a national opportunity. We can do something to stop that tragedy. And it costs so much less to prevent cancer than it does to cure it or treat it. The opportunity of prevention, this imperative of prevention, stems from one of the great changes in human history.
Throughout most of history, most people died from things they didn't choose: infectious disease, or war, or work-related accidents. Today, most people die from choices they make, bad choices about lifestyles that include tobacco, obesity, alcohol abuse, not wearing seatbelts, and the like. Now, more than ever, prevention is the first intervention in the campaign against cancer. And I don't have time to talk about the prevention that may come from administering a very small dose of an anti-cancer chemotherapeutic agent such as Tamoxifen.
I have high expectations of chemotherapeutic cancer prevention. Breast cancer incidence was reduced 50% in a fairly large trial with preventive Tamoxifen. And the selective estrogen receptor modulator (SERM), Raloxifene, in post-menopausal women reduced the incidence of breast cancer 70%. A multi-center study is encouraging with the cyclooxygenase (COX-2) inhibitor in colon cancer, which will be diagnosed 130,000 times this year, and kill 56,000. And new evidence shows that occult blood in an individual's stool is a more reliable predictor of cancer than was formerly thought. And, finally, virtual colonoscopy—non-invasive, computer-assisted technology—may make it possible to screen the entire population over 50.
So, there has been dramatic improvement in diagnosis, in the detection of cancer. Now, as I said before, many of you here possess a knowledge that exceeds mine on issues like this. But the main point is that we now have the ability to detect cancer at stages earlier in its development than was even imagined just 10 years ago. And, of course, this means that we can initiate treatment far sooner than before, and that means that we will be able to extend thousands of lives tens of years.
Our progress in detection and diagnosis makes it possible for us to catch early, not just a cancer here and a cancer there, in people who decide to go to a physician. But, more important, early detection means we can enact appropriately targeted population screening, so that we can pick up and then treat cancers in individuals who otherwise would not have come near a doctor until it was too late, until many treatment options were no longer viable.
Population medicine obviously pays the biggest dividends, not only in primary prevention, but also in secondary prevention, in the kind of early detection that enables early intervention. Cancer screening, at one time a distant goal, is now a reality for many of the most-feared types of cancer.
And then the third major area of our concern, following prevention and detection, is the challenge of treatment. Cancer treatment is where the stakes and the emotions seem highest. Cancer treatment is where we turn when prevention fails and detection succeeds. Cancer treatment—third in my sequence today, maybe even third in our minds—is first in our hearts, and certainly first in the eyes of the American people. A new cancer treatment, or even the hope of a new cancer treatment, trumps all the other news of the day.
The national mandate to increase our abilities to treat cancer requires us to make the necessary commitment of resources. Above all it requires a major new commitment to research. Now, some of that research must be applied, not to treatment, but to prevention. We need more research on how prevention works, especially expanding our knowledge through behavioral research. Money well spent on behavioral research now will lessen the need for treatment resources later on.
The same applies to research directed toward advances in detection, a great return for each dollar invested now. But, of course, in spite of prevention efforts, and because of detection efforts, Americans will continue to become afflicted with cancer, and they want effective treatment.
Perhaps the largest part of our bold new venture must be in the direction of research, with the attached mandate that the results of that research in cancer treatment are assured to reach all those Americans who need more treatment. As the studies with Tamoxifen suggest, we need more inhibiting agents and that means more diligent bench research and adequate clinical trials.
Research is expensive—with drugs like Tamoxifen (and we need more like Tamoxifen), extensive animal studies must precede human trials over long periods. Do you know how much it costs to feed and board a white rat in a lab? Two hundred dollars a year.
Recent studies of cancer treatment agree not only upon the great strides we have made in our ability to treat and even cure forms of cancer, but also that we have real problems in our delivery system. All too many Americans simply don't get what medicine has to offer them in the treatment of cancer, so we must make sure that whatever we accomplish in this bold new venture must be to the benefit of all those Americans who suffer from cancer.
Some of the problems of delivery are associated with inadequate medical knowledge on the part of the physicians or, more likely, attributable to the often inexplicable variations in practice patterns within American medicine. But, increasingly, the disparities in treatment are financially based, as payers, not physicians, call the shots. We can spend the next few minutes or the rest of our lives grumbling about the effect of managed care on the practice of medicine, but it would probably be more effective to actually do something about this. One way is to do the research that demonstrates to the payers the effectiveness of paying for early detection.
We know that the uninsured and the underinsured postpone diagnostic opportunities to the point that their treatment options are often the most costly. We need to demonstrate to payers, as well as to patients and physicians, the benefits of proven, even if costly, cancer treatments, and to set up the administrative machinery to insure the uniform availability of the most effective cancer treatments, regardless of where the patient lives or how the patient is insured.
So, there's no better way for the American health care system and the American people to open this new century than by this bold new venture to control and to defeat cancer—with the appropriate attention and devotion of resources to the critical areas of prevention, detection, and treatment, including research and clinical application. And while I could spend my last few minutes whipping us all into a frenzy of enthusiasm for all this (I trust that will happen even without my efforts), I think the time is better spent noting the real problems we face in each of these areas.
Realism is important, and those whose concern is cancer have learned to be realists. There are those who call upon us to eradicate cancer. That is a noble goal, perhaps our ultimate goal. But, at least right now, not too realistic. I don't see cancer going the way of smallpox. But then, probably Edward Jenner and Benjamin Rush didn't see the eradication of smallpox as a realistic possibility. For the time being, my lifetime and yours, I'll be content to increase by millions the number of lives without cancer; to increase by years and decades the lives with cancer.
First, when it comes to prevention, we need to realize that prevention comes close to being un-American. That's because prevention, the keystone of public health, is not seen as glamorous or glitzy as is treatment, and therefore has never been as successful in attracting funds or personnel, as has regular medicine. Second, prevention often brings some form of government intervention in our personal lives—either national, state, or local intervention—and that is something that most Americans strive to avoid. And, finally, prevention usually involves someone saying "No!" to us, and that is something to which most of us say "No!"
Prevention costs the least and accomplishes the most. And it is the most difficult to achieve. And that's one reason why we need attention to behavioral research, to find out how doing some things we want to do may have real health benefits.
And then there are problems with detection, some economic, some ethical. True, we now can detect the most minute of cancers in people who have no symptoms, no idea they have cancer. And when appropriate treatment follows at the appropriate time, we can save many lives. But our ability to detect earlier and smaller than ever before means that more and more Americans are going to be told, "You have cancer." Words that always change that life. And many of those people have cancers that wisdom says are too small or too quiet to treat, and yet they must live each of the rest of their days worrying about the cancer inside them.
As our detection efforts become increasingly sophisticated, we may find out more and more about cancers that pose little real physical threat, but cause great emotional stress. As they say, far more men die with prostate cancer than die of prostate cancer. Do all people with cancer that will not kill them need to know as early as possible that they have cancer? There are times when treatment should immediately follow detection. But there will be many times when it is appropriate to allow considerable time to elapse between detection and treatment (if at all), and we need to know a lot more about how to deal with those patients.
True, early detection will enable us to save many lives. But, at the same time, we need to develop the medical and counseling skills to deal with the folks who will live with cancer, as well as for those who may die from cancer. And then, in our efforts to support new treatment for cancer, both in research and its application in clinical settings, we must realize that we can end up fighting ourselves.
It has never been the American way to vote research funds for health. Instead, we devote research funds to disease. And it's our custom to do it one disease at a time. Starting with polio, and moving on to one disease after another, Americans have responded to disease-specific campaigns. Indeed, this is how the first real federal effort against cancer got going. Sparked by philanthropist Mary Lasker, the so-called "noble conspiracy" led by "Mary and Her Little Lambs" encouraged medical researchers to ask congress for more money than they ever imagined. And the funding came in, delegated to one disease at a time, targeted to one NIH Institute at a time. And the 1971 war on cancer was very much in the tradition of the disease-specific approach.
The problem we face now is that most Americans, and certainly the health care community and our political representatives, know that cancer is not one disease, but more than 100 different diseases. So what has happened, following the American tradition, is the advocates for spending for one cancer find themselves in competition with the advocates for finding a cure for another cancer—with each side competing with its celebrity patients trying to wring money out of Congress.
What we need in the cancer community is to end this competition, and replace it with collaboration, with effective coalitions. Rather than one cancer team competing with another cancer team for a slice of the national pie, we should form alliances to use each other to leverage more support for all, especially in an expanding economy. Rather than, say, prostate cancer going after breast cancer's money, we can leverage support for one to get the same for others. If breast cancer gets that much money, shouldn't prostate get the same? And so forth. Leveraging is a good old American tradition, and we might as well use it for the health of the American people.
Finally, I want to put a positive spin on all this. You might say that is difficult, to put a positive spin on cancer. But achieving our goals may depend upon how well we do that. "Cancer kills!" We all know that. All Americans know that. But they don't want to hear that, so they tune out messages based on that grim reality, no matter how true those messages might be.
When I was working with a number of public health professionals in our efforts to see what kind of messages might keep kids from smoking, we found you can accomplish far more with a positive message than with a negative one. Our bold new venture against cancer needs to have a positive tone.
You may have noticed that as I spoke to you today, I began my remarks by using military metaphors consistent with the "War on Cancer" theme from the 1971 National Cancer Act, but that as I went on, I tended to drop those military metaphors. I never really liked the idea of the "War on Cancer." True, the phrase came in the midst of another war, an increasingly unpopular war, and I've always thought that, not for the first nor for the last time, health issues were used for political purposes, as the declaration of a popular war on cancer might have been seen as a way to offset the unpopularity of the war in Southeast Asia.
No matter, I don't think a "War on Cancer" best expresses what we are all about. These days, military metaphors don't resonate the way they did with my generation, the World War II generation. And they mean little to voters, to taxpayers of early 21st century America. So for our bold new venture let's look forward. Not to one slogging, military campaign after another, but let's look with hope, with optimism to our ultimate goal. What we seek is quite simply: "Life without cancer." And if that's not always possible, then let's talk about "Living with cancer."
Living, life itself, that's why we are here today. Our concern may be cancer. But may our legacy be life.
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FOOTNOTES
This speech was delivered by Dr. C. Everett Koop at the National Dialogue on Cancer, December 2, 2000.
Received April 25, 2001; accepted for publication April 25, 2001.
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  R. A. Ingram Counting the True Cost and Value of Medicines Oncologist, February 1, 2003; 8(1): 2 - 4. [Full Text] [PDF]
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M. J. Murphy Jr. CEOs Consider Ways to Intensify the Battle Against Cancer Oncologist, June 1, 2001; 6(3): 228 - 229. [Full Text] [PDF]
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