The Cancer Industry: Hype Versus Reality

Mortality rates from specific cancers rise and fall, but the overall mortality rate today is only slightly less than what it was in 1930, in spite of huge expenditures on testing, treatment and research.

April 23, 2023. I write about lots of inconsequential things. Who cares, really, what quantum mechanics means, or how matter makes minds? But most of us care about cancer, which tortures, impoverishes and kills us. That is why I posted “The Cancer Industry: Hype Versus Reality” on ScientificAmerican.com in 2020. And that is why I am posting this revised, updated version here on my free website. —John Horgan

BIG BUSINESS, BIG HYPE

Cancer is the second biggest killer in the U.S., behind only heart disease. Almost 2 million Americans will be diagnosed with cancer in 2023, according to a recent estimate, and more than 609,000 will die of the disease.

Cancer has spawned an industrial complex involving biomedical firms, hospitals and clinics, government agencies, universities, professional societies, nonprofits and media. More than 1,000 cancer-care centers and programs have sprung up across the U.S., according to one count.

The costs of cancer care keep rising, from $192 billion in 2015 to $208 billion in 2020. Billions more are spent on research by foundations, corporations and government agencies. The 2023 budget of the National Cancer Institute is $7.3 billion.

Cancer-industry boosters assure us these investments are paying off. “We’re making progress,” proclaims the American Cancer Society, a nonprofit that raises money for “advocacy, research and patient support.” The society, which promotes screening and receives support from biomedical firms, presents “stories of hope” from cancer survivors, of which there are 18 million.

A 2016 study found that cancer experts and the media often describe new drugs with terms such as “breakthrough,” “game changer,” “miracle,” “cure,” “home run” and “life saver.” Cancer centers spent at least $173 million on advertising directed at the public in 2014. Nine out of ten top-spending centers engaged in “deceptive marketing,” according to the watchdog group Truth in Advertising. Ads are “overwhelmingly focused on stories of survival or cure, while actual informational content is scant and imbalanced.” 

LITTLE NET PROGRESS BESIDES ANTI-SMOKING EFFORTS

The reality behind the hype is grim. “No one is winning the war on cancer,” Azra Raza, an oncologist at Columbia, asserts in her 2019 book The First Cell: And the Costs of Pursuing Cancer to the Last. Trials have yielded improved treatments for childhood cancers and specific cancers of the blood, bone-marrow and lymph systems, Raza says. But these successes, which involve uncommon cancers, are exceptions among a “litany of failures.”

The best measure of progress is mortality rate, the number of people who succumb to cancer per unit of population per year. The risk of cancer grows with age. (Although childhood cancer gets lots of attention, Americans under 20 years old account for less than 0.3 percent of all U.S. cancer deaths.) Hence as the average life span of a population grows (for example, because of advances against heart and respiratory diseases), so does the cancer mortality rate. To calculate mortality trends over time, therefore, researchers adjust for the aging of the population.

With this adjustment—which, keep in mind, presents cancer medicine in a more favorable light—U.S. mortality rates have dropped 33 percent since 1991 to 143.8 deaths per 100,000 people, according to a 2023 report of the American Cancer Society. The report says the decline “increasingly reflects advances in treatment.” But the three-decade decline follows at least six decades of increases in cancer mortality, particularly among males. The age-adjusted cancer mortality rate in 2020 is only slightly lower than it was in 1930.

The rise and fall of mortality from lung cancer, which is by far the deadliest cancer, follows the rise and fall of smoking.

The rise and fall of cancer deaths track the rise and fall of smoking, with a lag of a couple of decades [see chart]. Cigarette consumption in the U.S. more than doubled between 1930 and the early 1970s and has fallen steadily since then, according to the nonprofit Our World in Data. Smoking raises the risk of many cancers but especially of lung cancer, which kills many more people than any other type of cancer.

Over the past three decades lung-cancer mortality has dropped in the U.S., but it still remains higher than it was in the 1960s, especially among women, according to Our World in Data. These data suggest that reductions in smoking are the primary contributor to recent declines in cancer mortality. 

NEW TREATMENTS YIELD SMALL BENEFITS, BIG COSTS

Research has linked cancer to many internal and external factors, notably oncogenes, hormones, viruses, carcinogens (such as those in tobacco) and random cellular-replication errors, or “bad luck.” But with the notable exception of the smoking/cancer link, which provoked effective anti-smoking measures, that knowledge has not translated into significantly improved preventive measures or treatments.

Pharmaceutical companies keep bringing new drugs to market. But clinical-cancer trials “have the highest failure rate compared with other therapeutic areas,” according to a 2012 paper. One study found that 72 new anticancer drugs approved by the FDA between 2004 and 2014 prolonged survival for an average of 2.1 months. A 2017 report concluded that “most cancer drug approvals have not been shown to, or do not, improve clinically relevant end points,” including survival and quality of life. 

Costs of cancer treatments have vastly outpaced inflation, and new drugs are estimated to cost on average more than $100,000/year. Patients end up bearing a significant proportion of costs; more than 40 percent of people diagnosed with cancer lose their life savings within 2 years, according to one estimate.

Immunotherapy, which seeks to stimulate immune responses to cancer, has generated “widespread excitement” and a “gold rush mentality,” The New York Times reported in 2016. According to a 2018 report in Stat News, drugs firms aggressively market immunotherapies, and patients are “pushing hard to try them, even when there is little to no evidence the drugs will work for their particular cancer.”

A 2017 analysis by oncologists Nathan Gay and Vinay Prasad estimated that fewer than 10 percent of cancer patients can benefit from immunotherapies, and that is a “best-case scenario.” Oncologist Siddhartha Mukherjee (author of The Emperor of All Maladies, a bestselling history of cancer medicine) reported in The New Yorker in 2019 that immunotherapies can trigger severe side effects and cost $1 million per patient or more; if widely prescribed, immunotherapies could “bankrupt the American health-care system.”

OVERDIAGNOSIS AND OVERTREATMENT

Evidence suggests that widespread screening of asymptomatic people does more harm than good.

The cancer industry, aided by organizations like the National Football League and celebrities who claim that tests saved their lives, asserts that screening reduces cancer mortality. The earlier cancer is detected, the better. Right? Wrong. Many of us have tumors and other anomalies that would never have compromised our health if left untreated.

Tests cannot reliably distinguish between harmful and harmless anomalies. Hence increased, higher-resolution testing leads to increased overdiagnosis, the term for diagnosis based on detection of harmless anomalies. Overdiagnosis leads in turn to overtreatment with unneeded chemotherapy, radiation and surgery. Gilbert Welch, a public-health expert who has drawn attention to overdiagnosis, calls it “an unfortunate side effect of our irrational exuberance for early detection.”

Mammograms and prostate-specific antigen (PSA) tests for breast and prostate cancer produce especially high rates of overdiagnosis. A 2013 meta-analysis by Cochrane, a nonprofit that assesses medical procedures, estimates that for every woman whose life is extended by a positive mammogram, ten healthy women are treated unnecessarily.

Another medical-assessment nonprofit, theNNT.com, offers an even more disturbing analysis. (NNT stands for “number needed to treat,” which refers to the number of people who must receive a treatment for one person to receive any benefit; ideally, the number is one.) The NNT notes that overdiagnosed women might “die due to aggressive therapies such as chemotherapy and major surgery.” Thus any benefit from screening “is balanced out by mortal harms from overdiagnosis and false-positives.”

As for PSA tests, a 2013 meta-analysis by Cochrane found “no significant reduction” in mortality related to prostate cancer. The NNT.com states that widespread PSA overdiagnosis leads to unnecessary biopsies, surgery, radiation and chemotherapy, which can result in incontinence, impotence and other harm. The discoverer of the prostate-specific antigen has called the PSA test a “profit-driven public health disaster.”

THE FALSE COMFORT OF SURVIVAL RATES

Studies of tests for a specific cancer generally look at mortality attributed to that cancer. Mammograms are thus deemed effective if women who get mammograms die less often from breast cancer than women who do not get mammograms. This method can overstate the benefits of tests, because it omits deaths resulting, directly or indirectly, from the diagnosis. As noted in the previous discussion of mammograms and PSA tests, treatments can have iatrogenic effects, including heart disease, infections, other forms of cancer and suicide.

Therefore some studies measure “all-cause” mortality, death from any cause.  A 2015 meta-analysis by epidemiologist John Ioannidis (renowned for bringing the scientific replication crisis to light) and others found no reductions in all-cause mortality from testing of asymptomatic patients for cancer of the breast, prostate, colon, lung, cervix, mouth or ovaries.

In an editorial in the European Journal of Clinical Investigation, Ioannidis and four co-authors propose that cancer screening (especially mammograms and PSA tests) does more harm than good and should be abandoned. They warn that this proposal will be met with “fierce opposition.” Screening, they note, “is big business: more screening means more patients, more clinical revenue to diagnostic and clinical departments, and more survivors in need of care and follow‐up.”

Cancer-industry boosters commonly cite increased survival rates, which measure the time between diagnosis and death, as a sign of progress. Survival rates for some cancers have indeed grown as a result of higher-resolution testing, which detects cancer earlier. But as a 2015 analysis points out, in general people do not live longer as a result of early detection; they simply live longer with a diagnosis of cancer, with all its harmful emotional, economic and physiological consequences.

Let me be blunt: The evidence suggests that, as a result of widespread screening, millions of men and women have endured the trauma of cancer diagnosis and treatment unnecessarily. This strikes me as a case of massive medical malpractice. 

CORRUPTION IN THE CANCER INDUSTRY

The aggressive, competitive, can-do American approach to health care isn’t working when it comes to medicine in general and cancer medicine in particular. The U.S. spends far more per capita on health care than any other country, but higher expenditures have not led to longer lives. Quite the contrary. Europe, which spends much less on cancer care than the U.S., has lower cancer mortality rates, according to a 2015 study.

The emphasis on profits also fosters corruption. In 2019 The N.Y. Times and ProPublica reported that top officials at Sloan Kettering Cancer Center “repeatedly violated policies on financial conflicts of interest, fostering a culture in which profits appeared to take precedence over research and patient care.”

In a 2019 essay in Stat News, oncologist Vinay Prasad notes that many cancer specialists accept payments from firms whose drugs they prescribe. This practice, Prasad agues, “leads us to celebrate marginal drugs as if they were game-changers. It leads experts to ignore or downplay flaws and deficits in cancer clinical trials. It keeps doctors silent about the crushing price of cancer medicines.”

The desperation of cancer researchers for positive, monetizable results might also compromise the quality of their work. A 2012 examination of 53 “landmark” cancer studies found that only six could be reproduced. Similarly, the so-called Reproducibility Project: Cancer Biology has had difficulty replicating peer-reviewed research on the biology of cancer. 

THE CONSERVATIVE SOLUTION

What’s the solution to all these problems? Some health-care experts espouse “conservative medicine” to reduce health-care costs and improve outcomes. In “The Case for Being a Medical Conservative,” four physicians urge colleagues to recognize the body’s self-healing capacity and to acknowledge “how little effect the clinician has on outcomes.” Physicians will thus protect themselves “against our greatest foe—hubris.” Medical conservatives adopt new therapies only “when the benefit is clear and the evidence strong and unbiased.”

Conservative cancer medicine, as I envision it, would engage in less testing, treatment, fear-mongering, military-style rhetoric and hype. It would recognize the limits of medicine, and it would honor the Hippocratic oath: First, do no harm. Physicians cannot bring about a shift toward conservative cancer medicine on their own. We consumers must help them. We must resist tests and treatments that have dubious benefits and recognize the limits of medicine.

We may never cure cancer, which stems from the collision of our complex biology with entropy, the tendency of all systems toward disorder. But if we can curtail our fear and greed, our cancer care will surely improve.

A final note: I’d like to thank the experts cited above as well as Cochrane and theNNT.com for their blunt, brave assessments of cancer medicine. People and groups like this represent our best hope for health-care reform. We just have to listen to them.

Further Reading:

See my follow-up column: We’re Too Scared of Skin Cancer.

Advice to Aspiring Science Writers: Think Like Marx

My Controversial Diatribe Against “Skeptics”

Keep an eye on this space for a follow-up column on colonoscopies.