Oncologist Discusses Advancements In Treatment And The Ongoing War On Cancer
TERRY GROSS, HOST:
This is FRESH AIR. I'm Terry Gross. My guest, Dr. Vincent DeVita, is a pioneer in the field of oncology and the author of the new book, "The Death Of Cancer." He started his career in 1963, as a member of the team that developed the combination chemotherapy that led to curing most childhood leukemia. Then he developed the combination chemotherapy to treat Hodgkin's disease, which cures most people with advanced disease. He went on to become the director of the National Cancer Institute and the physician in chief at a Memorial Sloan Kettering Cancer Center. He's now a professor of medicine at the Yale School of Medicine. Dr. DeVita was diagnosed with cancer in 2009 but now appears to be cancer-free. He learned firsthand what it's like to have a family member whose disease has no cure. His son Ted had a disorder of the bone marrow that left him without a functioning immune system, vulnerable to all germs. For eight years, until Ted's death at the age of 17, he lived at the National Cancer Institute in a special bubble-like hospital room designed to prevent a patient from coming in contact with germs. Dr. DeVita, welcome to FRESH AIR. Your breakthroughs in terms of chemotherapy research have been in the area of combination chemotherapy. So before we talk specifically about your research, what's the principle behind combination chemotherapy?
VINCENT DEVITA: Well, cancer cells are very wily little beasts. And we have learned that in order to destroy them, you have to hit them in multiple different places at different times to overcome resistance to the chemotherapeutic agents. So the principles are to use drugs that have a different mechanism of action and don't have overlapping toxicity so that you can give them in full doses. That was the background of the work that was done with our patients with Hodgkin's disease and with childhood leukemia.
GROSS: You were part of the team that first used combination chemotherapy. And that was on children with childhood leukemia. It was very controversial at the time. What was so controversial about it?
DEVITA: It was thought - the general rule in medicine was that you didn't use drugs in combination, period - for anything. And it sort of was given birth in the field of infectious diseases, where it was very tempting to combine antibiotics. The people in the field considered that sloppy medicine. And it sort of spilled over to all other parts of the field. And in the cancer field, because drugs tend to be more toxic, it was looked on askance because now you're giving not just one toxic drug but two toxic drugs at the same time. So it was really considered a violation of the basic principles of medicine.
GROSS: Why was childhood leukemia considered a good form of cancer to test combination chemotherapy on?
DEVITA: Leukemia is a good model because when you - you need to know what you're doing. And it - one of the problems we have even today is when you're treating people, you don't always know what the impact of your therapy is on a moment-by-moment basis. And childhood leukemia - or any leukemia that has malignant cells circulating around the blood - you can do - test an IV sample of blood. And then you can measure the leukemic cells. So if you give treatment and then you measure the cells and they disappear from the blood, then you know you're a step in the right direction. And in leukemics, we do - we go one step further. You do a bone marrow to see what's going on in the bone marrow. So it's one of those really easy models to work on.
GROSS: Because you could test it so...
DEVITA: Yeah, you know what you're doing.
GROSS: Right. So the doctors leading the experiment were considered kind of crazy. Their ward, which you were working on, was considered a butcher shop. Why?
DEVITA: (Laughter) I don't know. That was just the attitude of the time. These were people who were taking care of - all of us were taking care of young adults. Even the Hodgkin's kids were, you know, in their 20s and 30s. And in those days, we didn't have a lot of platelet transfusions. We were just developing them. So patients bled. Patients got infected. So - one very well-known guy used to call it a meat market and - at grand rounds, in front of a lot of people. It was quite stunning for someone to come new to that environment and see what was going on. There was a lot of vitriolic feeling about going ahead with this kind of work. So it changed - it changed what you did.
GROSS: So how come you weren't upset by - how come you didn't believe that? How come you were willing to pursue this research that some of your peers, some of your - some of the doctors who were working on cancer far longer than you were thought this was, you know, abusive to the patients?
DEVITA: That's an interesting question. I - you know, for about three months, I was feeling the same way, that we had gone into some sort of crazy land. And then I began to see things happen. You know, we came - you came out of medical school; you had never seen anything good happen to a cancer patient with chemotherapy. And all of a sudden, you put chemotherapy into a leukemic or a lymphoma patient, and all their disease goes away. So there was something to what was going on. And it just seemed exciting to me. After a few months, I switched sides. And I became sort of one - you know, one of the acolytes at that place.
GROSS: After having such success using combination chemotherapy on childhood leukemia, you wanted to try it on another form of cancer and led an experiment using combination chemotherapy on Hodgkin's lymphoma. And you didn't yet know for sure whether it was going to be an effective regimen. You were really putting them through hell, you know, severe vomiting, mouth sores. These are heavy duty toxic chemicals and more toxic, I think, than what's used today. Is that fair to say?
DEVITA: No - no, they weren't really. Today we have drugs that can prevent nausea and vomiting. And we have many more medicines that can sort of palliate patients. So it's a little easier for that reason. But in those days, we didn't have it.
DEVITA: I had - I had patients who, when I would walk in the room, they would vomit. They - you know, they associated me with giving them the chemotherapy. And the minute I walked in the room, they would vomit. It was like a Pavlovian dog. It was quite - (laughter) - it was quite interesting. And then I think as we point out in the book, we used to have a van that would drive patients back to the hotel where they were staying. And most of them wouldn't take it because they would get sick on the van. And they walked - they walked diagonally across the grounds of the NIH. And the nicknamed the pathway The Chemo Trail. I mean, they walked it so often that they wore a small dirt path through there. And while the NIH tried to grass it, they eventually gave it up and paved it in. So The Chemo Trail exists now as a paved trail. So that's the kind of problems we were having with it, the side effects. It was tough in those days.
GROSS: What was it like for you during this period, when people are like - they're throwing up. They're getting mouth sores. They're getting very sick from the treatment. You're hoping the treatment will finally cure them. But you don't know for sure. And in the meantime, you're putting them through hell. How did you handle that?
DEVITA: Yeah. Well, you remember we were seeing - these people were coming in quite sick. They were coming in with fevers. They were coming in with big lymph nodes everywhere. They had lost lots of weight. And we would start to treat them. And while they would get sick, these tumors would go away. The fevers would go away. Their appetite would return. So we were seeing the very positive things. And they were feeling the negative side effects. They and us both realized that the changes that were happening were better than the side effects that were causing them difficulty. So they were - they became quite enthusiastic and were willing to tolerate the side effects. And so were we.
GROSS: What's one of the greatest breakthroughs in cancer treatment that you've seen since your groundbreaking research into chemotherapy?
DEVITA: Well, there are two that strike me in dealing with patients with advanced cancer. One was the work done by Dr. Brian Druker in chronic myelocytic leukemia, where he used targeted therapy to attack the molecular lesion in what we call CNL and has really converted that disease into a chronic disease, where people live a perfectly normal lifespan as long as the drug companies can keep developing new versions as patients develop resistance to the old drugs. This was - this before was a universally fatal form of leukemia. It was - it took a little longer to kill a patient. That's why it was called chronic myelocytic leukemia. But it was a bad disease. And this was the basis, actually, for changing how we develop drugs. We used to develop drugs by getting a chemical structure that looked interesting, testing it in tumor systems and, if it had antitumor effects, then figure out how it worked. Now we develop a - we define the molecular target in a tumor. And then we develop a drug to attack the target. The second one is the recent studies in unblocking the immune system so that it could naturally attack cancer. And as we speak, it's being tested in virtually every type of cancer there is. And so far, pretty much every type of cancer under testing is responding to it. And some of them are very good responses in diseases that normally don't respond, like lung cancer. You know, lung cancer was a very difficult tumor to treat. And now we're seeing people who have responses that last years where we used to get responses that last months. So it's a very exciting time.
GROSS: So say immunotherapy successfully keeps moving forward. What would the implications be for different forms of cancer?
DEVITA: I think - well, I think it's going to be a mainstay for most cancers. It's probably going to have to be used in combination with other kinds of treatment or in combination with itself. For example, there's been a study recently approved by the Food and Drug Administration of using two of these unblocking drugs simultaneously, that they just attack a different target. And the results are very gratifying. So combination immunotherapy looks like it's going to be necessary. And I think you're going to have combination immunotherapy along with combination chemotherapy. So it's going to be - it's an interesting time because people now have to take all these things and learn how to use them together. And - but the point is that we have tools now pretty much to attack anything that the cancer cell needs to survive.
GROSS: How do the side effects of targeted chemotherapy and immunotherapy compare to the side effects of more traditional chemotherapy?
DEVITA: Well, there's no such thing as a free lunch. All drugs have side effects. Even aspirin, you know, a pretty routine drug, has lots of side effects. Immunotherapy has different side effects. The danger of unblocking treatments are that you're unblocking the immune system. And it can attack itself. A patient can now have very severe asthma or very severe GI problems.
GROSS: Autoimmune diseases.
DEVITA: Autoimmune disease. And so that - and certainly that's happening. So - so it's something that we have to learn to live with. We can treat, you know, some of these side effects very - if you have a patient where you've eradicated their tumor, we will learn to live with the side effects that are induced by the immunotherapy.
GROSS: If you're just joining us, my guest is Dr. Vincent DeVita. He's the author of the new book, "The Death Of Cancer." Let's take a short break. Then when we come back, we'll talk about what it was like when Dr. DeVita was diagnosed with cancer in 2009. We'll be right back. This is FRESH AIR.
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GROSS: This is FRESH AIR. And if you're just joining us, my guest is Dr. Vincent DeVita, author of the new book "The Death Of Cancer." He shares credit for developing the combination chemotherapy regimen that cures most cases of Hodgkin's lymphoma. He became the director of the National Cancer Institute and the physician in chief at Memorial Sloan Kettering Cancer Center. And he's a professor of medicine now at Yale School of Medicine.
Dr. DeVita, you were diagnosed with prostate cancer in 2009, and it was actually a problematic case, a difficult case to treat. But before we get to why, you explain in the book, as a doctor - you're one of those doctors who usually don't go to doctors. I know that's true of a lot of doctors. What was your reason for not taking the advice that you give patients to go to the doctor, get a checkup?
DEVITA: Yeah, well, this falls under the category of do as I say, not as I do. I - you know, I was, frankly, afraid to go to the doctors. I didn't - I didn't want to think about what they might find. In this case, I had an enlarged prostate. I had all the symptoms of an enlarged prostate. And it always bothered me that they might find prostate cancer, so I just avoided the subject entirely.
GROSS: What got you to finally go to the doctor?
DEVITA: Well, actually, I had some other problem. I had a knee problem. I ran, and I twisted a ligament in my knee and tore it. And then my urinary tract problem in the postoperative period forced the issue. I suddenly found myself in a hospital, and it became obvious that I'm going to have to have something done for the large prostate. And in the process of going through the procedure for a large prostate, the prostate cancer was diagnosed. Now, I was faced with what I'd always worried about.
GROSS: Why was your cancer so difficult to treat?
DEVITA: It was big. The prostate itself was unusually large. It wasn't just large; it was unusually large. So it would be a difficult operation, and it would be even more difficult to irradiate it. And then, when I was - I eventually was worked-up at Memorial Sloan Kettering, and they used a brand-new MRI machine that was a very suped-up kind of a machine. And there was some suggestion that I might have some disease outside the prostate, which would've made me in, you know, a very different category, the kind that you probably wouldn't operate on, especially if you have to face a difficult operation. So we had to make decisions about who would operate and who wanted to operate on me. I looked at the literature, but I didn't do a good job of it because I pretty much was sure what I would find. And while I do this for people all the time, I was having a hard time doing it for myself. So I asked my colleague, Steve Rosenberg, to help me out. And he took my case, blinded my name so people wouldn't know who they were talking about and got opinions about, you know, who should operate, what should be done. And even some of the most prominent prostate cancer surgeons in the country told Steve that they wouldn't operate on me.
GROSS: So how active were you in managing your own course of treatment? And how much did you want to know about what was going on and what the likely outcomes were?
DEVITA: When I face a doctor taking care of me, I usually tell them to pay no attention to what I say.
DEVITA: Yeah, because, you know, the old adage that a doctor who takes care of himself has a fool for a patient is true. So I do - I say, listen, tell me what you want, and pay no attention to what I say. Now, I violate the rule, and some of them pay attention to what I say. I have a terrific primary care doctor who doesn't. I mean, he just - he tells me what I should do. And if I tell him something that he thinks is stupid, he tells me. It's really fun because I can trust him that way. So it's hard. It's hard for me. I mean, you know, I can visualize. For example, with prostate cancer, I - when the diagnosis was made, I visualized every pathway that I was going to go down before I died and what would happen. And so it's - you know, you're always thinking or over-thinking your own case. And you tend to look at the negative side of it, not the positive side of it.
GROSS: So you had the surgery done, and it was effective?
DEVITA: It was effective, yes.
GROSS: Good. So are you saying that you think you were more occupied with worry than you think you otherwise would have been had you not been an oncologist?
DEVITA: Yes. I think you're certainly frightened and worried when you're given a diagnosis of cancer. But you don't automatically - if you're not an oncologist, you don't automatically think your way through the entire disease. I mean, I had myself dying half-a-dozen different ways, where the patient who doesn't have any medical background is just frightened for their life, and they want their doctor to tell them what to do. And so - so, yeah, I think it's - as an overlay, being a physician, that's a problem. And there's an overlay being a physician in your own - getting a disease in your own field - that makes it doubly a problem.
GROSS: If you don't mind my asking, when you were preoccupied with the worst-case scenarios for your cancer, what were the scariest scenarios that you played out in your head?
DEVITA: Well, prostate cancer can be a very painful cancer, you know? It goes to bone, and many patients with prostate cancer are having a very difficult time because it's very difficult to control their pain. It decreases their mobility. So, you know, I could see myself going in that direction, having, you know, multiple, multiple fractures and being immobile and being alive and not being able to do much about it. That was probably the scariest scenario.
GROSS: My guest is Dr. Vincent DeVita, the former head of the National Cancer Institute and author of the new book "The Death Of Cancer." After a short break, we'll talk about his son, who had a disease that eliminated his immune system. He lived in a protected bubble-like room for eight years, until his death. I'm Terry Gross, and this is FRESH AIR.
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GROSS: This is FRESH AIR, I'm Terry Gross. Back with Dr. Vincent DeVita, a pioneer in the field of oncology and the author of the new book "The Death Of Cancer." He was on the team that came up with the combination chemotherapy regiment that lead to curing most childhood leukemia. Then he developed the combination chemotherapy to treat Hodgkin's disease, which cures most people with advanced disease. He went on to become the director of the National Cancer Institute and the physician and chief at Memorial Sloan Kettering Cancer Center. He's now a professor of medicine at the Yale School of Medicine.
When we left off, we were talking about his experience when he had cancer.
With your permission, I'd like to bring up another very painful subject, which is your late son, Ted, who was diagnosed - in fact, you diagnosed him with a disease that left him without an immune system and left him vulnerable to any kind of invasive microorganism. What did he have and how did you manage to diagnose it?
DEVITA: He had Aplastic anemia. That is, the bone marrow just stops working. So the bone marrow produces red blood cells that, you know, transport oxygen. And they produce platelets that keep you from bleeding and white cells that keep you from getting infected. So he had no red cells, no white cells and no platelets.
What I saw was - he came in one day for breakfast, and I saw big bruises all over his legs and arms and I, you know, I knew something was wrong. And it was either going to be leukemia or probably Aplastic anemia. So I had to take him in to the hospital where a bone marrow was done. And it turned out it was Aplastic anemia. So the doctor who made the diagnosis - it was so bad, he said, that he didn't think that he could survive outside a laminar airflow room, a room that's kept sterile with positive pressure to keep any organisms from getting in and contaminating the room. So he put him in and said, you know, we put him in for awhile to see if his bone marrow is going to recover. Well, a while turned out to be eight years, so he was in the laminar airflow room for eight years at the clinical center...
DEVITA: ...And eventually died.
GROSS: So he lived for eight years in this protected room at the National Cancer Institute while you were directing the National Cancer Institute.
DEVITA: When it happened, I was chief of the medicine branch. And while he was in there, I became the director of the division of cancer treatment, which now included the branch that he was in. So I now had supervisory responsibility for the branch that my own son was in. And then when I was offered the job as director of the Cancer Institute, I went to my son and I said, I'm reluctant to take it because we have enough problems, all of us, with what we're dealing with. And he said to me, you know you want to take it. Take it. So I went on to become the director, and he died shortly after I became the director. So, yeah, I did, - I was director for part-time while he was in the room.
GROSS: I can't imagine what it was like for you to treat patients, including children and teenagers with cancer, and then have your son living in that same facility, suffering without an immune system.
DEVITA: It was very difficult. And, you know, my wife bore the brunt of it, really. She used to, you know, come in and spend - my daughter, same thing. My daughter, Elizabeth, they would come in and spend each - a night outside the laminar airflow room. It became our living room - and to try to keep his life as normal as possible while we kept looking for and trying anything new that came along. I could hide in my job, and that, you know, kept me somewhat sane, but it was a very, very difficult time.
GROSS: Your hope was that if he'd live long enough, that a treatment would come along that would cure him, but that never happened while he was alive. Is there a treatment now that might have worked?
DEVITA: There are several treatments that work, yes. They're not a hundred percent effective, but the majority of patients with Aplastic anemia do well and recover. So it would've, you know, it would've been another 10 years, likely, that the - those things to reach him in time. And so he would - he could not have tolerated being in the laminar airflow room for another 10 years.
GROSS: How did he tolerate it for over eight years?
DEVITA: I don't know. And I often think about it because, you know, there was no door on the laminar airflow room. He could've walked out anytime he wanted to. In fact, we took him out a couple of times. We worked with NASA and got one of the spacesuits that they develop for the astronauts and converted it into a positive pressure suit so he could go out. And we took him to a couple of concerts. It was modestly effective because he became a spectacle, and it was a little embarrassing, but we did take him out. But otherwise, anytime he wanted to, he could've turned around and walked out that door. He knew if he did, that he was likely going to die, so he stayed within the confines of the room, but he became a very good guitarist. He could write - could recite Shakespeare from memory of virtually anything. He read so much and lots and lots of people helped him. There was a fellow on the radio, he used to talk to him at night on the radio. And a man who we bought guitars from came in and taught him how to play the guitar, you know, we tried to keep his life as normal as possible.
GROSS: So people were able to go into the room?
DEVITA: You can go, you know - it was a room in a room. The laminar airflow room takes up about half of the room, and then the front part of the laminar airflow room, there are chairs and you can stand out there. You can't touch him. You can touch him, but you have to put your hand in these gloves in the plastic curtain to touch him. So we were not able to touch him at all in any particular way. But he could come to the door and stand, you know, a foot away from us. And I even snuck the dog in a couple of times, much to the dismay of the nurses.
GROSS: I'm just thinking that your life was total cancer-immersion. You know, you were working at the National Cancer Institute, you were treating cancer patients, you were looking at new treatments and at the same time, your son had cancer and was living at the National Cancer Institute. And I'm sure the family didn't get away very much, because they wanted to be, you know, near your son. So was there a period when you looked out at the world and all you could see was cancer?
DEVITA: Yes. It was a difficult eight years. But we didn't have a choice, really, there was nothing else. Once he was trapped in the laminar airflow room, we couldn't take him out. Nobody, you know, the doctors taking care of him said, look, if we take him out, he'll be dead within a couple of weeks. So we just - he was trapped there. I didn't travel. The director of the Cancer Institute has, you know, many obligations to travel to Europe and China - so forth. And I never traveled out of the country while he was there because I was afraid something would happen. And because Mary Kay was there day and night - a very strong woman.
GROSS: Your wife?
DEVITA: Yes. And Elizabeth, my daughter, she was five when this happened, and she grew up - her childhood was in the living room outside the laminar airflow room. And she wrote a book about it. She wrote a book called "The Empty Room," it's about sibling loss - a very nice contribution to the field of sibling loss.
GROSS: And she co-wrote your book?
DEVITA: She co-wrote my book and brought it to life. She's an extraordinary writer.
GROSS: Your book is called "The Death Of Cancer," do you really think we will see the end of cancer any time in the near future?
DEVITA: I think it's important to know that the critics of making estimates about the end of cancer say it's only valid if all cancer disappears. And I don't think it's ever going to happen. We are a very complex organism and lots of mistakes are made, and I think we'll always have cancer. The death rate's already coming down. In fact, the survival rates for cancer are extraordinarily high. So we've already succeeded in terms of altering the course of cancer in this country as a result of the war on cancer. I just think now that we have all the tools, we can really - probably with few exceptions, there's something that we can do for virtually every cancer and every patient with cancer. That's why I say in the book, if, you know, your doctor tells you you have cancer, there's nothing he can do for you, find another doctor because you can do something for virtually every patient. So I think we can convert a lot of cancers into chronic diseases. And, again, the paradigm shift I mentioned was chronic myelocytic leukemia, which the patients take a pill every day and they're otherwise perfectly normal. They do develop resistance to that pill and then they have to take a different one. And so far, there are about five of them available, so the pharmaceutical industry has been able to keep up with the development of resistance. But chronic myelocytic leukemia is a disease like diabetes now, you know, you take insulin and everything is fine and you worry about, you know, problems related to it but otherwise, you can live a normal life. So, yeah, I think we're going to see a time in the not-too-distant future when cancer is either curable or a chronic disease that has very little threat to your life.
GROSS: Well, Dr. DeVita, I want to thank you very much for talking with us and I wish you good health.
DEVITA: My pleasure - very nice talking to you.
GROSS: Dr. Vincent DeVita's new book is called "The Death Of Cancer." After we take a short break, our TV critic David Bianculli will review DVD box sets of two recent and two vintage TV series. This is FRESH AIR. Transcript provided by NPR, Copyright NPR.
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