Fresh Air Covers Cancer: New Developments in Treatment.

Show: FRESH AIR
Date: FEBRUARY 18, 1999
Time: 12:00
Tran: 021801np.217
Type: FEATURE
Head: Dr. Larry Norton
Sect: News; Domestic
Time: 12:06

TERRY GROSS, HOST: This is FRESH AIR. I'm Terry Gross.

Today we conclude our series on cancer with a look at some of the new developments in anti-cancer treatments. Last week, the National Cancer Institute announced that it will soon begin testing new drugs that destroyed cancerous tumors in mice.

These drugs work by attacking the blood vessels within the tumor thereby cutting off the tumorous cell's source of nourishment. We're going to talk about other promising developments with Dr. Larry Norton, head of Solid Tumor Oncology at Memorial Sloan Kettering Cancer Center in New York.

He's known for formulating new approaches to chemotherapy and hormonal therapy for breast cancer. His team of researchers was given a five million dollar grant from the National Cancer Institute. Dr. Norton says that chemotherapy is improving, becoming more effective and easier to tolerate.

I asked what's making it easier.

DR. LARRY NORTON, HEAD OF SOLID TUMOR ONCOLOGY, MEMORIAL SLOAN KETTERING CANCER CENTER: Well, two things are happening simultaneously: in terms of our ability to use established drugs like chemotherapy drugs, it's been better knowledge of the way to give them. Some drugs, for example, we're giving as a low dose once a week or even a low dose everyday. Whereas before we gave them big doses intermittently every three or four weeks. That's made a difference.

The major impact, however, has been the discovery of ways of reducing side effects. Nausea, for example, used to be a very severe and common side effect for many of our treatments. Now we have effective ways of treating nausea in the vast majority of circumstances, and it's just not a major problem for most people.

Low blood counts. One of the major things I learned when I trained as a cancer doctor was how to give the maximum amount of drug with the limitation of the patients blood counts. You know, chemotherapy drugs often can kill dividing cells in the bone marrow. And as a consequence of that, the white blood cell count would often drop from chemotherapy.

Then we discovered this marvelous molecule called GCSF, or granular (unintelligible) stimulating factor, that makes the white cells grow back faster so that low blood counts is not anywhere near as serious a problem as it used to be even a short time ago.

GROSS: Are there new ways of designing chemotherapy to fit the individual tumor that the patient has -- the individual type of cancer?

NORTON: Well, we're getting there. And that is actually one of the really exciting areas of cancer medicine now. For example, we have recently discovered that a sequence of drugs for the treatment of early breast cancer is more effective than the standard therapy which did not involve a sequence.

Early breast cancer is breast cancer discovered in the breast. It is usually operated on. It can be treated with mastectomy or lumpectomy with radiation. But still there is a possibility the cells have spread to other parts of the body. That likelihood is greater if a large number of lymph nodes under the arm pit are involved with tumor cells.

Now it used to be, not too long ago, that we couldn't do anything about that for the individual patient except to say that your chances are there are cells elsewhere and we have to just wait and see. But we've clearly proven over the last 20 years that if we give chemotherapy drugs that we can kill those cells in many cases outside of the area of the breast or the lymph nodes and prolong life and reduce the odds of the cancer ever coming back.

That's called adjuvant chemotherapy. We used to have a combination that evolved over years of two drugs called doxirubisin (ph) and cyclophosphamide, also called adromicincytoxan (ph) or AC for short; which we have proven conclusively is very effective as a anti-cancer treatment in that setting.

And we have just recently shown that if you give AC and then follow that in sequence with a drug called taxol, or paclitaxel, that we can indeed accomplish even greater good and prevent the cancer from coming back with greater probability and prolong survival with greater probability.

And that's been a very important discovery, and it shows how learning new ways of using old drugs can sometimes have very significant benefits for the patient.

GROSS: Now you mentioned taxol. What is taxol? This is one of the new things that is already being used, but I think a lot of us don't really know much about it.

NORTON: Well, taxol is derived from the bark, and other components of the Pacific yew tree, and has been known for many many years to have biological actions. In fact, Agatha Christie used it as a poison in one of her books to actually commit a murder of one of her characters.

In fact, the bark of this tree has been used by Native Americans in that region for many years as a poison -- as a way of poisoning arrows for example. So it has a lot of biological actions. We have discovered that there is a component of that complex mixture of that bark, and that's the drug that eventually became taxol or paclitaxel.

And that drug is a very effective way of killing certain cancer cells. And that, in fact, is one of the most potent that we now have available for killing breast cancer cells, ovarian cancer cells and other tumors. We've used it now for several years in the treatment of advanced disease, both advanced breast cancer and advanced ovarian cancer and other diseases.

Now we're finding that if taxol is used in the proper way in the management of breast cancer, it essentially doubles the efficacy of drug therapy and preventing the cancer from coming back or the cancer from actually being fatal. So it's a very important drug.

GROSS: Now does the taxol just kill the cancer cells, or does it kill a lot of normal cells too?

NORTON: It has effects on normal tissues, and that's been one of the real issues with these drugs. Because cancer cells are your own normal cells, and they're not all that different from your normal cells. In fact, most of their biochemical processes are exactly the same as your normal cells.

This means that the cells are -- that your normal cells are going to be hurt by the drug in some cases. Taxol has certain special side effects. It does cause hair loss, as many of these anti-cancer drugs do. It can cause tingling of the fingers and toes. It does not cause nausea.

In the old ways of giving it, it actually did suppress the white blood cell count, but now we have ways of giving it, for example, weekly that have much lesser effect in that area. Now, what are we doing with these drugs? We are killing the cells and we are affecting many biological processes in the cells and in many cells in the body.

Wouldn't it be nice if we knew the exact abnormality that made the cancer cell a cancer cell and could develop a drug or treatment that could attack just that abnormality. That's of course the holy grail of the field. And I think we're moving in that direction.

GROSS: So the more we learn about what makes a specific cancer cell a cancer the more scientists can design drugs that attack the cancer cells without attacking normal cells.

NORTON: Oh, absolutely. What we do now, for instance, in the treatment of infections is a good example. It used to be that we had very few antibiotics and we'd have to give these antibiotics to patients hoping that their infection -- the bacteria that was infecting them -- would be sensitive to the antibiotics.

Now we do -- routinely we take some of those bacteria out. We culture them in a dish and we see which antibiotics will work, and pick the antibiotic that works to kill those bacteria. And that's the antibiotic we give to the patient.

With cancer it's not that easy because it's very hard to get the cancer cells to grow, but we can analyze the cancer cells to find out what their components are. Something that people should be aware of is a dramatic advance that's occurring right now in all of biology which is called "micro-array technology."

Even today when we try to analyze what makes a cell tick we have to look one at a time at the important molecules inside the cell -- the DNA, the RNA, the proteins. But our cells are extraordinarily complex. Each cell in our body is more complex than any other system that you can imagine.

And there's an interplay of thousands, indeed tens of thousands of genes at any one time, that makes the cell tick. Well, analyzing any one or two things is not going to give us enough information to really understand that cell well. But now we have the ability -- we already have some of this and the technology is developing very rapidly of analyzing the function of thousands of genes simultaneously.

And so soon we'll be able to have a real blueprint of the inner machinery of the cells that are in the tumor. And by using that blueprint we'll know exactly the defects are and develop technologies to be able to attack those defects.

GROSS: I guess my rudimentary understanding of medicine enables me to comprehend a little bit how, say, an antibiotic would kill bad bacteria that you don't want in your system. But how do the new medicines go about attacking the genetics of the disease?

NORTON: Well, see, genetics only work -- your genes -- your DNA -- inside the center of the cell. And those genes make signals to the rest of the cells through another molecule called RNA, and the RNA tells the cell how to make proteins. For the most part, the proteins are what really determine how the cell functions.

So that having an abnormal piece of DNA for example, is not in and of itself dangerous. It's only dangerous if that abnormal piece of DNA either makes too much of a bad protein or too little of a good protein. Those proteins interact with other proteins and other components of the cell to function.

And so there are a lot of potential targets, things that we can attack. We can attack the proteins with anti-bodies. We can attack how the proteins attach to other proteins with little molecules called small molecules. They get in between two proteins and interfere with their ability to function one after the other.

We can actually insert good copies of genes into certain cells that might be able to kill them or signal the body's immune system to destroy them. We can develop vaccines that can teach the human body itself to attack the abnormal components of the cancer cells such as the abnormal proteins.

We are developing drugs that can actually slow the growth of cancer not by attacking the cancer itself, but by attacking the blood vessels that feed the cancer. That's called anti-angiogenesis (ph) therapy. Blood vessels are only one component of the complex structure that the cancer cells need to divide and grow and be viable. And we're developing approaches to attack those other components of the normal body that are central. So that there are a lot of different exciting approaches.

GROSS: If you're just joining us my guest is Dr. Larry Norton. He's the head of Solid Tumor Oncology at Memorial Sloan Kettering Cancer Center. Let's take a short break here and then we'll talk some more.

This is FRESH AIR.

BREAK

GROSS: We're talking about new cancer treatments and new treatments that are on the horizon. My guest is Dr. Larry Norton. He's head of Solid Tumor Oncology at Memorial Sloan Kettering Cancer Center in New York.

Let's look at SERUMs, and this stands for Selective Estrogen Receptor Modulator. And this is something that's coming into play for the treatment of breast cancer. Would you explain what a SERM is?

NORTON: Well, it's just what the name describes. One of the important proteins on the surface of many cancer cells and normal cells is estrogen receptor. How do the cells of your body communicate with each other? They communicate by sending off chemical signals that float in the blood and get in the vicinity of another cell.

And that cell can receive that signal because it has a receptor on its service. I think of it as a baseball mitt that catches the ball. The ball is the signal. We call that a lygand (ph). And the receptor is the baseball glove that catches that signal.

Well, how does estrogen make certain breast cells grow? Estrogen makes the breast cells grow because the cells have a receptor for estrogen. One of the very first things that happens when the baseball or the estrogen gets close to the cell that has the catchers mitt is that the whole complex, the ball and the glove together -- the receptor and the estrogen -- together go into the center of the cell where it actually attaches to DNA.

And when it attaches to DNA it -- that DNA sends off a signal that sends off another signal and another signal, and eventually you have signals that make these cells actually grow. Now many breast cancer cells, particularly breast cancer cells in people when they are getting older and post menopausal patients -- those breast cancer cells have estrogen receptors.

And they actually require estrogen to grow. So that if we can interfere with that estrogen receptor we can actually interfere with the growth of those cells. Well, we indeed have drugs that can interfere with the estrogen receptor. And the one that's oldest is called tamoxifen.

It's sold in the United States under the name Nolvadex. It's also available as tamoxifen. And that drug attaches to the estrogen receptor and does go to the nucleus in the cell where it does attach to the DNA. But when it does so it makes the DNA make signals that make other signals and other signals, that actually produced growth ending substances.

Substances that tell the cell to stop dividing. And in many cases that tell the cell to commit suicide. We call that apoptosis. Spelled, "A"-"P"-"O"-"P"-"T"-"O"-"S"-"I"-"S". And that's a form of cell suicide that we have built into all the cells of our body. That if there is something wrong with them, rather than for them to go on being abnormal, they kill themselves so they don't hurt the whole rest of the organism.

And you can signal cells to kill themselves by interfering with these receptors. And that's how tamoxifen works. Well, tamoxifen has tremendous benefit in the treatment of advanced breast cancer and in the treatment of early breast cancer in the adjuvant setting.

Tamoxifen has been proven now with more than 20 years of research to lower the chances of the cancer coming back if you receive it appropriately, and also to prolong survival: increase your odds of being alive without cancer and being alive for many years. So it's a great drug.

GROSS: On the other hand, doesn't it cause the risk of uterine cancer?

NORTON: That's one of the side effects. It has, by the way, it has other health benefits, by the way. It lowers cholesterol. It strengthens bones. It has other health benefits. But it has a drawback which is that when tamoxifen attaches to the estrogen receptor in the cells that line the uterus it actually doesn't shut off those cells -- doesn't make them go into apoptosis. It actually makes them divide.

That tamoxifen in the uterus looks like estrogen, and actually stimulates the cells to divide. And if those cells divide some of them can go wrong, and there is a chance of somebody developing uterine cancer from taking tamoxifen.

It's a very low chance. And people listening to this who are taking tamoxifen shouldn't panic. It's a very low odds. It's in the range of .1 percent per year of tamoxifen use. And tamoxifen is usually used for five years. So we're talking about around half a percent of patients taking it are going to develop uterine problems. And if they do, for the most part, those can be cured by hysterectomy. So it is not as terrible a problem as you can imagine. But it is there, and it's not zero.

However, there are other SERMs that have many of the beneficial effects of tamoxifen, in some cases more beneficial effects particularly on bone. But also don't stimulate the uterus. Actually cause apoptosis in the uterus just as they cause apoptosis in the breast cell. And those are very exciting compounds because they might give us all the benefits of tamoxifen and decrease the risk of the uterine cancer.

GROSS: These are drugs evista and raloxifene?

NORTON: Raloxifene and evista are the same drug. And yes, indeed, that's exactly what raloxifene does. It does many of the beneficial effects of tamoxifen. In fact, all of them that I can think of. But also it does not cause stimulation of the uterus. And that's just the beginning of a whole generation of new SERMs that we're going to see developed.

GROSS: Now at the same time that we're understanding how estrogen can cause certain breast cells to grow and therefore cause breast cancer -- do I have that right so far?

NORTON: Right. I think that's true.

GROSS: Yeah. Now at the same time we're learning that, there is like more women than ever who are taking estrogen replacement therapy for menopause. And does the estrogen that women take for estrogen -- for hormonal replacement therapy also possibly cause breast cells to become cancerous?

NORTON: Well, you've hit the number one most controversial topic in my world, which is hormone replacement therapy. This elicits stronger opinions than any other topic that I have to deal with. And people are turning to the medical profession for sort of very good advice -- uniform advice -- and they're not getting it because they're getting very conflicting advice from different doctors.

And that, I think, has created even greater confusion. My view is simply this: estrogen has many health benefits, and these are seen obviously in people who have deprivation of estrogen because their ovaries are not making it anymore in the post menopausal years.

Giving estrogen is good for their bones. It lowers their cholesterol. It may improve their blood vessels by other mechanisms. Clearly it's very effective for reducing hot flashes, which is a big problem for some women not all, but some women in the post menopausal years. And has a lot of health benefits.

However, it's not all women that have these problems. There are post menopausal women with very strong bones and with good cardiovascular systems and low cholesterol and good exercise tolerance. No hot flashes. Whether they are helped by estrogen or not is not at all clear.

That's one area of controversy. The other is how can the SERMs be used instead of estrogen...

GROSS: ...wait. Wait. I'm going to stop you and we'll get back to the SERMs.

NORTON: OK. Sure. OK.

GROSS: So you think for women who do have symptoms of menopause that they want to deal with, that it's OK to do the estrogen?

NORTON: No. I think that there are certain circumstances were estrogen is clearly beneficial, but not in all circumstances. Because we do have alternative ways of treating a lot of those problems now.

GROSS: I guess what I'm trying to ask is are you -- are you completely opposed to hormone replacement therapy or do you approve of it in certain circumstances?

NORTON: Yeah, I think like all medicines, estrogen replacement therapy -- like all medicines, there are pluses and minuses. There are costs and benefits. And the individual has to balance the benefits and the risks for her individual case to make that decision.

Are their some people who clearly benefit from estrogen in the post menopausal years and should take it? Absolutely. There are clearly some individuals who would benefit. And there clearly are some individuals who would not.

This has to be an individual choice. And no medicine, that I know of, no medicine is good for everybody. That individuals have to balance the benefits and the risks in their individual case.

GROSS: And how much of a risk do you think a woman is taking if she takes estrogen?

NORTON: It depends upon her underlying risks of developing breast cancer, for example. Some women have greater risks than other women. Women who have had a previous breast cancer, for example, I think are clearly at a higher risk to developing another breast lesion -- abnormality -- which could be cancerous.

And that's one group that especially should be careful of taking estrogen, in my view. That women with very strong family histories, we don't know the effects of estrogen in those circumstances. There are some women who are carrying a genetic susceptibility to breast cancer.

There are two genes that we now are sure that if you inherit an abnormal gene from your mother or your father you are at increased risk of developing breast cancer. And also cancer of the ovary.

These are called BRCA1 and BRCA2. Now BRCA1 is especially interesting in this regard because men who are born with the same genetic defect, they inherit from their mother father, these men do not have a higher risk of getting breast cancer. But the sister who inherits the abnormality from the mother or father, that woman carries a very high risk -- can be as high as 85 percent -- of developing breast cancer, for example.

What's the difference between them? The difference is that ones a woman and the other is a man. One is exposed to estrogen for a large and high concentrations for a large portion of her life. Whereas the man isn't.

So I think there's got to be an interplay between estrogen and breast cancer susceptibility. And I personally would have a lot of trouble, therefore, in taking a post menopausal woman who has intact breasts and is carrying one of these genetic abnormalities. And exposure for a longer period of her life to estrogen.

GROSS: Dr. Larry Norton is the head of Solid Tumor Oncology at Memorial Sloan Kettering Cancer Center in New York. He'll be back in the second half of the show.

I'm Terry Gross, and this is FRESH AIR.

BREAK

GROSS: This is FRESH AIR. I'm Terry Gross.

Back with more of our interview on new cancer drugs with Dr. Larry Norton, head of Solid Tumor Oncology at Memorial Sloan Kettering Cancer Center in New York. He specializes in breast cancer treatment and research.

When we left off we were talking about hormone replacement therapy for post menopausal women and the effects of the drugs known as SERMs -- Selective Estrogen Receptor Modulators.

I believe that there are new medicines that are trying to combine the beneficial effects of hormone replacement therapy without the bad side effects of it. Without the possible cancer inducing side effects.

NORTON: That's absolutely true. In fact, we may have some already. The drug raloxifene, or evista, that you mentioned earlier has many of the beneficial effects of estrogen.

GROSS: These are the same drugs that you mentioned for treating breast cancer.

NORTON: Absolutely. For treating and potentially preventing breast cancer. Tamoxifen, for example, has been shown in a very large trial to actually cut the risk of breast cancer development in half. In pre and post menopausal patients who have taken it. Patients to get into that trial had to be deemed at higher than average risk.

But when they took it, their risks were actually cut in half. There is evidence that has also been presented that evista has a similar activity. In fact, might be even a more potent way of preventing breast cancer in post menopausal women. And these were women who are taking evista in clinical trials to prevent bone loss.

But as a side effect of preventing bone loss, and it clearly has shown its ability to delay or prevent osteoporosis, and is actually approved by the Food and Drug Administration for that indication. But a side effect of that was a dramatic lowering of the breast cancer risk. So here we have a drug, let's just take evista -- raloxifene -- as an example, that can strengthen your bones.

It actually can reduce the fracture risk as much as estrogen can -- the risks of having an osteoporotic fracture. So it strengthens the bones. It can lower the cholesterol. And have other beneficial effects that are related to estrogen, but also reduce breast cancer risk and do that without causing an increased risk of other cancers. So that's a very very exciting drug.

What if you have hot flashes? There are other approaches to hot flashes now beside the use of estrogen. A drug called megase (ph), or meagastrol acetate (ph), is a derivative of progesterone from that family. And that drug has been shown to be rather effective in reducing hot flashes. And there are other drugs now that are not hormones at all that can reduce hot flashes.

GROSS: There are so many women now who seem to have breast cancer. I mean, just everyone I know seems to know someone who has it or has it themselves. And I'm wondering if the statistics bear that out to you. I mean, you're a researcher say you see things not just anecdotally, you look at the big picture statistically.

Statistically, how great is the rise do you think? And if it is big, what do you attribute it to?

NORTON: Well, it's not rising all that rapidly. And I think that the risks of an individual getting breast cancer are often difficult to assess. There's the one in nine or the one in ten statistic that's used. And that basically means that if you live a very long life -- into your 70s and 80s -- that your chances of not getting breast cancer is nine out of ten or eight out of nine if you live long enough.

And so that's where the statistic comes from. So that it's a very common disease, clearly, but that the risk is sometimes overestimated in the statistics for the individual. And for some individuals, in fact, the risk is higher than that.

As I said, some individuals carrying the BRCA1 or BRCA2 mutation that they inherit from the mother or father, they can have a risk as high as 85 percent. So that the risks vary enormously from individual to individual.

There is a slight increase in the incidence of breast cancer. Partially, this is due to the fact that the population is getting older and breast cancer is more common in older people. Partially, it's due to the fact that mammograms are now being done more commonly and we're diagnosing more breast cancers than we did before.

Sometimes breast cancers that never would have caused a problem in the individual patient, either because they grow so slowly that the patient would go on to her normal life without ever knowing that she had breast cancer.

But I think even if we control for the aging of the population and for mammographic diagnoses, there is still a slight increase that's occurring. And the reasons for that are not at all clear. There clearly could be some environmental factors, and that clearly is a possibility. Just because we don't know what they are doesn't mean they're not there.

We do see a higher incidence of breast cancer around urban centers. And that's hard to explain except if there is something in the environment in urban centers that is related to the risk of breast cancer. It's a very important topic of research, and I'm very glad to see that that research is underway right now in several places. I think we need more work in that direct.

But especially in the direction of understanding the genetic basis of breast cancer. And that is what are the genes that have to be turned on or off to get a breast cancer, and how do things in the environment effect those genes?

Estrogen is only one of the possible links. Somebody taking estrogen, for example, is affecting the way their cells functions. There may be other things in the environment such as pollutants and toxic substances and things that we're eating that could have that effect. That's a very important area for research.

GROSS: It seems for now that there are things that a woman can do to help prevent getting breast cancer if she knows she has the gene that predisposes her toward getting breast cancer. Can anyone get the genetic testing for breast cancer?

NORTON: Well, the test is available. It is commercially available. But what I strongly advise anybody who thinks that they are at a higher than normal risk of getting breast cancer to do is seek out consultation with an expert. There is a special kind of expert called a genetics counselor.

We don't have enough of them in United States yet, though we are trying to train as many as we can. That people that specialize in their ability to analyze somebody's genetic risk, and not just for breast cancer, for prostate cancer, colon cancer, that we know a lot about already. A variety of other cancers. Actually, certain rare cancers. These are all things that can have a clear cut hereditary link.

I want to clear up the term here because I think it's important for the listener. That all the cells in the body have genes, or at least at some point in the development they all have genes. And so cancer is a genetic disease in that -- the reason that cancer cells are cancer cells is because there's something wrong with the DNA -- with the genes -- in that cell.

That's different than hereditary disease were you inherit abnormal DNA. You can inherit an abnormal piece of DNA from your mother or father and that could predispose you. But even if you have perfectly normal DNA -- perfectly normal genes -- you can develop a mutation of those genes such as that caused by cigarette smoke or excessive sunlight to the skin. For example, radiation exposure.

And so all cancer is genetic, but not all cancer is inherited. So it's important to keep those two terms -- two terms separate.

GROSS: Thanks for clarifying that.

NORTON: Now in terms of the defects in the DNA -- the genetic defects that can occur, which can be induced by cigarette smoke, for example, or sunlight or radiation; understanding the basis in the DNA for the cancer is what's so important for our ability to understand how the environment interacts with those genes.

I think the really important research is going to be from understanding the DNA basis for cancer and with that as a basis, understanding how things in the environment affect the DNA. That's one of the really exciting areas for research right now.

GROSS: One last question. I'm wondering how optimistic you are that cancer will eventually be a curable disease. I know for some people it already is, but for many people it's not.

NORTON: Well, I'm glad you said that. Your comment is very important. People have to realize that most cancers now can be cured if they are detected early and the appropriate therapy is done. Ignorance is the enemy here in terms of even what we have currently available.

But in terms of where we're going in the future, there's absolutely no doubt in my mind that cancer is going to be amenable to all these advances as other diseases have been. Will we eradicate it 100 percent? Probably not. But will we make dramatic advances and reduce the chances, very significantly, of somebody getting cancer and somebody dying of it? Absolutely. There's no question about that.

GROSS: Dr. Norton, I want to thank you very much for talking with us.

NORTON: My pleasure. Thank you for having me.

GROSS: Dr. Larry Norton is the head of Solid Tumor Oncology at Memorial Sloan Kettering Cancer Center in New York.

This is FRESH AIR.

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Dateline: Terry Gross, Washington, DC
Guest: Dr. Larry Norton
High: Head of Solid Tumor Oncology at Memorial Sloan Kettering Cancer Center in New York, Dr. Larry Norton. He'll discuss the newest treatments for cancer.
Spec: Cancer; Diseases; Drugs; Lifestyle; Culture; Dr. Larry Norton

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Copy: Content and programming copyright 1999 WHYY, Inc. All rights reserved. Transcribed by FDCH, Inc. under license from WHYY, Inc. Formatting copyright 1999 FDCH, Inc. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to WHYY, Inc. This transcript may not be reproduced in whole or in part without prior written permission.
End-Story: Dr. Larry Norton

Show: FRESH AIR
Date: FEBRUARY 18, 1999
Time: 12:00
Tran: 021802NP.217
Type: FEATURE
Head: Michael Lerner
Sect: News; Domestic
Time: 12:40

TERRY GROSS, HOST: If you have cancer you don't necessarily have to choose between conventional and alternative therapies. You can combine both. Michael Lerner is a pioneer in integrating the two.

That integration is the subject of his book, "Choices in Healing." Lerner is the founder of Commonweal, a health research institute in Balinas, California, and the Commonweal Cancer Help program which is dedicated to helping people seeking physical, emotional and spiritual healing in the face of cancer.

He's running a cancer help program workshop this week, but was good enough to spend a few minutes with us. He first joined us on FRESH AIR five years ago.

I asked him what he thinks has been achieved since then in integrating conventional and alternative therapies.

MICHAEL LERNER, FOUNDER, THE COMMONWEAL CANCER HELP PROGRAM; AUTHOR, "CHOICES IN HEALING: INTEGRATING THE BEST OF CONVENTIONAL AND COMPLEMENTARY APPROACHES TO CANCER": Well, I think what is being achieved is really a recognition in medicine that there is more to helping people than helping try to cure them, which is of course is vitally important. And that it also really matters that you help people try to heal, and there's a big difference between healing and curing.

Curing is the effort to offer a treatment that will end a life threatening illness and return someone to full health. And healing is what comes from within people and their efforts physically, mentally, emotionally, and spiritually to become whole. And to do what they can, both in terms of quality of life and life extension or prevention of recurrence.

So there is an enormous recognition of this across the country, which is just one of the great changes in medical culture of our time. And that's a real accomplishment.

GROSS: The impression I've gotten from your reading is that your most comfortable with the therapeutic approaches that are psychological, spiritual, nutritional or physical -- physical like massage. As opposed to alternative medicines.

LERNER: That's essentially true, and let me tell you why that is. For 10 years I looked at the alternative medicines in great detail, and I did not find a cure for cancer among those medicines. Now, as the field of research and alternative medicines for cancer has exploded, it becomes increasingly difficult for any single human being to keep track of all the research that is taking place.

So what I was looking for is what are the sort of the essential long term truths that any cancer patient or any health practitioner can hold on to. As, over the next 10 or 20 years, we work out the debates about all the vital chemicals and the herbs and all the other specific medicines.

And the truth that has held clear and strong for me is that if you look at complementary cancer therapies you can divide them between spiritual approaches, psychological approaches, nutritional and physical approaches -- the four you just mentioned.

And then traditional medicines like traditional Chinese medicine, herbal medicines, pharmacological approaches like sharks cartilage, things like that. Electromagnetic therapies, unconventional uses of conventional therapies, various esoteric therapies like psychic surgery and sort of broadly humane approaches.

If you take that way of looking at complementary therapy, the first four: spiritual, psychological, nutritional and physical represent what I call the vital quartet of intrinsically health promoting approaches to cancer. And what we know, Terry, from the mainstream research literature is that patients who are healthier going into cancer, who have better -- what is called quality of life -- better, what the oncologists call, functional status which means that you can just sort of take care of yourself better.

Those patients, not surprisingly, tend to have better outcomes. They actually have better survival in many studies. So that the central truth to me and the meeting place between complementary and conventional therapy, is that patients and practitioners who seek to help patients integrate the best of both worlds should start with this vital quartet of spiritual, psychological, nutritional and physical approaches to simply getting healthier.

GROSS: What have you observed through the people you come in contact with at your cancer education center, Commonweal, that would help give you ideas of which physical, nutritional, spiritual and psychological therapies are most effective in improving quality of life and in helping the person be strong as they're fighting cancer?

LERNER: I think the answer to that is that the spiritual, psychological, nutritional and physical approaches that help patients most are for the most part as unique as each individual. It's almost like your own fingerprint.

You know, who can say what will bring spiritual or religious solace, or just a sense of integrity for people who don't like spiritual language, a sense of integrity or coherence to a person with a life-threatening illness? It's incredibly unique. The same is true of psychological approaches.

Even nutrition, people have enormously different nutritional needs. And at the physical level there are people who love massage or yoga or the Chinese discipline called Tigun (ph) that many cancer patients have used which is a yoga-like practice. There are others who prefer walks or exercise and so on.

So it's very very individual. It's just that those are four realms in which I think if people seek out what makes sense to them they often find they are feeling better, and in feeling better they often do better with difficult medical treatments and also with the progress of the illness itself.

GROSS: Would you recommend that people just educate themselves through reading or workshops on some of the alternatives available to them, and see which one feels most appropriate to them?

LERNER: Yes, and if possible get some guidance from somebody whose really thought about this. I mean, there are certain underlying principles. Let's just take one example is that we know that very high fat diets are associated with higher risk of fat related cancers.

So for many people a low fat diet makes a lot of sense. Generally, we know that there's a very important research literature that stress enhances tumor development in many animals. And it is almost certain that that is true for many human cancers as well.

Well, cancer is a stressful experience and modern life a stressful. So if you're faced with cancer then disciplines like meditation or progressive deep relaxation or spiritual perspectives that help you accept life with less stress are logically helpful in reducing the stresses that may enhance tumor development.

So there are certain underlying principles like that that no matter which way you go, spiritually, psychologically, nutritionally and physically -- they're sort of common sense principles.

GROSS: I think an important point that you're making here too, is whether you're oriented more toward the spiritual or the secular approach toward integration. There's a lot of alternatives out there and you don't have to seek the spiritual approach to find an approach that will help you feel more of a sense of meaning in life and also calmness.

LERNER: I completely agree with that. In fact, I am not at all happy with those who regard the preference for spiritual vocabulary as somehow superior to the preference for a secular vocabulary. For me, some of the most truly spiritual people I know have absolutely no use for the spiritual vocabulary and use a secular a vocabulary instead.

And I think that the secular vocabulary that works best is the vocabulary of meaning. Victor Frankel's concept of man's quest for meaning, when he was a prisoner of war in Auschwitz and was asking who survived in Auschwitz psychologically as well as physically. And he came to the conclusion that the people who survived best in Auschwitz were the people with a deep core of meaning in their lives.

And I think that's true in facing a life threatening illness. The capacity to survive the illness and the treatment, and indeed just the capacity to survive the versisitudes of life has an awful lot to do with whether we can find a core of meaning in ourselves that is beyond what life does to us.

GROSS: My guest is Michael Lerner, founder of the Commonweal Cancer Help program. And author of "Choices in Healing." We'll talk more after a break.

This is FRESH AIR.

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GROSS: My guest is Michael Lerner, author of "Choices in Healing," about integrating conventional and alternative cancer therapies. He's the founder of the research institute Commonweal and the Commonweal Cancer Help program.

Part of what you help people do at Commonweal is to find ways of surviving the treatments -- surviving the cancer treatment. And I'm wondering if there has been a lot of change on that front. I guess what I mean is have the treatments changed a lot in the years that you've been running these workshops at Commonweal? Are people having to deal with different problems posed by the treatments?

LERNER: Well, they are, Terry. And it's going in two directions almost simultaneously. On the one hand, you're seeing people going through more aggressive treatments like bone marrow transplant treatments, which are very very difficult treatments. And as the techniques get better and better and survival goes up and people are doing better on the other side of it, you see lots of people facing the consequences of having lived through bone marrow transplants.

On the other hand, the other enormous wave that has hit mainstream medicine in the past five years is managed care. And of course managed care is moving in exactly the opposite direction, which is it wants to cut costs. And therefore wants to do as little bone marrow transplants, and that kind of thing, as possible.

So managed care is actually driving us toward the European model of less aggressive treatments. America traditionally was much more aggressive in our medical interventions, whether for cancer or for anything else. And the Europeans tended to be more conservative, and to embrace more of the complementary therapies within the mainstream in a broad sense. We're moving in that direction under the impact of managed care.

GROSS: So some people are getting a more aggressive, and other people a less aggressive treatment.

LERNER: That's correct. It's moving in both directions simultaneously. In a deeper sense, we are facing the reality that as technology moves forward we become more and more capable of more and more expensive interventions to keep people alive and to treat them with a wide range of illnesses.

And so this forces a rationing process of some kind, because we could spend an infinite amount of money on these technologies with which we are more and more integrated in our lives. Managed care is one of the inadequate ways that we found to ration these very expensive technologies.

But the technologies are out there, and because they are promising -- and I think that's probably where the cure for cancer will probably come from, if they come. It will come from technological medicine. But there will be more and more need for rationing simply because we cannot afford to -- much as we all would wish to -- we simply cannot afford to give everybody an infinite amount of high tech medicine all the time.

GROSS: Complementary medicine like mainstream medicine tends to speak to the individual. What are some of the things that you think need to be done more as a society in terms of preventing cancer or dealing with cancer?

LERNER: Well, I think the answer -- that's a very interesting question to me that I've thought a lot about. And my perspective on what's happening to complementary medicine, just as its being integrated into the mainstream, is I think you could say that complementary medicine has enormously extended, in a sort of horizontal line, the range of treatments that patients and physicians can think about together.

What complementary medicine has not done yet, and I think it's the next really important development, is that it hasn't grounded its sense of what contributes to health and illness in nature and in economics as deeply as it should. Now what I mean by that is that -- for example, let's just take the economic aspect.

You can look at the whole literature on mind-body health and there are numerous discussions about healing and dying and so on and so forth. But there's almost nothing on the impact on people's health of job loss or poverty as a carcinogen. Or enormously well established facts like that that we know have powerful effects on health.

And yet that's almost absent from complementary medicine. And similarly, on the nature side the place where we fail to ground complementary medicine in nature; we haven't hooked up with the huge public interest in healthy foods and whole foods and concerns with chemicals in the environment.

And yet that concern with chemicals in the environment, again, does not make its way into the dialogue on mind-body health and complementary medicine. So I think it's just very striking that complementary medicine has followed the lead of mainstream medicine in focusing primarily on clinical interventions, and not looking at the public health dimension of both what human activity is doing to the biosphere and how that affects our health and what we're doing to each other through maldistribution of income and resources and how profoundly that affects health.

I don't think that complementary medicine can claim to be truly holistic unless it grounds itself in economics and nature, just as it has grounded itself in a broader perspective on clinical interventions.

GROSS: If you're seeing an oncologist and your particular oncologist doesn't know anything about complementary medicine, and isn't going to be very useful in recommending massage or acupuncture or meditation or relaxation technique. Is it OK to go someplace else? I mean, like if your doctor isn't informed about that are you violating their practices by educating yourself outside?

LERNER: Well, that's a really tough question for many cancer patients. And many cancer patients look for an oncologist who is compassionate and open-minded about complementary therapies. You know, Terry, I've reached the conclusion that what you really want most from an oncologist -- you certainly want somebody who will be kind and who will answer your questions. But I honestly think that it's less important that they are open-minded about complementary therapies than it is that they are very very good at what they do and very committed to you and your treatment.

Because in the face of managed care, what many cancer patients are facing is the real prospect that they will get inadequate mainstream treatment. That's a very real concern for many cancer patients. So finding an oncologist and a managed care system, if you're in managed care, that will take care of you in a really first rate way in terms of conventional treatments; I think that's the overwhelming priority.

I think that the question of how open the oncologist is to complementary therapies, that's an add-on. That's a bonus. Ideally, and we're moving in the direction, oncologists are open-minded. But I think the great dedication, and our great need from them, is first rate mainstream care.

GROSS: Well, I want to thank you very much for talking with us.

LERNER: It's a pleasure.

GROSS: Michael Lerner is the founder of Commonweal in Balinas, California and the Commonweal Cancer Help program. He is the author of "Choices in Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer."

I'm Terry Gross.

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Dateline: Terry Gross, Washington, DC
Guest: Michael Lerner
High: Authority on complementary cancer treatments Michael Lerner. He's author of the book, "Choices in Healing: Integrating the Best Conventional and Complementary Approaches to Cancer," and founder of the Commonweal Cancer Help program. Lerner won a MacArthur Prize Fellowship for his work in public health in 1983. His research institute was featured on Bill Moyers' PBS series "Healing and the Mind."
Spec: Cancer; Diseases; Lifestyle; Culture; Michael Lerner

Please note, this is not the final feed of record
Copy: Content and programming copyright 1999 WHYY, Inc. All rights reserved. Transcribed by FDCH, Inc. under license from WHYY, Inc. Formatting copyright 1999 FDCH, Inc. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to WHYY, Inc. This transcript may not be reproduced in whole or in part without prior written permission.
End-Story: Michael Lerner
Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.