Musings of a Cancer Doctor

Wide-ranging views and perspective from George W. Sledge, Jr., MD

Monday, May 21, 2018

Oncology Times at 40: Looking Back

Oncology Times is 40 years old this year, a healthy middle age for a print journal devoted to a medical specialty. I started reading it as an Assistant Professor, and enjoyed it for its ability to provide an overview of my chosen profession, as I still do. I read the New England Journal of Medicine, and Nature, and the JCO, each in its own way valuable, each serving a somewhat separate purpose. I have always found Oncology Times useful for taking the pulse of my profession, and for filling me in on advances in diseases I don't see in my clinic. And yes, for the gossip—pardon me, the news—about my colleagues around the country.

I asked our editorial staff to send me the oldest edition they had, so that I might get some sense of how things have changed. The journal has moved about over time, and in those moves, apparently older issues were misplaced. The oldest issues they could find were from 1989, already—at Volume 11—a well-established eyewitness to the world of cancer. I'm sure that somewhere, in the dusty stacks of some medical library, Volume 1 exists.

Or maybe not. Perhaps the first 10 volumes have ceased to exist. In our ever-expanding digital universe, we often catch only brief glimpses of the early universe. Many journals ceased to exist before the internet became the ubiquitous source of knowledge, and as such to most of the current world never existed. Those journals that failed to digitize their early years have also, for practical purposes, eliminated those years from the global consciousness. And given how journals come and go, how long before even many of today's works disappear, their servers no longer maintained by disinterested or extinct publishers?

But enough philosophical maunderings. What did 1989 look like to the Oncology Times?

What impresses, and what I forgot, was how much the period was tinged with AIDS. The entire decade, in fact, was the decade of AIDS in oncology, with spillover into the '90s. Prior to the control of HIV with HAART regimens, AIDS-related malignancy was a growth industry for cancer doctors.

On the very first page of Issue 1, one sees an article devoted to AIDS-related Kaposi's sarcoma, treated with alpha interferon. Subsequent articles discuss the use of MRI for brain infections in AIDS, the WHO global AIDS program, CD4 as a decoy for HIV, GM-CSF for neutropenia in AIDS patients, AIDS-related lymphomas, AIDS vaccine research, and that's just through June of 1989. Every issue had a page devoted to "AIDS Briefs." Oncology Times still occasionally discusses AIDS-related cancers, but they have become rarities, not the career-builders and (increasingly) life-enders they were in that awful decade.

Though I've always been a breast cancer doctor, there was a brief period where I treated patients with Kaposi's sarcoma, though I was never a true AIDS-focused doctor. What I remember most from that era was the story of Ryan White. My current fellows probably don't know that name. Ryan White was a teenager from Kokomo, Indiana, a little north and east of Indianapolis. He had received a tainted blood transfusion for his hemophilia, and then was diagnosed with AIDS late in 1994. He was, shall we say, treated poorly by the good citizens of Kokomo, who banned him from public school and generally abused him with a long litany of indignities. He became a national cause célèbre, the face of AIDS. He lived, and died, bravely.

I would occasionally see him on the IU Medical School campus, where he received much of his treatment and where he died in 1990, just a few years short of HAART and the transformation it created. I have had friends and colleagues with hemophilia, and that period was absolutely terrifying for them. After Ryan White died, the U.S. Congress passed the Ryan White CARE Act to provide health care funding for AIDS patients. Anyone who doubts the reality of medical progress need only remember AIDS in 1989.

And, of course, AIDS-related malignancies were not the only cancer problems on the rise in 1989. Several articles discussing the rising tide of lung cancer deaths, the inadequacy of therapy for the disease, and the need for greater preventive measures. A guest editorial by William Tipping of the ACS, "Taking Tobacco's Measure," is a reminder of what we have accomplished in the smoking cessation arena. In 1989, Congress was voting on legislation limiting smoking on flights greater than 2 hours, almost unimaginable today. The airlines were balking.

On a lighter note, one of the pleasures of reviewing old issues of the Oncology Times is the opportunity to visit old friends. I hate my old pictures. I have never been even minimally photogenic, or maybe I just really look that ugly. I suspect, perusing Volume 11, that some of my colleagues share this statement. There were a lot of really funny-looking moustaches that my friends (I will not name/shame them) no longer wear. And my generation was so young then!

And the older generation? There were giants in those days, and many made it into Oncology Times that year: I see pictures of Bob Young (then still young and just-appointed president of Fox Chase), Bernie Fisher, Larry Einhorn, B.J. Kennedy, Richard Peto, Janet Rowley, Peter Nowell, Syd Salmon, Josh Fidler, and many others. Many of these have passed from the scene, and many are only remembered by aging oncologists soon to retire. We are a field strangely uninterested in our own history, but reading Volume 11 is a reminder, not only of how far we have come, but of the visionaries who brought us to where we are today.

The drug picture was also quite interesting. You see this primarily through the ads. Oncology Times, then and now, survives on advertising revenues, and ads are a great place to look at new drugs. As a breast cancer doc, I see ads for tamoxifen: while the drug had already been around for a decade; adjuvant hormonal therapy was still relatively new. But no HER2-targeted drugs, though there is an article on HER2, primarily as a potential prognostic factor. Trastuzumab was not yet even a twinkle in Genentech's eye, and most of the drugs I use today in the metastatic setting, even the chemotherapeutics, are missing. From a chemotherapy standpoint, a full-page advertisement for Adriamycin bragged "ADRIAMYCIN IS NOW 97% PURE," which says all you need to know about the relative therapeutic poverty of the era.

Today, oncologists can draw on an immense number of agents. My boss, a cardiologist, tells me that most of the drugs he uses are off-patent, which is a foreign thought to today's cancer doctors and the source of both our patients' hopes and economic woes. But in 1989, the biotech revolution was in its infancy, tamoxifen was pretty much the only targeted therapy for cancer, there were no "ibs," no "mabs," nothing we currently take for granted. Even modern supportive care drugs have not yet entered practice: the anti-emetics ads are for Marinol and Compazine.

Oncology Times had a wonderful business reporter at the time, named Robert Teitelman, whose beat was the biotech business. His articles discuss companies I had long forgotten, such as Chiron, Integrated Genetics, Hybritech, NeoRx, and Centocor. Then, as now, the big fish were busy eating up the minnows, and most of these names disappeared into the welcoming arms of some larger company. What differed was the cost of the buy-outs, in the tens of millions as opposed to today's billions. There are hints of what's to come, with a scramble to produce monoclonal antibodies, and lymphoma mentioned as a prominent target, as well as IDEC as a company interested in the area, though no rituximab is yet on the scene. Oh, for a time machine and access to a stockbroker (you couldn't yet order your shares online).

There are other promising notes in that year's issues. The 1989 Nobel Prize for Physiology or Medicine went to UCSF's Michael Bishop and Harold Varmus, for their demonstration that the Rous sarcoma virus was in fact a mutated normal cellular gene. This discovery led to the oncogene revolution, with far-reaching effects for diagnosis and treatment of human cancer. It was clear, even then, that the way forward would require the application of that biologic evolution to the clinic, though it was also evident that the path upward was difficult, twisty, and covered with obscuring undergrowth.

Some things haven't changed. The November issue reports a survey of oncologist's attitudes towards their specialty. Oncologists in 1989 stressed about their patient's high mortality rates, and their own long hours and inadequate work-life balance. But they love their patients, and obtain personal satisfaction from offering them help, even if that help paled in comparison to what we can offer today. Other articles discussed issues we still face: the cost of quality care (if only we knew then how cheap things actually were, and how expensive they were destined to be), nursing burnout and retention, health disparities related to access, race and poverty. In other words, plus ça change, plus c'est la même chose. But the progress is real. I wonder what Volume 80 will say? I hope there is no Volume 80, or no need for it. But until then, Oncology Times will still have a proper place. Read on, for there are wonders ahead.