Hospitals and Health

GUEST: Paul Marks
VTR: 2/15/1982

I’m Richard Heffner, your host on THE OPEN MIND. In December 1980, Paul Marks, a distinguished physician, former Dean of the Faculty of Medicine at Columbia, became President of Memorial Sloan Kettering Cancer Center, the most comprehensive private hospital and research institute in the United States dedicated to the cancer problem that looms so large in the life of each person on this planet. In his inaugural remarks, Dr. Marks raised several question, raised several points that must command the most profound attention of all of us. “What can we reasonably expect to achieve in reducing the burden of cancer”, he asked, pointing out that we have two approaches to decreasing the death rate from cancer: prevention and treatment. And I’d like to talk with Dr. Marks about both of them.

Thanks for joining me today, Paul Marks. And I want to say that, starting with prevention, you comment further in your inaugural remarks that we can anticipate that over the next several years we will identify an increasing number of preventable causes of common cancers. But you go on to say that environmental factors which contribute to the causation of up to 80 percent of all cancers are perceived by many to be an inevitable part of our daily lives. What chance do we have then of preventing cancer?

Marks: Well, I think that the problems related to the prevention of cancer, as you imply, are very complex. We’re now in the process, which has been one that’s been going on over a number of years but has been really intensified, I believe, over the last four or five years, or identifying the relationship between certain environmental factors and the process of cancer. What’s also become apparent, particularly in the last three to five years, is the fact that the, all of us carry genes probably that play a role in determining susceptibility or resistance to many forms of cancer. And the interaction between environmental factors and our genetic makeup are probably very important aspects of our understanding of the process of cancer. And through that process hopefully we will be able to define approaches to prevention. Now, it’s clear, as for example the Surgeon General just reaffirmed, that one of the factors, one of the environmental factors contributing to many forms of cancer, particularly lung cancer, appear to be certain elements in cigarette smoke. And we’ve known that for a number of years, and yet the incidence of lung cancer has not shown any dramatic decrease. Presumably this relates to the fact that there is a very important missing link in our understanding of how to prevent cancer – and I mean this very substantively – which is now to translate our scientific knowledge, if you will, our understanding, which is increasing, of the factors involved in cancer into the practical terms that motivate people to do their part so to speak in approaching this whole question of prevention of cancer.

Heffner: You’re being very kind. It seems to me as you just suggested the Surgeon General has again reaffirmed what just about everybody has known. And I think you and I both know people who will say, “Yes, we know”, and continue to puff. Now, that’s not a problem that you have at your institution because you want to prevent cancer. But essentially aren’t people simply saying “We don’t care enough”, that it’s not your fault that your ability to communicate or inability, but we just don’t care enough? Could it be anything else?

Marks: There are tradeoffs obviously in all these things. And what you might say is that I doubt very much that anyone would come straight up and say to you (at least it hasn’t been my experience), that, “I don’t really care whether I get cancer or I don’t get cancer”. The tradeoffs that seem to be involved in the kinds of interventions that are called upon on the part of the individual to participate as they must, because prevention is going to demand a great deal of participation on the part of the individual, and I can get to some other examples other than smoking in a minute, the tradeoffs are the things we have to analyze. Why do people smoke in the fact of what is a recognized hazard to health? And we don’t fully understand that in the ways that we can provide these individuals with either a substitute, a safer substitute for whatever smoking provides them, or be able to, from a behavioral point of view, motivate them to modify their personal behavior. Now, that may be a little complicated way of looking at the problem, but I think from my experience it’s probably as realistic an approach as we have.

Heffner: Surely we’ve scared the hell out of people by now.

Marks: And that isn’t working. It simply isn’t working. Scaring people doesn’t work. Because, you know, I think in part this may have to do with the nature of cancer. The fact that there is such a long lag period apparently between the insult and the clinical appearance of cancer as we know. I mean, the data suggest that you may have to be a smoker for 15 to 20 years to see the effect. And also there is the fact that only a relatively small proportion of the population that smokes gets cancer. So clearly people can opt out by saying, “Well, it’s going to be the other person”.

Heffner: You mean its Russian roulette?

Marks: Russian roulette. But it really isn’t obviously. That’s one of the areas I think where research is going to be very important. We have to be able to begin to understand why some people seem to be more susceptible to environmental hazards such as smoking in relation to cancer and others less susceptible. Whether this, whether through such knowledge, approaches that will be able to focus on individuals, so to speak, who have that susceptibility will provide us with a better program I prevention or not I can’t say. But clearly I’m optimistic that it will. I think if we go up to an individual, so to speak, and can identify the risks to the individual as opposed to the population, you will advance the program of prevention of cancer substantially.

Heffner: Has that been true in those groups where perhaps you haven’t found the test mechanisms to be able to say to an individual, “You’re at risk”, where there’s been a history of cancer, have you found success in getting people to avoid that environmental input, that environmental insight?

Marks: Well, I think the data are very limited because our capacity to really identify the individual at risk for one or another cancer is relatively limited right now. But I would say that in at least two groups where it has been possible to identify individuals at risk for cancer – and these are rare forms, in one instance of breast cancer, the other instance of colon cancer – there’s no question that programs of prevention have been effective, have literally changed the prognosis in these individuals. I would emphasize the experience is limited because they’re relatively rare. They are instances however where we have the capacity to identify a person, a specific person at risk.

Heffner: What about the other environmental causes that put people, not genetically, but otherwise at risk? The certain things in the air, certain things that we manage to pollute the air with, certain materials. Are you satisfied that we’ve made more, less, or the same progress or lack of progress that we’ve made in the area of cigarette smoking?

Marks: Well, clearly we, there are a few instances where an environmental factor plays a very strong role in increasing the incidence of a particular kind of cancer such as asbestos or polyvinyl chloride, where there is a clear relationship between exposure to these agents and certain kinds of cancer. It does however seem that for the really common forms of cancer, specific environmental factors that are playing a role are broad and complex, or whether it means that genetic factors are very much more important, say, than the environmental factors, we don’t yet. But we are beginning to, for example, understand on a molecular level how genes can affect susceptibility. And it’s clearer that the mechanisms involved may include, if you will, the turning on of these genes which are normally turned off. In other words, these genes exist but they are not turned on. The turning on of these genes may relate to specific environmental factors. In the models that have been explored these factors are viruses. It’s clear also that probably very few human cancers are actually related to viral etiologies, but viruses are being shown to be an environmental factor in the causation of certain, a few types of cancer.

Heffner: Do developments in genetic manipulation add to any optimism you might feel given what you’ve just said?

Marks: Well, they certainly add to my optimism with regard to our ability to probe the basic nature of the cancer process. The new techniques of recombinant DA, of the development of specific antibodies through hybridomas are giving us extremely powerful tools to probe these problems. And I think that basically as we increase our understanding we will begin to get very practical approaches to prevention and early diagnosis. And I think that’s where the payoff is going to be down the pike in progress in cancer.

Heffner: Early diagnosis?

Marks: Early diagnosis. Right now even the common forms of cancer such as breast cancer, cancer of the colon, and so on are curable if they’re diagnosed early. And I couldn’t emphasize that enough. I mean, the cancer is clearly a curable disease if certain circumstances prevail. And the chief among them that we can identify right now is early diagnosis.

Heffner: And how good are your tools and the mechanisms for early diagnosis?

Marks: It varies with the kind of cancer of course. And on the whole they’re not as good as we would like them to be. But I would say that in the majority of cases we should be able to diagnose breast cancer early at a stage when it is curable by surgery. Similarly in other forms of solid tumors that involve organs that are relatively accessible we should be able to diagnose them early and have the opportunity to cure them by surgery. In some instances, some few cancers such as Hodgkin’s disease, early diagnosis means that we can cure the vast majority by radiotherapy or radiotherapy and chemotherapy. Again the recurring theme I think throughout the scope of cancer is the importance of early diagnosis.

Heffner: Dr. Marks, is there – I won’t say a reliable – but is there or are there mechanisms that are general, that are systemic in their capacity to identify the presence of cancer cells in an individual, a blood test, whatever it might be?

Marks: No. I think there are very few things to which you can give a categorical answer to this problem. But i would say that there is no specific, reliable blood test for cancer. There are blood tests which are helpful in the diagnosis of certain types of cancer, but usually they’re only helpful, rarely are they specific, and rarely can you make the diagnosis solely on the basis of blood test. It’s usually a combination of careful history, clinical examination, and a variety of laboratory tests.

Heffner: Well, if we’re resistant as a population in large numbers at any rate to doing something intelligent about the knowledge we have about the relationship between smoking cigarettes and the development of cancer and other diseases, how resistant have we been to the effort we’ve made at early diagnosis?

Marks: well, I think here too we have a major problem. Because we technically have a greater capability for early diagnosis of various type of cancer than I think is apparently occurring based on the stage of cancer which we see on the average as patients come in.

Heffner: You mean we’re not taking advantage?

Marks: Individuals are not taking advantage of the technical capability. It’s also fair to say that sometimes physicians are not bringing to bear all the technology we have in making the diagnosis.

Heffner: Technology or attitudes?

Marks: Well, it’s both in a sense. In other words, the patient has, I mean the individual has to recognize that while cancer is a serious problem it is not necessarily a fatal problem by a long shot. Forty-five percent of the patients coming into Memorial Hospital today have the expectation of leaving with the cancer cured. That is I think a substantial achievement that has occurred slowly over the last several decades, but also it is a sort of a very positive fact, I would think. Most people are surprised that it’s that high. And we aren’t including things like skin cancer or cervical cancer, where the cure rate should be essentially 95 to 100 percent.

Heffner: You’re not upping the cure rate with those?

Marks: We’re not, no. they’re not including these kind of data. Because I think that that would distort the…

Heffner: Right, right.

Marks: So I would say that it is extremely important for individuals to be sensitive to the fact that cancer can potentially be cured. One of the most determining factors right now is early diagnosis. And the extent to which we can achieve early diagnosis. And the extent to which we can achieve early diagnosis relies very heavily on the individual, the willingness of the individual, the ability of the individual to go to their physician at a time when they, some of the supposed signs of cancer may occur.

Heffner: But then you suggested that aside from the willingness or unwillingness there is the phenomenon of the physician using the technology available.

Marks: That’ right.

Heffner: And you have some question about whether that’s done sufficiently.

Marks: That’s right. I think that there are techniques now for examination, particularly of internal organs, which require fairly sophisticated equipment and even sophisticated or experienced interpretation of the findings with these various techniques. I think they are becoming more broadly available, but I would suspect they’re not uniformly available and used at the same level of expertise throughout the, say, the health care system, if you can characterize health care as a system.

Heffner: Are there regional centers so that perhaps Memorial Sloan Kettering Center is a regional center as well as a national center to which individuals could insist that they be allowed to repair?

Marks: Well, that’s a very pertinent question, and one that we’re trying to deal with now. The answer of course is that it isn’t just the regional, so-called comprehensive centers that I think have this capability by a long shot. Many community-based hospitals and community-based physicians have requisite levels of expertise in these areas. But there are clearly networks now that are being developed, fostered in no small part by the National Cancer Program which came into law just about a decade ago, which have this concept that comprehensive centers such as Memorial would link up with community-based hospitals to assure state-of-the-art transfer of know-how in diagnosis as well as treatment. I think this is happening to a greater or lesser extent in different parts of the country or more or less effectively. It’s not yet uniform. But it is true that some places do it better than others. And that’s one of the problems of the system. How do you identify the places that do it better than others?

Heffner: How?

Marks: How? I guess one of the ways is having a good friend you know who’s a physician, who is knowledgeable as to what centers really are state-of-the-art or where a doctor is really state-of-the-art. It is unfortunately not a very, I might say, not a very rigorous area where individuals can always be assured of state-of-the-art care.

Heffner: You know, that answer, which I know is sincere and is real, is the scariest thing I’ve heard in a long time. But I know how right you are. But our time is short. Let me ask you about this business of, you said, before we talked about this a moment ago, but you wrote in your inaugural comments, “People may not be willing to change their living habits in order to diminish their chance of getting cancer in old age. Nor is it certain that they should be frightened, legislated, or otherwise coerced into doing so”. Why do you say that?

Marks: Well, because again, not based on any rigorous scientific analysis, but I, you know, I instinctively approach this problem by feeling that there are tradeoffs in everything we do. In other words, legislating certain types of behavior is anathema in our society.

Heffner: We do it to kids going into school. You can’t get into school without certain injections.

Marks: That’s true. But it’s still anathema as you know. I mean, there are really problems even there. And we’ve had to take what in our society appear to be rather extreme measures to make sure that what we feel is the best health practices are maintained. When you move into areas where we’re less certain, such as the cancer area, certainly less certain on an individual basis even in the smoking thing, you begin to have to deal with the question of what’s the payoff. And we can’t give an individual the payoff. We can give a population the payoff. And that is a payoff only in a very narrow sense. I mean, what are sacrificing in terms of the individual or in terms of a larger group of individuals by scaring, trying to scare people into doing one thing or another? I can cite some of the potential gains. I can’t fully fill out the other half of the ledger.

Heffner: the other question that I wanted to put to you, you said at the end of your comments, “This search for progress in our understanding of the nature of cancer cannot in any sense be a crash program”.

Marks: Right.

Heffner: I gather we’ve learned that in our efforts to pour funds into crash programs.

Marks: Right. Well, we’re learning it.

Heffner: You mean we haven’t learned it yet?

Marks: We haven’t learned it completely. I think that if there is one thing that I would hope we are learning is that progress in cancer, in the control of cancer, is slow. Now, I think even some of my colleagues have overpromised in this area, in the sense of the fact that one cannot define a timetable for specific achievements related to any specific area of cancer. The very nature of the problem requires what we call basic research. And by definition, “basic research” means we don’t know the answers. So we don’t know when we’re going to get them. Also, I think there’s one other aspect. And I would try to say this in perspective because it may sound a little frightening. I think cancer is a very varied disease, first of all. There is not just one type of cancer. So there’s not just going to be one approach to the control of cancer; there are going to be a variety of approaches, a variety of treatments. The other thing that I think is becoming apparent is that cancer or the development of cancer in certain instances at least may be part and parcel of living if you will. The concept that we’re going to eliminate cancer the way we eliminated polio does not seem to be scientifically a sound one. And we certainly can reduce markedly the burden of cancer on society and for the individual make the total difference if we can cure it. But I think if what we are looking for as a society is a vaccine to prevent cancer or a treatment that’s going to just cure it so long as we diagnose it early when we get it, that I don’t think is in the cards on the basis of the very biology, if you will, of the problem.

Heffner: Dr. Marks, what will be the impact of that thought, of those comments on funding for basic research in this area?

Marks: I don’t know what it will be. What I would like it to be is an understanding that this is a continuing long-term effort that is going to be required to really substantially reduce the burden of cancer in our society. I think that as we go forward we will make progress. That progress will be studied. It will be substantial. In terms of dollar return it will be enormous, because just in terms of the cost of caring for patients with cancer it is much less expensive to care for a patient with cancer that we can cure because of early diagnosis than it is for the patient who we are maintaining as we gain the ability to maintain for long periods of time. And of course the impact of cancer on the individual, cutting short life, the impact on the family and so on, those costs are very difficult to estimate.

Heffner: Thanks, Paul Marks. Thank you very much for joining me today on the Open Mind. And thanks, too, to you in the audience. I hope you’ll join us here again on THE OPEN MIND. Meanwhile, as another old friend used to say, “Good night and good luck.”