This Is Not Your Grandmother’s Cancer

When I reflect back on nearly thirty years of clinical experience in medical oncology, the most striking feature is how different our approach to cancer care is today compared to what I encountered when I entered into specialty training. We used to say that medical knowledge doubles every five years. After thirty years, then, which represents six doublings, we should expect there to be about 64 times as much to know in medicine compared to when we started. Not merely 64 additional pieces of knowledge; if I had to know a thousand things in 1992 in order to take good care of my cancer patients, I should now need to know 64,000 things to maintain good clinical competency. That’s sobering, particularly when I consider that the five-year doubling estimate probably underestimates the current rate of change. Furthermore, some of what we thought we knew in 1992 proved wrong later. Medicine keeps a guy humble. You learn to hold your “facts” loosely.

As a first-year clinical trainee in oncology, I had few tools at my disposal to take care of my patients with advanced lung cancer, then as it still is now the leading cause of cancer-related deaths. If someone managed to receive a lung cancer diagnosis at an early stage, when she could undergo an operation intended to remove all the cancer cells all at once, she was one of the fortunate few. Lung cancer so often is silent early on and eludes detection. We had no effective ways to screen asymptomatic people at high risk of developing lung cancer—regular chest x-rays proved completely inadequate and CT scans had not yet matured enough to take their place. Most lung cancer patients sought medical attention when they had symptoms, but by then the disease typically had passed the point of possible surgical correction. We can tell the same story about stomach cancer and pancreatic cancer.

We fished around in our medical bags to see what other tools we could use to help this person. Chemotherapy was practically useless, particularly for the common type of lung cancer called non-small cell cancer. Matters were brighter in some respects for people with the less-common small cell lung cancer, because there we had useful chemotherapy drugs, treatment that could secure a strong remission, at least for a while. This type of lung cancer inevitably recurs. Until very recently, I told my patients with small cell lung cancer that their chance of achieving a complete remission was high, probably as high as 80 percent. Getting to remission was easy; staying in remission, that was a different prospect. Curing Grandma’s lung cancer in the 1990s was a hard task.

It is no longer quite so hard to do.

What changed? We found better tools and smartened up about how to use some of the tools we already had. New, more effective drugs arrived. We learned how to use these drugs in combination with radiation therapy. We discovered that sometimes radiation by itself can replace surgery and spare some patients the risks of a major operation. We learned about uncommon genetic mutations some lung cancer cells possess that make them susceptible to a “designer drug” that targets and negates the effect of the adverse mutation. Immunotherapy—treatments that recruit the immune system to identify, control, and destroy cancer cells—finally became both practical and effective after decades of wrong turns and dead ends. My discussions with people who come to the office with a new diagnosis of lung cancer, once grim and depressing, now contain much hope and even optimism. More people are living longer and better with lung cancer. Many people with other types of cancer can now say the same.

I wonder what my 1992 self would think about all this. Once he got past the daunting avalanche of new knowledge to be gained, and the shock of having aged 30 years, he would no doubt be pleased to have so much more to offer his patients. After all, that’s why he got into this field. And that’s why he hangs around all these years later. Still humble, but happier.