Transcripts For CSPAN2 Book Discussion On The Death Of Cancer 20160306

Watching the nonfiction authors on book tv is the best television for series for your readers. The. On cspan they can have a longer conversation and delve into their subjects. Book tv weekends. They bringyou author after author after author. Its the work of fascinating people. I love book tvand im a cspan 2 fan. Good evening everybody. Im kelly gruden, on the Program Director at the westportlibrary and im pleased to welcome you to this Evenings Program just a few housekeeping items before we get started. If you could please take a moment to silence your cell phone , we noticed a few cameras in the room and we are pleased to have cspan 2 here to film this Evenings Program. This is an onstage conversation and there will be an opportunity for audience questions at the end and im going to ask you please wait for the microphone and speak into it clearly so the question can be heard after the discussion the authors will be pleased to sign copies of their book. The books are available here and the authors will sign the book here to my right here, if you could please form a line at the table in front of the stage that would be great. And for those with a book in hand already you can jump right into line thank you so much for supporting the library and its programs whether its through your yearly gift or by purchasing a book at tonights program those things all help the library to bring these wonderful programs to you. Tonight, we have pioneering oncologist doctor vincent devita, jr. Whos going to share a personal history of one of the greatest science stories of our time, the fight against cancer. The book the death of cancer after 50 years on the frontline of medicine, pioneering oncologist reveals why the war on cancer is winnable and how we can get there. Its cowritten by journalist elizabeth devitaraeburn and yes, they are related. We are privileged to have the opportunity to have them both here to discuss the book which has received wide praise for its insight, craftsmanship, hope and humanity. Tonight, elizabeth will interview her father about his work and explore his personal stories to go doctor davida arrived at the Cancer Institute in 1963, eventually becoming a director and moving on to top level positions at memorial Sloan Kettering answer center and Yale University where he is currently the amy and Joseph Barela fellow of medicine and professor of methodology. Elizabeth devitaraeburn received a masters degree in Public Health from Columbia University and she writes about science, health and society. Her stories haveappeared in the washington post, self , health, psychology today and Harpers Bazaar among others. Please welcome doctor devita and elizabeth devitaraeburn. [applause] host thank you all for coming. Im a bit of a low talker can you hear me . Ive been asked to interview my father for you which is something ive done a lot of over the course of putting this book together though most of our conversations actually took place over a scotch when we were together but we will do our best in this format put together and try to evoke some of the good stories that came out of that process and before we begin i like to introduce my mother, mary kay hitting in the front row over here who lived through many of these conversations in this book. [applause] and now will begin. So this book is about the war on cancer and your journey through it but most people dont really know that much about how it came to be. Why dont you tell us a little bit about the back story . Guest the war on cancer began in 1971 through the National Cancer act on december 23, 1971, its a Christmas Gift to the nation. It was a grandchild of mary lasker, a very wealthy philanthropist in greenwich nearby, among other places and it was a very Controversial Program for a lot of reasons. One of which is it proposed that the nci, the national Cancer Institute taken out of the National Institutes of health and be given to a separate agency reporting to the president. The proposed the fda control of drugs for shipment to the national Cancer Institute and it was controversial for one other big reason, i asked mary lanser to give a true concert in which she had big influence in the conference, promised to eradicate cancer by the bicentennial. Now no one believed that was true. I dont believe mary believed that was true. Host no scientist believe it was true. Guest the press believed it for about 30 days and afterward we went down after that so it was a very accomplished program. They put 100 billion of tax dollars into Cancer Research and so this book is really about my trek through the war on cancer. Host mary had something in mind for this for a while that she was biding her time. What was she waiting for . Guest she always had an interest in cancer. Mary, we had one version of the book called mary and her machine. She had somebody here in congress. She had and lenders who was part of her operation and when the cancer act was passed she wrote ann landers an open letter to congress saying put this to the american people, tell them your congressman for the bill. Congress was delivered. So she had this big machine that she set in motion and very successful endeavor. We tell the story in the book, theres an ironic twist to it. It was 1969 and i was sitting in my office and the phone rang and it was when i recall from those days from boston Regional Health and she said i have a patient who has gallbladder cancer. He had just been operated on the great claude welch who was the most famous abdominal surgeon in the country and he lived in washington and worked with congress and he wanted to be treated and i was working on lymphoma and we were taking on cases and we also look forward at that time. Host on drug, right . Guest there was one drug, four or five years old so i said thank you very much but i cant take in. 10 minutes later the phone rang and i was sitting and he said to me, he told me about the patient and he said doctor farber, you will take this patient. And i was cocky but i wasnt stupid. So i said yes after farber, ill take the patient so we took the patient and when i examined him, im looking for lymph nodes and so on i felt both armpits and that diseases many things but it doesnt go to lymph nodes in your arms so it turned out he had lymphoma and he taught had a type of lymphoma we were working on, we now had a second drug treatment that we developed for lymphoma and was working well and we treated it and they went into remission and mary lasker, she thought we had provided the missing link to most people dont die from the cancer when it starts, they die from secondary deposits elsewhere. Women in Breast Cancer dont die from the cancer in the breast, they die from metastasis. Once we proved you could treat effectively adults with cancer and mary said we havent seen it. Host we should see how lou quinn is connected to marriage. Guest luke quinn was working for the american cancer society. Mary lasker had paid his salary and he was her eyes and the ears on the hill. He had been a colonel in the air force and was the Armed Forces Liaison with congress so we have a lot of contacts in congress but he basically was a part of her machine. He was her eyes and ears on the hill and would identify congressman who would support whatever effort she was putting out. Those that were neutral and mary would deal with each one of them in a different way so they were important men. Once he was in remission began to put witnesses together and testify before congress and he wrote the National Cancer act and so i followed it as it went through the congress. He never asked me for testimony and he never asked people i suggested to testify. He said he needed somebody was more of a believer to appear before congress and it was a very interestingcharacter. Host i dont think any escutcheon about mary is complete unless you describe what a contradiction she was and the way in which she appeared versus how she acted. Guest there was nobody like mary lasker before and nobody like mary lasker sense. When i first met her she was coming to the National Cancer Advisory Council and she would come and with a mink coat on and drape it over the chair. She had this big bouffant in her hairdo and every 10 minutes sitting at a Board Meeting she would take out her compact and put her makeup on and you would get the impression that maybe she was just frivolous observer but nothing could be further from the truth. She was a very sharp woman and knew what was going on and then i met her when i became the director of the treatment division, one of the first coat phone calls i got was mary lasker. She wanted to become a student and i remember posting to my staff, dont worry. I can take care of mary lasker. She took into my office and 15 minutes later she had me eating out of her hand. She was a logical woman and a smart woman and you couldnt really argue with someone of her logic. So i became a believer and a friend and she used to take me around to congress with her so i got to hear from her, from mary and all of my Life Experiences come from there. Host sometimes she had unorthodox methods to advance her goals so tell everyone about the lunch. One of my favorite stories. Guest in the spring you have the budget hearings in washington so she would come down and stay with her good friend dena blair at a lovely home on foxboro road outside washington and she would visit. And take me some time with her to see congressman if she had dinners and lunches at the house but the dinners we were always sitting next to somebody who needed the information you had to sort of carefully planned. One day i got a call, this is how much detail she went into. From dena blair saying when you come to hodges today. I said, im busy. Ive got plenty of staff and ive got a very stern voice said, mary wants you to come. Please come. So i rearranged my schedule, down there and got in this big blackgovernment limousine sitting in front of the house and i was introduced to Mister Featherstone read. We had lunch had the usual routine. She would tell him about all the things we could do with more money and turned to me and asked me what was going on and about an hour later he got up and said he had to return to congress and he left. Mary took her coffee to the living room and i went in with her and i said mary, whois featherstone read said , hes 90 stryker. Maggie was miss magnuson, the chair of the Senate Appropriations committee, the guy who handled all the money. Show she has seen my shocked look. She put her hands up and said, he drives maggie to work every day. He drives mrs. Maggie around shopping all day and this is maggie is the last person who puts down. Warren magnus and was a friend of hers but she was surrounding him with people who were all apprised of all the information to pass the budget. I said he didnt stand a chance. Host so the war on cancer was a very popular idea in public when it was passed but there were many suckers doctors and scientists who were appalled by it before it was an Unpopular Program in academia. First of all the implication was, that money was going to buy ideas and the mantra for people in academics was money doesnt buy ideas. Ideas spring from the minds of scientists. But thats not true. You get money to good scientists, they go to work, ideas pop out but first of all, you cant pour money into a problem and to make it work. Then the universities want money to go into grants, the small Grant Programs used who support them. Thats the way they support their families and so they were unhappy about the money sifted out from their favorite programs and they didnt want anybody telling them what to do anyways. Doctor rick edelson sitting over there smiling at me, he succeeded me as the director of the Cancer Center and i think you could agree that it was not terribly Popular Program but in fact until recently it hasnt been a Popular Program. I would say last two years. Host so you edited a textbook on cancer and i was going to bring the stone because its 11 and a half pounds but i couldnt get it in mybackpack. You wrote this relatively slim volume by comparison to the layperson. What compelled you to go from writing for doctors to writing for lay people about this . Guest she probably wouldnt say it. She said it was clever of us to develop a mock Treatment Program so we would have somebody to chronicle what wedid. Having this to work with made it easier. Thatsthe reason the book is readable , she made it readable but theres another reason. One is first of all, i think 100 billion is a lot of money and the people who put it up i think should know something about it and should know something about it the way it actually happened, not the imaginary flowery language. Second is, there was nobody, im very fortunate. I was there at the Cancer Institute before the act was signed. The work we did in part led to it. Became director of the Cancer Institute so i ran it then i went to the biggest Cancer Center in the country as position in chief then i went to elite university and then i was president of the american cancer society. I had cancer myself as if i didnt know enough about it. So im in the unique position to describe the whole thing and bracket the program and i thought given the fact that i think the public needs to know and i have a unique opportunity that i should do it. In fact weve been talking about it for 20 years knowing that at some point in time we really should do the book and as i said, if you, if anybody whos read it enjoyed it, thats the reason right there. Host there are some things in the book that some might construe as being inflammatory and in fact youve gotten a lot of emails saying how courageous it is for you to have said the things you said. Did anyone caution you about writing the things that you did or tell you not to do it . Guest yeah, i guess five or six years ago i went down to mount sinai for a sabbatical for four months and my good friend jim collins, one of the pioneers in the chemotherapy field was there so we went out and had lunch, a little Italian Restaurant down the street and i cant describe him. Hes a guy, wears loud ties, its really fun being around him and i told him about the book and he got very serious. I expected hail and well met, go ahead and do it. Instead he looked down at me he said vince, people dont really need to know the story. You really shouldnt do it and i said, i was a little shocked. I didnt say i wasnt going to do it but in the front of the book i mentioned thestory. Ive not yet heard from jim collins so, hes a wonderful man andone of the pioneers in the field but it was so out of character from him that we did put the story in the book. Guest host were you concerned about any response that you might get when this came out . Guest yeah, we do tell stories about people and people seem surprised. I mention names and institutions and tell the truth. I think everything inthe book is truthful as i can remember. As one person said to me, if people complain tell them to write their own book and i would say, find yourself in the limited. Host what criticism do you think has been the hardest and how would you respond to it . What criticism has come out since the book has come out and has been the hardest and how would you respond . Guest we been reviewed twice in the New York Times and one was wonderful, the other one was not bad. He said he liked the book but. Host the second to the last paragraph. Guest he said he would have liked to see more retaliation which the medicine is wonderful. I believe in it wholeheartedly but i was writing the book about the whole field, i was writing about my experience. And then he said, i described a friend of mine we took care of, a patient named lee and how i moved him from institution to institution to get access to new drugs to keep them alive and he said at the last, i forgot to mention the nextnew drug would only improve median survival by 3. 9 months. Its one of my favorite depictions of this is what i call median disease. He suffered from median busy. I was trying to get him into a study with the Survival Program was like this. So median disease, half the people at this point survived and if you look at the survival. Of one year and two year and 25 percent of the people were surviving and responding. I was shooting for that and he was worried about median diseases. Median is what we use at a fish network of many years who would tell you more. We did statistical tools where we compare studies but he suffered from median disease. And laboratory science, wonderful scientists, doctor edmonds in london wrote a review and he said you know, its good. Look, we dont know enough. My responses, you dont know enough. But we know enough and the reason that is, Laboratory Scientists can, people who spend all their time in a laboratory tend to want to know everything before you do anything and in the cancer field you dont have to do tha. What you have to do is fix critical parts of the cancer cell during the time its exposed to a treatment and in the book we describe the hallmarks of cancer. If you can jimmy them so you can get them back to where they were before during the period of time, you dont have to know everything. You can direct the cancer otherwise we wouldnt have been able to do what we did with some of the other treatments so those are the two i think bothered me the most. Their understandable and we got very good reviews so i cant really complain but. Host early in the book, you start a chapter with a scene from a party and your new at the nih and its a party thrown by your bosses. One of them is at the door with overflowing martinis and eventually sits at a table and crashes to the ground,classis wine and passes out in the bathtub. The other one of your bosses is seencarrying a laptop over his shoulder. These guys are actually your mentors. You came to admire them. So some people have asked why would you show them that way so early in the book . What were you trying to say there . Guest mary kay remembers that night because we went to this party with all these scenes, there was a partner out on the floor before our eyes and we were the most junior people there so it was a little bit uncomfortable and by the way, tom fry who walked on his hands could walk on his hands better than most people could walk on their feet. He was really an athletic guy. Two reasons. One is their very important people and they , throughout the book i make it clear that their contribution was really very important and i thought it was important to describe them the way they were. They worked very hard, they played very hard and jay was a very, we have a photo showing jay. You can look in his eyes and see, you looked at him and knew he was very intense sort of personso i thought that was important. The other thing was i had to make the decision , these people were so far out of the norm in the field that we were worn when we went to the Cancer Institute, stay away from them. We went there because it was a privilege to go there. If you didnt go there, you were in vietnam being shot at so we wanted to be there. But people said its good to go for that reason but dont get too close to them. That was professionally and now im at a party and they sound like theyre as crazy as everybody said they were. Running around gettingdrunk and walking on their hands. I had to make a decision about , i couldnt stay with these people and work on this but the power of what i saw going on there was a important that i realized it was the right thing to do and what they were doing was really terrific and i was a little worried about jake. I sent him a copy of the book and wrote him a note saying some of the stories would make him uncomfortable if you remember them. And i got a lovely letter from him a month ago saying he loved the book and he thought it was an important contribution and he was so proud we worked together. It was a very important for me. Im very fond of the man and i still work with him. Hes indestructible. Host a little mellower, maybe. Guest a lot mellower. We interviewed him for four hours for the book. That interview itself is really very interesting book. In fact, Malcolm Gladwell bought a book called outliers and in one chapter is all about jay farren. He talked to me and told him all the stories. I didnt put the batteries in. Host you first stepped out in the ward in 1963. Can you describe this ward and the patients on them and when you first got there . Guest in 1963 , if you got cancer if you were lucky you were operated on and if they got it, it was early enough you might survive but a lot of people didnt and there were radiotherapy was around but none of the really good radiotherapy machines were available so the overall survival rate was about 37 percent for all cancers combined. Chemotherapy was considered kind of a lunatic fringe. Most people didnt believe in it so the wards were very peculiar. One floor, i worked on both because i was a laboratory that supplied young faculty. One word was a ward of people who had advanced cancers, all of whom died and there was not much excitement. It was just testing new drugs without much hope that they were going to do much for that particular patient. Host and one at a time, right . Guest the other ward was the Young Children with leukemia. And theres was a lot of hostility toward doing this kind of thing, young doctors coming in that hadnt done it before really unhappy. There may not have liked it and some people didnt but there was no escaping, he was a super doctor. He would hold it over his patients and you saw things happening that you never saw before. So despite the fact that most would avoid these people, my eyes were telling me something different. And we told the story in the book, there was a very wellknown hematologist at the Cancer Institute, George Drucker who was an internationally known and when we did bone marrow which we did all the time on these kids we got to take the slides down and George Drucker would read them and he just couldnt stand trial right. He would say, he had one eye in the microscope and look at me with the other one and say its crazy what theyre doing there. Its just insane. Im a young guy trying not to shiver and then he would say okay, the marrow is coming back and the drugs were still in the veins of these kids but the bone marrow is coming back and leukemia cells are disappearing and im saying to myself hes saying im crazy but telling me its working. Thats how locked in the people at hospice this kind of approach was so it was an interesting time. Even within the Cancer Institute there was a lot of hostility. You used to have rounds on the 12th or, what we called grand rounds and me and rick were on the 12th floor, we crossed past at the Cancer Institute and people at the other departments which out things like, this is a butcher shop i never heard this before. At the university you didnt hear this kind of stuff it seemed to make people blood boil so the people who were around at that time had been sending me letters saying that we captured theatmosphere of that time very well in the book. Host we should point out what fry was doing on the leukemia words that were different on the other wards. Guest at that time using drugs more than, in combination was considered bad medicine and it started out in bad medicine in infectious diseases. You didnt get to antibiotics at the same time. Cancer drugs were considered to be worthless so giving two toxic drugs at the same time was considered bad medicine, giving four was considered a little bit insane. And eric had developed a program where each initial stands for a different drug in combination and it was, it turned out to be a very useful combination in leukemia so they were considered, up there they were giving drugs one at a time and they were not happy with the thought of doing anything different because we did a mock program upstairs so it was an interesting time, the turmoil was unusual to say the least. Host so mock was the regiment you came up with hodgkins disease but that wasnt your first stab at it. You had one before that. Guest we had to do a pilot because there was so much bad feeling about doing it, we had to do a pilot trial, we called it mom tv. Initials for drugs. And it was a shorter study and it was a little more toxic than the mock program. But what happened was we put patients in reverse isolation, we were very careful with them, afraid they were going to get infected. We didnt have drugs in those days to control nausea and vomiting so these people got sick. It was a very trying time but it worked and nine of the first 14 patients went into remission so we began to face a very unusual problem that was important for the later use of mom tv. We knew we wanted to do something for a longer duration. When youre treating leukemia you are treating the bone marrow so you just seriously treat until leukemia cells are gone and you stop and wait for it to come back. When you are treating Something Like hodgkins disease the bone marrow is narrow so you have to work around bone marrow and give it long enough so you dont let me grow between treatments so we did not experience and then made translations from the mouse to the human. We studied bone marrow in humans and in mouses and we came up with a very complicated schedule for giving momt. I did this with my first partner in this, jack markley and jack did the mock program and i did that m. O. M. T. Jacksoninteresting story becausewhen i first met him , we shake hands, how are you , where are you from, who are you going to be after you leave here and jack said i want to be a dean. Nobody wanted to be a dean so it was very unusual and sure enough after we get the m. O. M. T. Program jack went back to boston and three years later he was the dean of the biggest medicines for school in the country. People would ask what happened to Jack Montford . He disappeared after the first study but we still stay in touch. So we converted m. O. M. T. Into mock with avery complex schedule which became a problem. Host what was the biggest obstacle in getting m. O. M. T. To patients. Guest after the first four years we were pretty sure that we were curing these because usually if the patient was going to recur they would recur in the first four years so we were pretty confident that we could cure them. The data was very good but they are asking people whod never done things like this to now use a combination and if you didnt believe you could cure then you are making patients sick for nothing. They say its not worth wild so getting doctors to work on the schedule that you put together was very difficult. I tell the story about memorial Sloan Kettering. I was invited up for a grant before i got there as physician in chief. I went for grand rounds and they warned me when i was coming up that could make it work. And they were going to grill me pretty good. My father worked in new york decided he was goingto come so he showed up. I presented my data, happy that i had all this data and one after another they got up and said we can make it work. The implication was, the kindest implication was that i was taking easy cases and they were taking the hard cases. The reverse was true. They thought i was somehow fudging with the data so i said, what do you do . I didnt get it. They said well, we dont like nitrogen mustard, that was the first m so we use our own drug. They put a dose in that was easy to use and pro forma scene makes you throw up so we cut that dose in half. This one causes nerve damage so we cut that dose. We carefully worked out schedules so we could get the drug in and keep the tumor from going back without damaging the marrow. They just threw it out the window and couldnt do it in two weeks between the cycle so i finallys sort of blew up and said why in hell did you do this . They said our patients come to us on the subway and we dont want them to vomit when theyre going home so i said to them, listen. Could you tell the patients either they can vomit and be cured or not vomit and die of a disease. But that was emblematic of the problem of getting people to stick to the dose schedule. When i went to Memorial Hospital as position in chief, and i can give you an idea of some fears that people had. A tackle from one of the local football teams develop hodgkins disease. He was 260 pounds, six foot seven and when they calculated the dose according to my schedule because i was there they said this is crazy. They wouldnt do it. Im not going to get it. I had to go to the clinic and inject this giant with the dose because we do the dose on the base of surface area and he had a big body surface area. You dont give a sumo wrestler and someone my size the same dose. You have to go in the clinic and im surrounded by the nurses and doctors all expecting him to fall over dead and he went into remission and had less toxicity than most people from the drug but this is the kind of problem you have. We still have it because if you are in private practice you need regimens you can give easily because otherwise it ties up your office and doctors look for them. Hopefully they are comfortable regimens but in those days there wasnt anything but the m. O. M. T. Programs. Guest out. Host i want to ask you about the fda. What are they getting wrong and how would you like to see them fix it . Guest anybody from the fda here . [laughter] somebody sent me a note saying are you sure they are having somebody sent out to kill you. We need the fda. They do lots of good things. And they are a no win job because if they approve drugs rapidly half the people criticize them for going too fast, they go slowly and people like me criticize them for being too slow but they are not approving cancer drugs. Cancers are special. Cancer is the most curable chronic disease and at the most fatal chronic disease in people dying of cancer dont want to wait 10 years before the next new drug will come out so they tend to rely on comparing a new drug to an old drug and looking at survival as an endpoint which is very difficult under the circumstances they are testing. What they should do is they should approve a drug based on if its a safe drug, they do early studies its safe and if it hits the biologic target. Now you can sequence the genome, you can pick out mutations a cancer has. If it hits the target and its safe it should be approved. Most of the dances we are talking about like m. O. M. T. , they were done in the postmodern. You should give these tools to the oncologist who already use them and let them come up with the new ways of curing cancer. And the way to do that is to approve them on the basis of safety, hitting the target and then delegate these early trials to the Cancer Center so they are what we call phase i and phase ii studies. The earliest of clinical studies would be done in the Cancer Centers. The fda could retain the right to audit which they have now but the way it is now, if you set up a protocol and if somebody wrote a paper on this that in some cases it takes 800 days to get the protocol approved. It goes through three or five committees at yale then goes to the mci and a couple more committees, the fbi and if you make a change in the protocol go back to the system again. We havent mentioned yet but one of the meetings that i attended when i first came to the nci was nicknamed by my colleague george canalis was a greatnickname or as the society of jabbering idiots. It was because the room was chaotic. Black walls all around it and people would take a piece of chalk and run off and it was the most exciting meeting ive ever attended in all my years in cancer the name is misleading. What it was what were room. You took the latest information you had and brought everybody together and would decide how you would adjust the protocol and the next day you change the protocol. Now if you do that the next day might be 800 days away. If you do what i said, approve it based on the basis of safety and hitting the target, delegate the phase 1 and phase 2 of the Cancer Centers you would revolutionize how you approve new drugs and it would cost less. Did you know and anything in government that ever costless . You have more kind of people who run committees go and it would be a much better, faster and better system. The fda will not do that on their own. Believe me, i ran the Cancer Institute for many years. Government institutions do not give up power or authority. It has to be squeezed out of them though it would take some interest from the congress to go to them and get them to change. Host we need another ann landers writing a letter. Guest and we dont have mary laster. I never went to a meeting where mary laster was in the audience and the senator was speaking that they didnt refer to her as the angel of mercy. They really loved mary laster and she could move them to do something. But we dont have an organization that comes close to being like mary laster. Host what changes are in motion in the field that we can look forward to in terms of new treatment . Before a lot of people ask me questions about things within the papers recently that are very exciting. The most exciting is immunotherapy. We are nibbling at it for years and not making much progress except wet rick edelson developed years ago. He developed one of the most successful programs but it was the one tumor and it was finding for how we could get the immune system to react to cancers. We didnt know why they didnt and in 1996 a doctor from m. D. Anderson hospital in texas , doctor ellison, he had what i remember wecalled checkpoints. They were little receptors on lymphocytes that could be, they would turn the lymphocytes down so they wouldnt react. The way the body protects us from our own lymphocytes, you could now develop drugs that block the checkpoint. The cancel cells are widely and if it turned on the checkpoint you could turn on the lymphocytes. Now we had checkpoints and they had been approved for use in melanoma and it had changed how melanomas are treated. We are seeing patients with melanomas, living years with metastatic sized disease. Its working in lung cancer with very difficult tumors to treat. In fact, its working in pretty much every cancer thats been tried and not to the same degree. Breast cancer, the Response Rate is lower but its there and we are working out the details so now we have chemotherapy, we have immunotherapy. We have surgery and Radiation Therapy and we can mix and match withall these things. I think thats probably one other thing you can now engineer a few cells. Theyre calledantigen receptor cells. You can bind a mutation and my colleague Steve Rosenberg at the Cancer Institute did this. He took up tumor of sarcoma which rarely response to anything. They sequenced the genome and found a mutation that was unique to that particular cancer. They engineered the t cell receptor to respond to it and they got responses that no ones ever seen with that particular form of cancer. Thats a very personalized medicine because you have to take the tumor, sequenced the genome, find your receptor and tcell so you have to have sophisticated laboratories todo it but as time goes on it will be more widely available. Host one last quick question. As the cancer act fulfilled its mandate and are we winning the court war on cancer . Guest about 70 percent of hundred billion dollars went into basic Laboratory Research. When i used to go with mary laster she would ask me, she would say to me im going to ask for 200 million above the president s budget. I said mary, nothing i can say and justified 200 extra million. She said dont worry, ill only get half. Sure enough, we get half. 5 million would go into the area i talked about. 95 million would go into Laboratory Research which is fine. Thats the way it should be at the time so we supported research to reduce the incidence is coming out because there were Smoking Cessation programs that have been successful. Cold cancer incidences out because we can prevent polyps from going into malignancy so we produced incidence of the number of cancers and morbidity is so much less for tumors. Being older in the field, thats the advantage of being able to see both ends you take Breast Cancer, the difference in outcome for Breast Cancer then and now is enormous. And mortality is down. Over 25 percent. These data are five years old because it takes us five years to collect the data so 25 percent is when we get to measure 2015, its going to be 35 percent. Thats my estimate. So we supported research, we reduced the incidence, we reduced morbidity and reduced mortality. The fateful mistake mary estimated was promising to do oil all that by the bicentennial which it was not possible and it was a wild to do it but the best is yet to come. All these things have yet to come with approaches to treatment. Were not even measuring the impact of immunotherapy or new targeted therapy so ithink were in for a very exciting time. Host thank you. We left some time for questions if anybody has some. Theres a woman with a microphone. Guest i dont hear as well as id like you have to use a microphone. Id like to ask you what you think is the role of hope in the treatment of cancer . Guest its very important. We have a called entropy and if cells have energy and they pump ions out of the cells and when you die you reach entropy. Theres no difference between the inside and outside of the cell. I used to say i saw patients responding to treatment gave up who died fighting the treatment so i think the ability to say im going to do this and im going to be it is very important. Motivation is a very important component of treatment. I have a funny story of a patient i treated with hodgkins disease who is alive today 40 years and when he used to come back he said to me, when i leave here i get the treatment and when i walk out, now were in bethesda maryland at the national Cancer Institute. As you walk outside there were two pools by either side of the pool. They were symbolic, the healing pool. When he left he said he used to take his socks and shoes off and walks in the pool. Which you think will work, the pools or the treatment . I said i will take all the help i can get. Thank you for your talk. My husband had Esophageal Cancer. He was fortunate to be operated by doctor swanson who teaches now at harvard medical school. But what progress has been mad . Thats a difficult cancer and then the program problem with swallowing afterwards. Has anything, has any progress been made . Guest we usually dontdo surgery alone anymore. Patients treated with chemotherapy, Radiation Therapy and may not have surgery depending how they respond. So a lot of people, its still a difficult treatment to treat but a quarter of the patients will be treated without surgery and just radiotherapy and chemotherapy. Thats inadvance for those. It doesnt make any difference anymore. Its easier. Its actually easier to give surgery and chemotherapy, im sorry radiotherapy and chemotherapy than to have surgery so its an easier treatment with a better result. Fill a long way to go and Esophageal Cancer is one of the tough ones. Hello doctor. A lot of the, we talked about the cost of cancer care and even if the fda approval process was shortened and these new drugs were being given to patients, alot of patients dont have the means to pay for a lot of these drugs. This one is almost 200,000 a year and thats what jimmy carter got his cancer freeze so im wondering how to deal with the pharma side of things and the crazy prices. Guest jimmy carter by the way received radiation to his brain which i think took care of the brain waves but he is on that because he had diseases elsewhere and it was one of the drugs well known. The cost is complicated. The ones who have died who bought the old drugs and increase the price of 700 percent, he got what he deserved. Thats justgouging people. The question is cost to who . If its approved and the Insurance Company pays for it if the cost to the system not to that patient. If its not approved then it becomes the cost to the patient. We had a system for giving drugs out to Cancer Patients when i was at the Cancer Institute that worked well. The fda just blew it away. In those cases the pharmaceutical companies pick up the cost of the new drug and were happy to do it because the Cancer Institute said it was good enough to give to patients even though it wasnt approved it gave them some credit to the drug but i think, ive been on the boards of some companies that manufacture drugs and the one company i was on, the drug we put out was still out there and a very successful drug. It cost 800 million to develop your and the ceos and the boards have to do each of the shareholders to make sure the company doesnt go bankrupt. They go bankrupt, you dont get any new drugs so it was a tough issue. It needs a lot of discussion and clarification but its not all one way or the other and i still think the guy who charged 700 percent for that drug should go tojail. In the addition to the advances in treatment can you cover some of the advances that may be made in the early identification of cancer, particularly pancreatic and ovarian and those cancers that have very low success rate. Guest those are the two big onesfor being able to identify the cancer. Data cancer, one of the reasons its difficult to treat is because you dont know its there for a long time. The answer is yes. Somebody asked me this earlier, theres a lot of talk in the newspapers about liquid biopsy, measuring the dna from tumor cells. Thats the holy grail for cancer treatment, being able to tell whether or not a single cancer cell as they are. If we had an essay that can tell you whether or not there was cancer cells present, if you had surgery and took that test and it was negative we have no more treatment. Or if you had advanced cancer like skins disease and it went into remission you just keep measuring it and being able to tell when you could stop therapy. You did not have to give two cycles are eight cycles. I think it will happen but its going to take a lot of doing and a lot of people are reporting private resources into it so im hopeful. Right now we have one tumor we can do that with. Thats choreo carcinoma, a tumor that begins in the placenta. When he goes to zero that means you dont have any cancer cells. They can measure as few as 1000 but we dont have that yet. Pancreatic cancer, is it recommended that this ad immunotherapy to chemotherapy . Guest i have not seen any data for pancreas cancer. I was asked that question and an email in one of the reasons is pancreas cancer is one of the last tumors to test something new. It gets very difficult to measure whats going on. Patient is sick, patient is failing or dying but you cant feel the tumor so when people are developing new drugs they are looking to measure how theyre doing and they havent done it so i dont know that anybody hasnt done it but i haventseen it. If i had pancreas cancer i would knock on someones door and say i will give it a try. Could get doctor olson in . I think i should emphasize that i think more than anybody else in the field of cancer you have an unrelenting, uncompromising and dealing with the barriers of progress. It really comes through very clearly in your book. But there are too many vincent devitas. When you are talking about Malcolm Gladwell as the tipping point, its hard to get against some of these obstacles where the innovators of yesterday become the laggards of tomorro. What about those people that are coming up in this day and age with really significant advances but dont yet have the momentum to fight the system . How do you get those people accelerated . Guest i think one of the reasons i wrote the book is i hope we can open a few doors for people like that. Maybe some of the barriers can come down and make a few freedoms. I would not bewanting to do , we were doing mock today, we get it in about three years then could follow the patients after. It would take 15 years at a minimum with all the rules and regulations in place and thats what they are facing. How do you maintain momentum . How do you maintain enthusiasm . I sent in our fellows that there is no energy left after they fight all these protocols and Committee Reviews and so forth they cant fight the system anymore. Its a difficult time i think. I think its a shame because we put 100 billion into this and if we loosened up thesystem and would happen faster. Id like to thank you both very much for the book. I think its really motivating for a lot of buyers. Besides cancer early identification what you think would be the best preventative method for cancer whether it be smoking prevention, things like that. What do you think is the future of Cancer Prevention . Guest stop smoking. 40 percent of all cancers are related to cigarette smoking so weve now cut smoking rates in half since the cancer act was passed. So i think the biggest, let me just tell you the story. Theres lots of new stories about faith in fact. Every day the risk of getting mild cancer is higher than if you dont eat bacon every day but if you compare it to if you smoke and ate bacon, the thing to do is quit smoking and keep eating bacon because the risk is just so much different. You have to keep that in mind. We know that people who migrate from certain areas where they have a good diet, a diet for example have a lower incidence of cancer or japan, the japanese have a lower incidence. We know diet important but we havent learned very well how to manipulate it so so many, a good sign is we dont know theres a lot. A few different diets people recommend so i think the one thing we do know is quit smoking. You had spoken briefly about hopefully there are people in the private sector that have been stepping up and helping to avert some of the frustration onto putting this out there because my father has been very involved in since his alzheimers but he was a Venture Capitalist in his career and hes actually now started a company, a nonprofit but they are using the Venture Capital as method to attract investors and what they are doing is finding certain doctors in certain programs they think have a potentially excellent success rate and putting money behind it. Guest i think thats very good. They stand up to cancer, a program does that but when they put 50 million in the hands of doctors like that they still have to go through allthese hoops. So 50 million goes in and at the other end they are squeezing stuff out. There are a couple of people up here who have been raising their hands. Thanks for coming. How close are we to walking into a laboratory and getting five cc and coming up with a diagnosis of cancer and dna sequencing. Guest i dont know if i would guess that. I think there are companies now that exist solely for that purpose. And its a real difficulty. Its a very difficult test to prove. It takes a long time to prove that it actually will show that you are diagnosing cancer. There are lots of tests that give you a warning that there may be a cancer present but what do you do if theres a false positive say 20 percent of the time . Do you spend a zillion dollars working up all those patients question mark its hard to do. I dont really know how long its going to take to get that done. I think you are more likely to see tests for specific cancers than you are for a test for all cancers