Dr. Vincent DeVita Jr., director of the Yale Cancer Center, has been on the front lines of the war against cancer since that battle officially began with the establishment of the 1971 National Cancer Act. (See related stories on lung cancer and breast cancer).

The law established cancer research as a national priority and paved the way for the network of cancer centers that now participate in basic cancer research and clinical trials.

DeVita began his medical career as a pediatric oncologist and went on to become director of the National Cancer Institute (NCI), which oversees the nation's cancer program. In 1999 he won the Mary Waterman Award from the Breast Cancer Alliance of Greenwich for his outstanding achievements in the fight against breast cancer.

Recently, he was asked to take a national role again, this time as co-chair of a committee to revamp the National Cancer Act. The committee evolved from the National Dialogue on Cancer, a group assembled two years ago by former President George Bush. The goal of the National Dialogue on Cancer -- and now the new committee -- is to help plan the federal government's future role in cancer research and treatment.

DeVita met recently with the Yale Bulletin & Calendar to talk about the agenda for the new committee and to give his perspective on the current status of cancer. He also spoke about a book he will begin writing on sabbatical this year, on "The War on Cancer." Excerpts from that conversation follow.

What is the overall goal of the committee looking at the National Cancer Act?

It's based on the premise that if we had the kind of resources in cancer today that we had as a result of the last National Cancer Act, we could go over the top. We went from $200 million in 1972 to $1 billion in 1980 -- a five-fold increase in money. If we had a five-fold increase in research support now, it is the feeling of a great number of people that we could make cancer a disease that is background noise in the next 10 to 20 years.

What issues have been raised by members of the National Dialogue on Cancer?

The general feeling is that what has been neglected is the capability to efficiently translate research into practical treatment and prevention methods for the public at large. We continue to support the research environment and have seen the enormous fruits of that labor and now we want to actually provide the tools to translate it. Even the most skeptical scientists of the past are now saying this is possible. We understand cancer now in ways we could only imagine in the past, and we know what many of the precise targets are.

The pharmaceutical industry, for example, went from a situation where there were very few targets for anti-cancer drugs to a situation where they are almost overwhelmed by targets. They have so many targets that they don't have the resources to test them all. The federal government, through the Cancer Act and through research supported by the Cancer Act, created this mass of targets. We should now create the means to test them so that we can fulfill the dream of the people who put the first Cancer Act together.

What role will the National Cancer Institute play in all of this?

One issue being discussed by the committee is whether it is unrealistic to expect the National Cancer Institute to be the leader of a national program that is going to knit together insurance companies, industry, the practice of medicine, cancer research, all those things.

Is it unrealistic for the NCI to take such a role?

When I was director of the National Cancer Institute, there was hardly any cancer drug industry. The pharmaceutical industry was not a major player. Medical oncology didn't begin until 1974. So, you were dealing with a completely different time when you could realistically expect that, given the authority of the NCI director, you could do these kinds of things. But nowadays it doesn't seem reasonable to anybody that you can do that. The issue has come up of establishing a National Cancer Authority of some sort.

How would that work?

For example, the Centers for Disease Control would handle a lot of the cancer control part of the cancer plan. You could see a scenario where the CDC could receive a great deal of money and let the states apply for grants to support cancer control programs. If this turned out to be $400 million a year, it wouldn't go into the NCI at all. It would go into the CDC. So the NCI wouldn't be thrown out of balance with the other components of the National Institutes of Health. If you created some sort of a national fund for support of clinical trials, which is desperately needed, and you funded it outside of the NCI, then that money wouldn't go into the NIH budget either. That would take some of the anxiety away that people usually have about putting a lot of money into one basket. We're starting to hear that.

What are some of the concerns?

One of the criticisms came at the peak of funding for the original Cancer Act. The NCI was 33% of the NIH budget. There were 14 institutes at NIH. There was this concern that if you add a lot of money you upset the balance of a very delicate kind of institution. If you had a National Cancer Authority then you would be able to distribute the funds to places other than the NIH.

What are some of the reservations about a new national cancer policy?

There are all the old images of someone telling everyone what to do. The worry is that if you create this kind of a National Cancer Authority, that you come into your office in the morning and you wait for the telephone to ring, and it does, and it's the head of the National Cancer Authority who says, "Dr. DeVita, today I'd like you to do the following things." That, of course, is an illusion. It can't happen. It wouldn't happen.

You have said that about 70% of children with cancer are enrolled in clinical trials, but only 5% of adults with cancer are participating in clinical trials. Why is there an imbalance?

I think most general pediatricians do not like to take care of kids with cancer. It's demanding. There's a whole array of things that happen to children when it comes to cancer. So these doctors are more willing to refer their patients to cancer specialists. When I started in this field I was a pediatric oncologist. I took care of a ward full of kids with leukemia. And I can see the faces of those kids still. They're emblazoned in my brain. Some doctors are extremely good at it, and others just can't handle it.

There are only 500 to 600 oncology pediatricians in this country, and they all tend to get most of their patients involved in clinical trials. And their patients are better for it. When pediatricians see a case of leukemia they send it to a hematologist who's already part of clinical studies. That's why mortality rates in children have fallen faster than in adults.

Why are so few adults in clinical trials?

With adults, it's a whole different story. There's competition and more medical economics. Adult oncologists don't like to refer their patients for clinical trials. They're afraid if they put them in a clinical trial they'll lose them. And it takes time to enroll a patient in a clinical trial. Sometimes at the Cancer Center we forget that.

When I was at Memorial Sloan Kettering they operated on 1,500 new cases of localized breast cancer every year. That's a lot of cases. Few patients were going on any kind of medical study. It was a tragedy for an institution like that. My predecessor told me he just couldn't get it done. I began to look at why. I talked to the surgeons who said they were very willing, but they just didn't have the time. If a surgeon wanted to get a patient enrolled in a clinical trial, it often took half an hour for the informed consent process alone and since each clinic visit normally lasted only ten minutes or so, you can see the impact. So we changed the process so that a nurse could do it and the doctor simply had to sign it. Since that time they have deluged the medical people with patients in clinical trials. It was not an issue of unwillingness to participate but rather one of logistics.

What do you see as the timeline for doubling the cancer cure rate?

Doubling the cure rate is different than declining mortality. In 1984 the NCI projected goals for the year 2000. The year 2000 is here. We said if we applied everything we knew at that time mortality could decrease anywhere from 25% to 50%. People said we were crazy. They said mortality was going to keep rising. Although we will not be able to measure what is going on in 2000 until 2006 at the earliest, because of the way data are collected and analyzed, it turns out they were wrong. Starting in 1990 -- the data just came out in the last couple of years -- both the incidence of cancer and mortality rates from cancer have been declining in adults. We've probably hit breast cancer right on the head. Due to widespread screening and new effective adjuvant treatments, the mortality for breast cancer, we estimate, is now down as much as 20%. Colon cancer is already down 30%. Lung cancer mortality has started to come down largely because the incidence of lung cancer has started to fall. Smoking cessation programs have started to work. And yet, we haven't even begun to see the impact of all of these molecular advances that we paid for. These things are just beginning to hit the clinic. I don't think it's so far-fetched to think that we could halve the mortality rate of cancer in the next 20 years.

One of the points that came out of the National Cancer Dialogue is to commission a fellow who works with statistics to come up with a couple of paragraphs to explain to the public what we mean when we say "survival rates," what we mean when we say "age-adjusted mortality rates." We want to present the message in a way that everyone can understand.

What has Yale's role been in cancer research and treatment over the years?

Yale has had some involvement in all of this in interesting ways. Yale was the first place where chemotherapy was ever used on humans with cancer. That was in 1943. The specialty of Medical Oncology was born here in 1965. Dr. Paul Calabresi, who was at Yale when I came here as a trainee, was the first chief of Medical Oncology in the country and is now the chair of the Yale Cancer Center's advisory committee. And Yale was one of the first recipients of a core grant from the NCI to establish a cancer center. The Cancer Act was passed in December 1971. The first money that was ever put into research from the Cancer Act was in late 1972. There were only three cancer centers in 1972 and 1973. There was a year-long debate on how to build cancer center programs and when they decided to build them at universities, we became one of the first of the new batch in 1974.

What can Yale do to remain competitive in cancer treatment?

Yale is filled with very talented scientists, but Yale has not concentrated in the past on developing the other half of the program, which is bringing the scientific discoveries into the clinics. That's what we have been trying to build here for the last five or six years. We have presented a plan to the Dean and the President of Yale-New Haven Hospital, which they asked for, for a new Yale Cancer Center organization and a new facility.

Yale, in this sense, is no different than other major universities. Most universities have clinics that are crowded and inefficient. Patients come in and wait for hours, then they walk three blocks to get an x-ray, then they go somewhere else for a lab test. Then they come back and wait. Our facilities were not designed to encompass the concept of "centerness." Medicine is big business in this country; we're talking about a trillion-dollar industry. So, the private sector has begun to open modern facilities to take care of cancer patients. The private sector needs to focus on the impact of volume on income. So now we have private facilities around the state, around the country, that are splendid but can't do what major cancer centers can do scientifically and medically, but they have built facilities where cancer patients feel comfortable.

The patients might see an atrium with a waterfall. Within a hundred feet of that waterfall are all the places you have to go to get what you need. We teach. We get grants. We do research. Our focus has been different but we need to remain competitive not only for financial reasons but because we need access to patients to translate research findings into practical use. Universities have been slow to recognize that that's not necessarily bad. There's nothing wrong with coming to a university and being treated in a very comfortable environment, while at the same time you get all of the advantages you need from being close to the science that leads to new advances. The best and new approaches have always come out of university cancer centers. Every practicing doctor in the city is using something we developed in one of our cancer centers 20 years ago, and they're out there waiting for the next new development.

You mentioned that you will be going on sabbatical in February to begin writing a book about the war on cancer. Could you tell us about that?

My idea is to do a book for the lay public. The public needs to understand where their money went, what's behind the scenes, what takes place. Some of the stories are sad, in many cases, and others are funny. The stories show that science and research work in strange ways. There are people involved, there are jealousies and petty things and luck and so on. I have two thousand folders of one sort or another on the subject. The challenge is going to be to pare it down.

-- By Karen Peart and Jacqueline Weaver

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