Open Heart (18 page)

The reasons for increases and decreases are variable, controversial, and complex; still, what the data reveal is that progress, as we usually understand it—despite the multitude of new medications, therapies, screenings, and technologies—has been, at best, irregular. Surely, the original objective of the National Cancer Institute—that we reduce age-adjusted mortality from cancer 50 percent by the year 2000—has come nowhere near to being achieved. And again, as with infectious diseases, it turns out in many cases that the major salutary changes from which we do benefit occurred
before
the introduction of new cancer therapies—and that they came about not because of specifically medical measures, but because of preventive measures.

In a study published in 1986 by the Department of Health Studies at the University of Chicago, researchers conclude that “some 35 years of intense effort focused largely on improving [cancer] treatment must be judged a qualified failure.”
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Choosing as the “single best
measure of progress against cancer,” the mortality rate for all forms of cancer combined, age-adjusted to the U.S. 1980 standard (a measure also adopted by the National Cancer Institute), they find that “age-adjusted mortality rates have shown a slow and steady increase over several decades, and [that] there is no evidence of a recent downward trend.” In 1997, the University of Chicago researchers reviewed their 1986 findings. They write that “with 12 more years of data and experience, we see little reason to change [our earlier] conclusion.”

“Despite numerous past claims that success was just around the corner,” they write (Dr. Vincent De Vita, of the National Cancer Institute, predicted in 1981 that “fifty percent of all cancers will be curable within ten years”), “hopes for a substantial reduction in mortality by the year 2000 were clearly misplaced.”

Moreover, they are skeptical about “new therapeutic approaches rooted in molecular medicine” because “the arguments are similar in tone and rhetoric to those of decades past about chemotherapy, tumor virology, immunology, and other approaches.” They continue: “In our view, prudence requires a skeptical view of the tacit assumption that marvelous new treatments for cancer are just waiting to be discovered.” While they “earnestly hope that such discoveries can and will be made,” they suggest a modest reordering of priorities: “The effect of primary prevention (e.g., reductions in the prevalence of smoking) and secondary prevention (e.g., the Papanicolaou smear) on mortality due to cancer indicates a pressing need for reevaluation of the dominant research strategies of the past 40 years, particularly the emphasis on improving treatments, and a redirection of effort toward prevention.”

But won't our new understanding of the human genome, along with ongoing developments in genetic engineering, gene therapy, DNA cloning, et cetera, lead to discoveries that will enable us to treat cancers with increasing success?

“What the human genome project gives us seems to me to be beyond the clinical realm at the present time,” Phil says. “Now someday I think we may all go around with medical cards that have our genetic IDs on them because the genome project will help us to devise
treatments specific to your specific genetic make-up. So that, for example, we wouldn't give Lipitor to everyone with high cholesterol, but only to those whose genetic ID shows a particular disposition to atherosclerosis for which Lipitor will probably be helpful. There may be some rare genetic diseases where what we learn from the genome project can be helpful sooner, but for a long time to come it's not going to have anything to do with the everyday practice of medicine.”

“The genome project has been a remarkable achievement, even though the hype about its potential value in the diagnosis and treatment of disease has been overblown and simplistic,” Rich says. “Currently, we know little about the factors that determine how genes cause disease, and we need to know a lot more about issues like gene penetrance, what turns genes on and off, and the importance of gene interactions.

“In my view, the most common diseases, such as coronary disease and cancer, result from a complex interaction of genes, the environment, and what's been called ‘the mind-body interaction,' but to date, what's been done is simply to catalogue the genes, much like naming cities on a map without knowing much about them. Still, I'm optimistic that over the next five to ten years, we will increasingly understand how genes function and interact, and what the causative genes and combinations of genes are for significant diseases.

“Eventually I think the genome project will prove useful to our understanding and treatment of disease, though it will not be the panacea its enthusiasts have made it out to be. Many of our most worthwhile discoveries in medicine have come about not when we were looking for a specific cure for a specific illness, but serendipitously—look at penicillin, at peptic ulcers, at the uses we've found for cortisone and aspirin. When you have enough good people working on something, as we do in genetic research, then the probability of serendipity—of discovery—increases. That's just basic statistics and probability. But to date, the unbridled zeal for the genome project seems excessive.”

“What bothers me about the attention given to the human genome project,” Jerry adds, “is that while we extol its virtues and invest
large sums of money in research that will not, for a long while, be useful to any but a small number of human beings, tens of millions of human beings are languishing and dying for want of basic care and of known treatments that can, as with AIDS, relieve suffering and save lives now.”

Dr. Richard Horton, editor of
Lancet
, reiterates Jerry's view when he writes that “the major issue in medicine is not one of maintaining the past pace of discovery, but of making sure there is equitable access, throughout the world, to the discoveries we have already made.”
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And the distorted priorities that often determine how we appropriate human and economic resources would seem to derive, at least in part, from a glorification and, at times, deification of biotechnology. Thus we have President Clinton declaring that by deciphering most of the human genome “we are learning the language in which God created life”; or Frances S. Collins, director of the National Human Genome Research Institute, saying that “we have caught the first glimpses of our instruction book, previously known only to God”; or
Time
magazine proclaiming that “armed with the genetic code, scientists can now start teasing out the secrets of human health and disease…that will lead at the very least to a revolution in diagnosing and treating everything from Alzheimer's to heart disease to cancer, and more.”

The problem with such extravagant claims, as Horton points out, is that “research tends to support [the] view that genes are mostly a minor determinant of human disease” and that “it is very unlikely that a simple and directly causal link between genes and most common diseases will ever be found.”
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As to the usefulness of the genome project with respect to cancer, he notes that progress “will be painfully slow,” and, like my friends, though a quarter century younger, Horton doubts that “we will get far along this path during [his] lifetime.”

In
One Renegade Cell: How Cancer Begins
(1999), Robert Weinberg, a biologist who pioneered studies in gene therapy for cancer, estimates that by the second decade of the twenty-first century scientists are going to know the elements of cellular wiring in such detail that they will have a catalogue of tumor-suppressive genes that
will enable them to predict an individual's susceptibility to a wide spectrum of cancers. Weinberg believes, further, that “the prospects for the development of totally novel anticancer therapeutics are bright.”
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Nonetheless, he too concludes that “the big decreases in cancer deaths will… come from preventing disease rather than discovering new cures,” by which he means dealing not with the biology of cancer itself, but with its “ultimate causes”—those that “really begin far outside the individual cell, in our environment, in the food we ingest, and the smoke we inhale.”

Other scientists and scholars, however, are not as certain that, when it comes to cancer, prevention will have such large and propitious effects. Gerald Grob, for example, writes that “the effort to link cancer to diet, carcinogens, and behavior—which have been central to the campaign to prevent and control the disease—have been rooted largely in belief and hope rather than fact.
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“Smoking,” he adds, “is the one notable exception.” (Weinberg contends that virtually the entire increase in cancer from 1930 to 1990 was due to the use of tobacco, and that had lung cancer been omitted, the overall adjusted cancer death rate between 1950 and 1990 would have fallen by 14 percent.) Moreover, most other proven carcinogens, such as asbestos and high-level radiation, Grob points out, affect few people.

In addition, prevention places a high premium on individual responsibility for one's own health and well-being. Most of us, for example, are aware of the ways in which friends and relatives who contract, say, lethal forms of breast or prostate cancer often blame themselves for their fate—for not having been vigilant enough; for not having had regular and timely screenings; for not having paid attention to this symptom or that health advisory; or for not having stuck to diet A instead of having indulged in diet B, and so on—all of which, by lodging cause and culpability in one's individual negligence, ignorance, and/or irresponsibility, becomes a particularly deadly way of blaming oneself for one's own execution.

Nor is this way of experiencing and understanding one's health—especially one's ill health—new. In the Psalms and, particularly, in the Book of Job, for example, we are told again and again that the presence of a physical affliction or ailment is the outward sign—the
visible punishment—for (unseen) irresponsibility and wrongdoing. (See Psalm 1—“Blessed is the man that walketh not in the counsel of the ungodly, nor standeth in the way of sinners, nor sitteth in the seat of the scornful… For the Lord knoweth the way of the righteous; but the way of the ungodly shall perish.”) Consider Job's friends, who, though they consider Job a pious and righteous man and know of nothing he has
done
that in any way is immoral or evil, nevertheless assume, given his afflictions, that he
must
have done something terrible to be suffering such a dreadful fate. (Thus Bildad the Shuhite: “If thou wert pure and upright; surely now He would awake for thee, and make the habitation of thy righteousness prosperous.” And Elihu: “Therefore He knoweth their works, and He overturneth them in the night, so that they are destroyed. He striketh them as wicked men in the open sight of others.” And Eliphaz: “Is there any secret thing with thee?”)

In 1996, the Harvard Center for Cancer Prevention published a report that attempted to summarize current knowledge regarding cancer risk. Its conclusion: cancer is “a preventable illness.”
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The center estimated the “percentage of total cancer deaths” attributable to what it determined were the established causes of cancer (for example, tobacco, 30 percent; diet/obesity, 30 percent; sedentary lifestyles, 5 percent) and calculated that “family history of cancer” was responsible for 5 percent of total cancer—thereby implying that virtually all cancer risk, with the possible exception of this 5 percent, was a result of potentially modifiable environmental risk factors.

The alternative to this view, Grob suggests—“that the etiology of cancer [is] endogenous and not necessarily amenable to individual volition—[is] hardly attractive.”
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Still, “it is entirely plausible,” he writes, “that cancer is closely related to aging and genetic mutations, which together impair the ability of the immune system to identify and attack malignant cells and thus permit them to multiply. If there is at present no way to arrest the aging process, then cancer mortality may be inevitable. Moreover, some of the genetic mutations that eventually lead to cancer may occur randomly, and thus cannot be prevented.”

“There is also,” he concludes, “little evidence that cancer mortality
is appreciably reduced either by screening to detect the disease in its early stages or [by] a variety of medical therapies.”

But how can this be, I wonder, even as I review the data that seem to prove it is so. Is it possible that all these cholesterol screenings, CAT-scans, mammograms, and PSA tests, along with the much-publicized surgical and chemical therapies commonly used to treat problems revealed by the screenings and tests, are, at best, of secondary value (and may sometimes do more harm than good)? Have we really, in these matters, achieved only minor progress?

I review my own experience, where neither blood tests, cholesterol screenings, an EKG, an echocardiogram, nor a complete physical were helpful in revealing the seriousness of my condition. Nor, for that matter, had other much-lauded habits and activities—a lifetime of being a nonsmoker, along with years of vigorous daily exercise, the maintenance of a low-fat diet, and the taking of cholesterol-lowering medications and an aspirin a day—prevented my arteries from becoming clogged.

The more I read, and the more I talk with my friends, the more I come away thinking, again: How little we know about things medical and biological—about why what's beneficial to one person proves useless for another; about how and why and when, that is, some of us live and some of us die.

At the same time, skepticism leavened by my sheer joy at being alive, it becomes clear that, unlike the situation with respect to many cancers, when it comes to heart disease, no matter the vast realms of our ignorance, we
have
, in recent years, made truly significant life-saving and life-enhancing gains. “One advantage we have in cardiology,” Rich says, “is that the heart lends itself to plumbing and mechanics—to gross approaches. I mean, just look at you and Dick Cheney—at David Letterman.” He laughs. “Better living through plumbing, right?” Right indeed, I think—because hundreds of thousands of men and women, like me, are alive and doing well because of the gains we've made—a half-million benefiting from bypass surgery alone each year. And even when one reads outcome studies indicating that some of us may not live longer with this surgery than without it, it seems indisputable that the
quality
of our
lives, whatever the number of years each of us may have left, will, in most instances, be better than it otherwise would have been.