Book Review

Who Survives Cancer?

N Engl J Med 1993; 329:817-818September 9, 1993

Article

Who Survives Cancer?
By Howard P. Greenwald. 280 pp. Berkeley, Calif., University of California Press, 1992. $25. ISBN: 0-520-07725-3

Who, indeed, survives cancer? We know a great deal at a rough descriptive level. The clinical stage at the time of diagnosis matters a lot; the anatomical stage matters more. The histologic type matters, and so do many microscopical features of cells and tissues. The laboratory can tell us something (e.g., estrogen-receptor status). The type, timing, and quality of treatment can be important.

Overall, very close to 50 percent of patients with cancer in the United States are alive five years after diagnosis (with adjustment for mortality due to unrelated causes), but a wise and well-informed physician could divide the whole into one group with a good prognosis and another with a much worse outlook. I might guess that a simple classification according to the site of cancer might be used to divide all patients into two equal groups with overall survival rates of, say, 75 percent and 25 percent, and further refinements based on present knowledge (including the items listed above) might increase the spread to as much as the difference between 90 percent and 10 percent. This is still a good bit short of perfect prognosis (in which we could predict survival without error, 100 percent vs. 0 percent). This gap is explored by Greenwald. But there is more than description here. When we know who survives, we begin to understand why they survive, and that is a big step toward changing things. Greenwald explores these needed changes as they relate to survival time and quality of life as well as to “cure.”

These matters -- first predicting, then improving survival -- lead Greenwald to an unusually rich mix of themes that I can only sample here. Earlier detection of cancer may well have contributed more to survival than has improvement in treatment. Expanded access to health care over the past 50 years has reduced but not eliminated economic and cultural disparities in both access to treatment and outcome. Parts of the public have somehow acquired massive misconceptions about the effects of personal courage and positive thinking on both the development of cancer and survival; about the frequency and likelihood of breakthroughs in cancer research; and about the limited (though still important) role of single-agent exposure to synthetic chemicals in water, food, and air. Timely access to high-quality standard medical care in the community is the first and best line of defense for persons who have, or may have, cancer. Few patients treated under research protocols gain much from experimental treatment. The breakthrough may never come. Recent changes in our health care system have major implications for the prevention and treatment of cancer and many other diseases; not all these implications are good. Access to appropriate care is becoming more difficult, especially for those who do not know how to use the system. Overall, many deaths due to cancer could be prevented by what is already known. Greenwald carefully defines, then uses, the idea of appropriate care that matches the specific needs of each patient; this concept raises issues of monetary and nonmonetary costs, including the massive costs of simply waiting for a doctor or a hospital bed.

Despite its great strengths, this book has problems. One is style; much of the book seems to be written as if we were already well into the 21st century -- for example, “But in the 1990s, science and medicine did not seem poised for breakthroughs.” A well-informed reader will notice occasional errors of fact, failures to make needed distinctions, or a lack of skepticism about weaknesses in the author's sources. Greenwald properly debunks claims that up to 90 percent of cancers have environmental causes, but he seems to ignore broad epidemiologic information about temporal trends and migrant populations that suggest that the figure is well above 50 percent (though not all of these cancers are necessarily due to feasibly preventable causes). Nor does he refer to the likelihood that decades of intense research, such as have already been devoted to research on treatment, might reveal new causes of cancer and new ways to prevent the disease. His faith in early (not just earlier) detection is tempered by realism, but perhaps not tempered enough. There is no comment on the problem of overdiagnosis of cancer, which has been clearly established for breast, lung, and prostate cancer and may be much more widespread than we think; this should temper conclusions about the value of detecting “cancers” that are very small, are still localized, do not produce symptoms, and are most likely to be found in routine examinations. He gives insufficient attention to recent changes in standards of diagnosis and reporting as a partial cause of recent increases in the reported incidence of cancer (though not mortality). There are numerous redundancies, since many topics recur.

Although Greenwald brings out the need for substantially more attention to prevention, his main message is that for most people who already have cancer, survival depends primarily on gaining access to good, conventional treatment. That will no doubt surprise some readers and disappoint others, but he is exactly right. His book will promote the wider knowledge and the will to act that are the prerequisites for the wider use of appropriate care. Physicians will profit from reading this work, as will their patients, makers of health care policy, and the public at large.

John C. Bailar, M.D.
McGill University, Montreal, QC H3A 1A2, Canada