50 years after the US declared war against cancer, the fight continues. These are the 10 biggest victories. – USA TODAY

Fifty years ago today, President Richard Nixon officially declared war on cancer.

In signing the National Cancer Act and increasing funding for cancer research in 1971, Nixon said with confidence that if the nation could put a man on the moon in eight years, it could solve cancer in the same timeframe.

It turned out to be far more challenging.

Roughly 600,000 Americans die of cancer every year, and many more worldwide.

The fact that cancer hasn’t been solved even after 50 years of dedicated work doesn’t mean the effort was a failure – just that the goal was an audacious one and the task difficult, according to more than a dozen experts USA TODAY spoke with about the anniversary. 

Without aiming big, much less would have been accomplished, said Dr. Claire Pomeroy, president and CEO of the Albert and Mary Lasker Foundation, whose co-founder, Mary Lasker, lobbied Congress and the president to pass the act.

“You have to have a common message that mobilizes everybody around a common goal,” Pomeroy said. “We all remember the War on Cancer.”

For most major cancer types, there’s been incremental but real progress over the decades.

Over the past 50 years, death rates dropped by 70% for childhood cancer, 56% for colorectal cancer and 39% for female breast cancer, according to the American Cancer Society. Five-year survival for lung cancer has improved in the past decade thanks to targeted therapies and immunotherapies.

Unfortunately, some cancer types, including pancreatic cancer and glioblastoma – the worst kind of brain cancer – remain nearly as deadly as they were when Nixon was president.

“The more we understand about the biology of cancer, the more amazingly complex and mysterious it is,” said Fred Appelbaum, deputy director of the Fred Hutchinson Cancer Research Center in Seattle.

Not much was known about the difference between tumor cells and healthy ones back in Nixon’s time, said Dr. David Tuveson, an expert in pancreatic cancer at Cold Spring Harbor Laboratory Cancer Center in New York and president of the American Association for Cancer Research. “We didn’t actually know what cancer was.”

Since then, researchers have learned that cancer is created when some cells develop genetic mutations that allow them to reproduce wildly without being detected by the immune system.

Sometimes, those mutations are inherited from parents, sometimes they come from environmental causes such as tobacco or sun exposure, sometimes from pathogens such as the human papillomavirus (HPV). Sometimes it’s age or simply bad luck.

Different causes, we know, may require different treatments.

Some of the advances have been in new technologies, such as proton beam therapy that’s “totally amazing” for treating cancers in children and brain tumors, Tuveson said. 

Other advances came by learning what doesn’t need to be done.

Surgeons used to perform very aggressive double-mastectomies on every woman with breast cancer; now it’s known that in many cases, a lumpectomy is just as effective.

The National Cancer Act created a network of cancer centers – including the Fred Hutch, MD Anderson, Dana-Farber and Memorial Sloan-Kettering – now numbering 70 nationwide, which emphasize research as well as clinical care.

Those centers encouraged collaborations between research scientists and the doctors who treated patients and involve biologists, neurologists, physicists and other specialists, as well as industry. 

But the system remains too fragmented, said Kathy Giusti, founder of the Multiple Myeloma Research Foundation. More could be accomplished if researchers simply talked to each other, she said.

Many of the scientific advances made against cancer remain available only to a limited population, noted Harold Freeman, a retired breast cancer surgeon.

In a sense, the War on Cancer was destined to fail from the start, Freeman said, because it focused on research advances rather than on delivering those advances to everybody who needed them.

“I think we need to give high praise for what has happened – I’m thrilled by what has happened,” said Freeman, a past president of the American Cancer Society. “But I think we have to rethink what we mean by winning the war on cancer.”

It needs to be guerrilla warfare, he said, fought in every community in the country.

Cancer doctors and researchers, people who have spent their entire careers fighting this invisible foe, said they’ve never been more optimistic. 

“There’s never been an era like the last 10 years,” said Dr. Peter Pisters, president of the University of Texas MD Anderson Cancer Center. “We have so much hope, optimism and excitement for what lies ahead.”

To take stock of the National Cancer Act’s impact, USA TODAY compiled a list of the top advances in cancer care since its passage 50 years ago. To develop the list, we spoke with 14 cancer researchers and doctors, from a current and former head of the National Cancer Institute, to leaders in the field of immuno-oncology, radiology, gynecology and prevention, among others.

1. Imaging

Doctors and researchers can see inside the body, identifying and diagnosing tumors, tracking their progress and determining if treatment is working. It’s hard to remember a time before MRIs and CT and PET scans, but they have transformed cancer care. 

Before CT scans, which also celebrate their 50th anniversary this year, surgeons had to open someone up to see what was going on, said Dr. Elliot Fishman, a professor of radiology at Johns Hopkins Hospital in Baltimore.

In the recovery room, they either told patients, “Good news I found nothing,” Fishman said, or bad news that they had cancer. “Now, you have symptoms and you get a CT scan, and then you’re able to see what’s going on.”

New modalities that can track cellular metabolism offer even more promise for understanding how cancer works and how to fight it, he and others said.

2. Survivorship

As more people live for years with or after their cancer, the medical establishment focuses on ways to improve quality of life for those who long outlive their diagnosis.

Advances include lowering doses of chemotherapy and radiation, performing minimally invasive and less radical surgeries and helping people recover physically and emotionally from the trauma of diagnosis and treatment.

“Many times, less is more,” Pisters said.

Pharmaceutical companies don’t want to conduct studies that say lower doses of their drug would be just as effective, he noted, so federal funding for cancer research plays an important role in learning when it’s OK to dial back treatment.

3. Prevention

The single biggest reduction in cancer deaths has come from smoking cessation.

“There are still 30 million Americans who smoke, but it’s a lot less than it used to be and it has a profound impact on public health,” said Dr. Ned Sharpless, director of the National Cancer Institute. Smoking cessation reduced rates of lung, head and neck and bladder cancer, as well as heart and lung disease.

Getting rid of carcinogens such as asbestos also made a difference, he said.

Other areas of prevention include the HPV vaccine, which prevents cervical cancer in women and head and neck cancer in men. 

Efforts to reduce obesity need work, experts said, as weight-related cancers are poised to overtake those caused by tobacco.  

4. Screening

Early diagnosis can increase survival in many cancers, and screening tools such as colonoscopies and, for women, pap smears and mammograms, have reduced cancer deaths.

Most of the breast cancer patients she saw 30 years ago were diagnosed with lethal stage 4 tumors, said Carol Brown, a gynecologic oncologist at Memorial Sloan Kettering Cancer Center in New York City. Now, most are caught at stage 1 when they are much more treatable. 

Breast cancer mortality among women has fallen more than 40% since it peaked in 1989, said Ahmedin Jemal, an epidemiologist at the American Cancer Society. In earlier years, about half of the decline came from screening and the other half from better treatments. More recently, treatment advances have driven improvements, he said.

Lung cancer screening for former smokers is underused but highly effective at identifying tumors early when they are more treatable.

Researchers speak with great hope about the potential for “liquid biopsies” – detecting cancer cells in blood or urine long before they can be spotted on a mammogram or with a biopsy.

5. Genetics  

Cancer researchers discovered in the 1970s that cancer is basically a disease of genetics.

That means some people inherit extra risk from their parents, and by identifying those with risk genes, such as ones associated with breast and ovarian cancer, they may be able to take preventive action to change their fate.   

Genetic sequencing of the differences between tumor cells and healthy ones can help researchers understand what goes wrong with cancer and what they can do to reverse the problem.

6. Personalized, targeted therapy

Even people with the same type of cancer may need very different treatment. Lung cancer used to be categorized into one of two subtypes. Now there are dozens, each of which can be effectively treated, but not with the same therapy.

“It was always this one-size-fits-all philosophy. Now, it’s (everyone) is different,” Fishman said. “It’s being able to figure out what makes people unique and how to treat their disease.”

Identifying a person’s cancer at the molecular level, made possible by advances in genetics, can help match patients to effective therapies.

As examples, experts most often cited therapies such as Gleevec, which transformed treatment of gastrointestinal stromal tumors, and herceptin, a monoclonal antibody that can reduce the rate of a breast cancer relapse by 50%.

7. Combination treatments  

Many treatments fail because cancer develops resistance to them. Researchers are increasingly discovering ways to provide better treatments by combining therapies, maybe several different types of chemo, or surgery followed by chemo plus immunotherapy.

Hitting the cancer from several different directions at once or in sequence may enable patients to live longer or even reach a cure.

Big data and artificial intelligence have begun to make a major difference in treatment by identifying the most effective combinations, said Robert Weinberg, a biologist at the Massachusetts Institute of Technology.

8. Cost consideration 

As the cost of cancer therapies skyrockets, cancer doctors are thinking more about the “financial toxicity” of treatments that can run into the tens or hundreds of thousands of dollars a year, regardless of insurance coverage.

The National Cancer Institute funds a lot of research trying to understand this terrible cancer “side effect,” Sharpless said. When he was in medical school, doctors were taught not to worry about the cost of a treatment. “If you don’t have an appreciation of the costs,” he said, “you might treat their cancer but also cause bankruptcy and financial ruin.”

Unfortunately, incentives that encouraged companies to find innovative cancer therapies add to this problem, he said. The hope is that once new therapies become available, their costs can eventually be brought down.

“That’s an issue that keeps us up at night at the NCI,” he said.

Money – and health insurance coverage – affects the quality of care people receive.

Almost 65% of people over 50 with private insurance have had a colonoscopy compared with 30% of those who are uninsured, Jemal said. About 20% of teenage girls in Mississippi are screened for HPV, compared with 80% in some New England states.

9. Immune warriors

Research has repeatedly shown the power of the immune system to fight cancer once it learns how to distinguish between healthy cells and cancerous ones.

Decades ago, the National Cancer Act supported the advancement of bone marrow transplants now used to treat blood cancers as well as conditions unrelated to cancer, such as sickle cell disease, Appelbaum said.

Melanoma used to be a rapid death sentence, but drugs that lift the brakes cancer places on the immune system have transformed its treatment, offering long-term survival for a large fraction of patients. Other tumors, including some lung cancers. have responded well.

Another type of immune therapy, in which immune cells are removed from the body and engineered to attack cancer, has been effective against many types of blood cancer.

Researchers work to improve their control over the immune system, extending immunotherapy’s benefits to more people and tumor types. 

There is hope, Weinberg said, that immunotherapy “will actually elicit cures in patients who were otherwise destined to die rather quickly.”

10. Access and empowerment

Deaths from cancer would fall precipitously if people everywhere in this country had the same access to care as the wealthiest Americans, Freeman and others said.

Disparities research has become a respected field as more scientists realized that interesting insights could come from understanding why one group of cancer patients fares better than another.

Breast cancer is often deadlier for Black women than white, for instance, Freeman said. That’s in part because Black women tend to develop an aggressive form of the disease but also because they have less access to mammograms and treatments such as tamoxifen that prevent recurrence. They receive less education on health behaviors that might reduce their risk, he said.  

Patients have become more empowered and often drive research agendas.

In the mid-20th century, few people would even say the word “cancer” out loud. The National Cancer Act removed a lot of the stigma around a diagnosis, said Pomeroy of the Lasker Foundation. 

“Patient empowerment and openness in our society about cancer is critical to the advances that have been made,” she said.

Social media and the internet opened more opportunities for cancer patients to learn about their disease (using reliable sites), to communicate and commiserate with others in similar circumstances and to collaborate and organize to fight their cancer, said Giusti, who founded the Multiple Myeloma Foundation as part of her own battle against the blood cancer. 

“With all this science and great hope out there, it’s (still) up to patients to find the best approaches for them,” she said. “That can be helped with social media and things like that, but it can also be the greatest challenge and frustration. They’ve got to figure out how to do it wisely.”

SOURCES: 

Fred Appelbaum, executive vice president and deputy director of the Fred Hutchinson Cancer Research Center in Seattle. He studies the biology of blood cancers.

Carol Brown, a gynecologic oncologist at Memorial Sloan Kettering Cancer Center in New York City.

George Demetri, senior vice president for experimental therapeutics and an institute physician at the Dana-Farber Cancer Institute and a professor at Harvard Medical School in Boston. He is an expert in sarcomas and gastrointestinal stromal tumors.

Dr. Andrew von Eschenbach, president of the consulting group Samaritan Health Initiatives and former director of the National Cancer Institute and Food and Drug Administration commissioner.

Dr. Elliot Fishman, a professor of radiology at Johns Hopkins Hospital in Baltimore.

Harold Freeman, president and CEO of the Harold P. Freeman Patient Navigation Institute in New York City. He is a professor of surgery emeritus at Columbia University and served as director of surgery at Harlem Hospital.

Kathy Giusti, founder of the Multiple Myeloma Research Foundation (MMRF) and co-chair of the Harvard Business School Kraft Precision Medicine Accelerator.

Dr. Ahmedin Jemal, senior vice president of the surveillance and health equity science department of the American Cancer Society. 

Peter Pisters, president of the University of Texas MD Anderson Cancer Center and a cancer surgeon.

Dr. Claire Pomeroy, president and chief executive officer of the Albert and Mary Lasker Foundation, which issues annual awards for medical research often compared to the Nobel Prize. 

Dr. Antoni Ribas, professor at the University of California, Los Angeles and an expert in the use of immunotherapy against melanoma. He is the immediate past president of the American Association for Cancer Research.

Dr. Ned Sharpless, director of the National Cancer Institute, former acting FDA commissioner and former head of the Lineberger Comprehensive Cancer Center at the University of North Carolina.

Dr. David Tuveson, director of the Cold Spring Harbor Laboratory Cancer Center in Cold Spring Harbor, New York, and president of the American Association for Cancer Research. He has an expertise in pancreatic cancer.

Robert Weinberg, a biologist at the Massachusetts Institute of Technology and the Whitehead Institute, the first to discover a gene that can cause normal cells to form tumors and the first tumor-suppressor gene.

Contact Karen Weintraub at kweintraub@usatoday.com.

Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.