“The Emperor of All Maladies” was a history of oncology, and a good one. “The Death of Cancer” is a memoir of one of the greats of medical oncology. It is a history from someone who was there, making history.
In scientific terms, Siddhartha Mukherjee’s book has the limitations of a retrospective study; Vince DeVita’s book is more like a prospective clinical trial.
I trained at the NCI in the 1980’s. I openly admit that Otis Brawley the medical oncology fellow was intimidated by the mere mention of “Dr. DeVita.”
I have since realized that he is a nice, supportive, even approachable man with an intensity of purpose. The intensity was and is fueled by the serious fact that people die from cancer, and it is our calling as research physicians to stop the dying.
Indeed, our common values of respect for truth, orthodoxy to scientific principles and support of research, all derive from having watched people die from this disease.
The first half of the book tells a number of touching and surprising personal stories of a young DeVita. Many involve the founding fathers of medical oncology, including Gordon Zubrod, Tom Frei, Jay Freireich, George Canellos, and Paul Carbone.
These are men oncologists of my generation have been taught to look up to. Eventually, I would come to meet all of them and become friends with some. Even now, having met them makes me feel like the Forrest Gump of medical oncology.
I was very ready and prepared to hear about the eccentricity of Tom Frei and the outrageous behavior of Freireich. They pushed the envelope, and exhibited a total devotion and disciplined approach to the care of patients and development of treatments.
I could easily see Jay Freireich enjoying himself at a party one evening and being on the wards the next morning knowing about abnormal lab results before the fellow who ordered it. I am, however, startled at the thought of Tom Frei walking on his hands to entertain guests at an NCI party.
The above were stories of DeVita as a fellow. It is equally fascinating to hear of DeVita’s trials and tribulations on senior staff at NCI and later as NCI director. This includes: his survival of the Reagan Administration inquisition of Democrats in government and his clashes with Sen. Ted Kennedy.
As director in the 1980s, he tried to reduce waste in the NCI funding programs. He battled the bad doctor habit of rejecting paradigm shifting research findings, such as those of Bernard Fisher’s breast cancer studies—and he recounts the struggles to get Fisher’s results published.
This book contains important lessons about moderating and creating reasonable expectations as we try to increase support for cancer research. Many members of Congress unrealistically expected the National Cancer Act of 1971 to result in a cure for cancer by the 1976 bicentennial.
DeVita became director a decade after passage of the act, and he had to deal with the fact that many were miffed that cancer had not been cured for much of his directorship.
DeVita has much to say about the NCI-designated cancer centers, cancer research and treatment today. He offers ideas on how to jump-start the National Cancer Program. He calls for a new National Cancer Act—and the naming of a federal cancer czar.
And he is critical of the FDA’s regulation of cancer drugs throughout the last five decades. At one point, he says, “the air pumped into the FDA building must have some kind of regulatory gas in it.”
This is where I have some disagreement with a man I have tremendous respect for. There is a greater need for a strong FDA with rigorous evaluation of drugs. I believe FDA, over at least the past twenty years, has been far better than it was in the 1970s, when a heavy-handed agency delayed approval of cisplatin for testes cancer treatment for more than three years.
I concur that there has been overreliance on phase III clinical trials. These studies provide for drugs that give us clinically mediocre two-month or three-month increases in median survival.
Drugs that really move the needle show usefulness without such large trials. This is going to be even more important as oncology moves toward precision medicine.
Think of imatinib for CML or crizotinib for ALK-positive lung cancer. The future is precision medicine, studies like the Lung-MAP and bucket trials. The move toward precision medicine is a dividend of the National Cancer Act of 1971.
One final note about an extraordinary book and an extraordinary story:
I appreciate the admission that big jobs such as NCI director can cause mild depression. From time to time, DeVita’s therapy was to “put time aside to make regular rounds on the cancer floors.” This reminded him why he was doing what he was doing.
This again points to seriousness of our jobs as oncologists.
A large proportion of the people we care for die of this disease. This was a theme throughout the book, reinforcing the need for intensity, the commitment to basic principles, and to orthodox science.
DeVita-the-writer is as optimistic as DeVita-the-doctor. He reminds us that we cannot do what we do if we are not optimistic about the death of cancer.
Brawley is the chief medical officer of the American Cancer Society.