By Richard Halicks
The Atlanta Journal-Constitution
Published on: 09/30/07
Americans launched the war on cancer in 1971 with high optimism and fierce determination: We would find this disease and kill it —- a search and destroy mission that would deploy tens of thousands of medical professionals and expend tens of billions of dollars.
We've been fighting the wrong war, says a new book, "The Secret History of the War on Cancer." Author Devra Davis, an epidemiologist, says the nation's effort has largely ignored the central causes of cancer and focused instead on detection and treatment. As a consequence, Davis said, we are simply "becoming more efficient at processing more sick people."
Davis, director of the Center for Environmental Oncology at the University of Pittsburgh Cancer Institute, lost her parents and a close friend to cancer. In "The Secret History," she interweaves the stories of her personal and professional lives; the resulting book is part memoir and part expose, with powerful measures of grief and outrage. The outrage has mostly to do with interference in cancer research —- outright lies by corporations, cover-ups by government, eminent researchers secretly taking cash from cancer-causing industries.
The book, which follows Davis's highly regarded debut "When Smoke Ran Like Water," goes on sale this week. In telephone interviews with The Journal-Constitution last week, Davis reviewed her findings. Here is an edited transcript of those conversations:
Q&A / DEVRA DAVIS, epidemiologist
Q. Your thesis is that we have trained the weapons in the war on cancer on the wrong targets. Can you offer a summary of where we've gone wrong?
A. The basic analogy is very simple. We're fighting the disease, but not the things that cause it. To use the term from the presidential election: It's not the disease, stupid, it's the causes. We know that tobacco causes cancer. And yet the war on cancer had nothing to do with tobacco, nothing to do with asbestos, nothing to do with benzene, nothing to do with hormones, or diagnostic radiation, or solar radiation, all of which were known at the time to cause cancer. So in a sense it became focused on finding and treating the disease, and not on figuring out how to keep you from getting sick. I think we now understand that we have to figure out how to keep people from getting cancer and to keep the disease from coming back once you've had it. And that means paying more attention to the things that cause it.
Q. Another striking point in your book is that we have actually known a great deal about environmental causes of cancer for a very long time.
A. We have. I cannot convey how astonished I was to find the 1936 account of what scientists knew about the causes of cancer, how they understood then that hormones caused cancer, how they understood that diagnostic radiation and solar radiation and benzene and tars and soots all increase the risk of cancer. I was shocked when I found it because I hadn't realized how sophisticated the science had been at that time.
What happened is, the world goes to war. We've never really gotten off that footing when it comes to thinking about this disease. If you are at war, and you think you're going to be killed the next day, you don't think about the long term. As Keynes famously put it, "In the long run, we are all dead." Cancer's a long-term disease. It takes a while for it to develop, and if you're focused on your survival, then people don't think about the long term.
Q. This warlike footing, this war on cancer —- wouldn't it have been just as simple to declare war on the causes?
A. No, of course not, because the causes are highly profitable. Why did it take us so long to deal with tobacco? And why today —- we have to ask this question that no one seems to be asking —- why on earth does the United States not have a national ban on smoking? Ireland does. Italy does. Uruguay does. Bulgaria does. Why can't we do that nationwide?
Q. As you tell it in the book, the history of the Pap smear is disgraceful. Would you relate that story?
A. In 1928, a Greek-American researcher named [George] Papanicolaou showed that you could take a few cells from the opening of the cervix, swab them, and from the look of those cells, you could tell whether cancer had already occurred or was about to occur. And if you caught them early enough, you could actually prevent the cancer from occurring. But the Papanicolaou test was not put to use, because of a conflict that emerged between all of the surgeons and pathologists and physicians who thought that only doctors should be able to carry out the practice of medicine. The idea that someone who wasn't a physician could actually take a smear and read it under a microscope would be a threat to the practice of medicine.
Q. So this was a case of interference within medicine itself?
A. Within medicine itself. There was a real resistance to public health, to the very notion that someone other than a doctor could do routine screening and testing. ... Within the American Cancer Society itself, there was this big debate. In 1943 Papanicaolaou and [H.E.] Trout showed that medical technologists could actually read a Pap smear. That was a big breakthrough. ... Meanwhile, the British physicians took the position that you just couldn't do Pap smears. They didn't think that nonphysicians would be capable of doing them. "Nonphysicians," by the way, was code for "women." In fact, in 1968 a British report said there was no proof that Pap smears really worked. All the countries that implemented the Pap smear saw a drop in deaths from cervix cancer. And guess where England and Scotland are? They see an increase, because they didn't implement Pap smear screening until the late 1980s.
[A table in the book compares incidence of cervical cancer in the 1960s vs. the 1980s, by country. Finland's incidence fell from 14.8 cases per 100,000 to 3.4; Denmark's from 31.3 to 15.2; Canada's from 27.1 to 11.1; and Scotland, where the test was not widely administered, the rate rose from 12.4 to 13.2.]
Q. There's an age at which mammography becomes a really important diagnostic tool. And before that age, if I read you right, it's more dangerous than it useful.
A. Yes. Mammography works to save life in women age 50 and older who are close to menopause. I do not recommend mammography screening in women under age 40. And unfortunately that screening is being done more and more on younger women. In younger women, I think it carries two risks: One is the risk of unnecessary surgery and the terror that goes with it. And the other is the risk of radiation itself. We know that young women who were girls at the time of the Hiroshima bombing, who were exposed to radiation when they were preteenagers, have a much higher risk of breast cancer when they get to be in their 40s and 50s. That's because radiation to the young breast is a risk.
Q. Diagnostic radiation in general is a key issue, isn't it?
A. As I was finishing the book, the American College of Radiology issued a white paper. It's an astonishing document. They warn that today in the United States, we receive as much radiation from diagnostic procedures every year as was released through the Chernobyl accident, which spewed hundreds of Hiroshimas into the environment. And the American College of Radiology is calling for a summit meeting with emergency room physicians to come up with ways to reduce unnecessary diagnostic radiation.
Q. You note several times in the book that cancer research, at least until recently, has often ignored black Americans. Was that just racism under yet another guise, or is there some other reason for it?
A. As you know, writing from where you are, that is a very complex issue. As someone who is Jewish, whenever people talk about genes and cancer, my hackles tend to go up. I don't have a simple answer. Sometimes the failure to look at a question is as important as what we do look at. The failure to ask the question about race and cancer may well reflect the legacy of racism that we know very well.
With few exceptions, one of them being sickle cell, there are very, very few traits that differ between whites in America and blacks in America. Having said that, there are distinct genetic differences between blacks in Jamaica and blacks in certain areas of Africa. But anyone who knows anything about Africa knows that there isn't one black African gene. There are hundreds of genetic groups within Africa itself. Racially, blacks and whites in America are more similar genetically than blacks in America and blacks in Africa are.
What I think is important is that African-Americans are one in eight of the population, but one in two of sanitation workers; one in three of bus drivers or people who work in dirty factory jobs. So trying to understand why more blacks die of certain types of cancer, why they get breast cancer more often, for example, is not something that can be easily separated from the culture in which these problems exist.
I'm not giving you a direct answer, because I think it would be a disservice to say, yes, this is just the legacy of racism. But that's part of it. And part of it is that we know that on average blacks live in dirtier places and work in dirtier jobs.
Q. It seems to me, in reading through the book, that a great many of the more prominent cancer researchers in the middle part of the century were also secretly on the payroll of companies that made cancer-causing substances, yes?
A. Yes. Epidemiologists had to make a Faustian bargain with industry. If the epidemiologists had not cooperated with industry, they wouldn't have gotten the data. So in the very beginning, to get data on asbestos, for example, they had to cooperate. But ironically, that cooperation often led to cooptation. In the case of Richard Doll, one of the world's leading epidemiologists, a man highly respected and revered by me and others, I was appalled to learn that he worked very closely with the asbestos industry behind the scenes. And yet, if he hadn't worked with them, they wouldn't have given him the data that he was able to publish in the first place about the risks of asbestos. But he apparently worked much more closely with them than any of us ever imagined at the time, and did that as well on vinyl chloride and a host of other things.
On a personal note, I was a young scientist when I first began to publish my findings that there was an increase in cancer that could not be explained by smoking or aging alone. And I was really honored when I was with the World Health Organization, to find myself spending much of an evening with Sir Richard Doll. He made the time to talk to me, he explained, because he wanted to convince me that I was wrong. I, of course, was terribly flattered by this attention from the man who was a hero for so many of us.
Doll told me that I was wrong, that in fact these cancers that seemed to have increased were simply being reported better, that all over the world doctors were suddenly doing a better job of finding cancer and reporting it. He said that if I looked carefully, I would find that senility had declined as a cause of death, and specific cancers had increased.
I'd spent my life trying to get this work right. It was terribly important. My father had died a few months earlier of this disease. I only learned this year that Richard Doll was receiving $1,500 a day from Monsanto at the time he met with me. It makes me wonder now —- to this day, I don't know what Doll really thought.
I don't know whether he was taking money from industry because he really believed [in what industry was doing], or whether he was doing what a lot of others have done in my field, which is to dance with the ones that brung them, so to speak. And I'll never know, because he's gone now [Doll died in 2005 at 92]. But it was a tradition for epidemiologists all along to work very closely with industry in order to get the data. It's kind of like, when you play with fire, you don't know when you're going to get burned.
EXCERPT: From "The Secret History of the War on Cancer," by Devra Davis.
I know what cancer looks like, feels like and smells like. Like many of my generation, I am a cancer orphan. The disease cut short the lives of both my parents. I know what it means to live with unanswered questions. I understand the terror of waiting. ...
There is no one who deals with the disease now who doubts we need to open a new front. To reduce the burden of cancer, we must prevent it from arising, and we have to find ways to keep cancer survivors from relapsing. I believe that if we had acted on what has long been known about the industrial and environmental causes of cancer when this war first began, at least a million and a half lives could have been spared, a huge casualty rate that those who have managed the war on cancer must answer for.
Diana Ruth Olegre
Washington State Department of Ecology
Hazardous Waste and Toxics Reduction Program
Community Outreach and Environmental Education Specialist
dole461@ecy.wa.gov
360-407-6609
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