American Journal of Epidemiology Advance Access originally published online on July 16, 2008
American Journal of Epidemiology 2008 168(10):1211-1212; doi:10.1093/aje/kwn210
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BOOK REVIEW |
The Secret History of the War on Cancer
By Devra Davis
Tobacco Control Research Branch, National Cancer Institute, Bethesda, MD 20892
(e-mail: paramark{at}mail.nih.gov)
ISBN 978-0465015665, Basic Books, New York, New York (Telephone: 800-343-4499, Fax: 800-351-5073, Website: http://www.perseusbooksgroup.com/basic/contact_us.jsp), 2007, 505 pp., $27.95 (Hardcover)
In 1936, 200 of the world's top medical scientists met in Brussels to address an emerging epidemic. Since the turn of the century, cancer had been steadily growing as a major cause of death. Naturally, researchers looked first to environmental factors, particularly agents of the Industrial Age, such as asbestos, road tar, ionizing radiation, and synthetic dyes. Since then, however, attention has been diverted away from such important environmental causes of cancer, especially where economic interests are at stake, according to Dr. Devra Davis in The Secret History of the War on Cancer (1).
This expansive, ambitious book spans nearly a century and dozens of controversies, anecdotes, and personal stories. Davis devotes a chapter to describing the growth of the eugenics movement and Nazi medicine. Another chapter details the evolution of the nation's leading voluntary anticancer organization, from the grassroots anticancer advocacy of the American Society for the Control of Cancer's Women's Field Army to the corporate Lasker-era American Cancer Society. She describes how professional turf battles delayed the introduction of the Papanicolaou smear for over a decade. In subsequent chapters, she warns of the possible hazards to physician-researchers in working with novel compounds, the overselling of routine mammography, the role of paid experts in environmental tort litigation, the politics of establishing regulatory standards for environmental and occupational exposures, and the potential as-yet-unproven hazards of cell phones.
A key theme running throughout the book is how financial interests, professional allegiances, and political ideology can manipulate the scientific process. Archives and court documents reveal how well-meaning scientists have at times become complicit in defending industrial interests at the expense of public health. There is no "secret history" here, however, as these histories are largely drawn from the work of other scholars. One exception is Davis's own study of the papers of Robert Kehoe, a key figure in the development of the occupational health field who conducted a wide range of toxicology research under contract for various industries. These documents provide a unique case study of how one academic laboratory functioned and interacted with its industry sponsors, and one wishes they were more fully explored here.
Unsurprisingly, tobacco figures big in Davis's story. She touts German physician Franz H. Müller's 1939 case-control study of lung cancer and smoking (previously described in Robert Proctor's The Nazi War on Cancer (2)) as "the first irrefutable modern proof that smoking causes lung cancer in humans" (1, p. 61). This work was largely ignored by American and British researchers conducting their own case-control studies 10 years later. Davis faults these latecomers with failing to immediately denounce cigarettes, whereas Müller had definitively declared tobacco to be "the single most important cause of the rising incidence of lung cancer" (1, p. 53).
Davis's argument here and repeated throughout the book is that, when the bar for medical proof is set too high, life-saving public health action is delayed. By the time of the 1964 Surgeon General's report (3), an unprecedented wealth of evidence had been amassed, including seven cohort studies and over 30 case-control studies implicating cigarettes as a cause of cancer. However, public health interventions often have to be taken on lesser evidence. Davis criticizes reliance on epidemiology as the "gold standard," demanding an alternative to "waiting for enough bodies to drop or sicken before we decide we've got a problem" (1, pp. 399–400). Yet how much and what kind of evidence should be required to act? Unfortunately, Davis stops short of proposing any concrete answers to this question.
There are a number of factual and historical errors in the book that detract from its force. For example, Davis devotes a page to describing Clarence C. Little's tenure as "the first Director of the fledgling National Cancer Institute" (1, pp. 120–121). In fact, he never held this post, although he did serve as one of six original members of the National Advisory Cancer Council. She claims that the Council for Tobacco Research gave money "directly" to Wilhelm Hueper and Tom Mancuso to study the environmental and occupational causes of cancer. However, the document she cites for this makes it clear that funds were given to Mancuso but not to Hueper (1, p. 153). She has both R. A. Fisher and Nathan Mantel working "directly" for the tobacco industry in 1967; this is unlikely as Fisher died in 1962 and Mantel was still at the National Cancer Institute (1, p. 189).
Davis is at her strongest when telling her own story. She provides engaging, first-hand accounts of her early career in the 1980s as a junior epidemiologist tackling big issues, such as assessing the disease burden for victims of exposure to hazardous wastes and studying whether cancer rates were increasing. Davis began working on the latter question under the guidance of Abe Lilienfeld at The John Hopkins University. She found that the incidence of multiple myeloma and brain cancer in men over 45 years of age had grown by more than a third in less than two decades, and a resulting paper in the Lancet (4) drew major headlines. Davis describes an encounter with Richard Doll, in which he told her that she had made a "colossal error" and that her findings would be explained by improved diagnosis and record keeping for these particular cancers (1, p. 257). She held to her story and gathered the evidence to prove Doll's hypothesis wrong.
She also incorporates personal stories and encounters with cancer, including her own brush with a suspicious mammography reading, her family's exposure to the legacy of environmental pollution in Pennsylvania, and the experiences of friends and colleagues facing difficult decisions and questions about treatment options. Throughout, she also raises questions about what might have been done differently to prevent these cancers.
In the end, however, the book is frustrating for its lack of explicit conclusions or recommendations about how things should be done differently. After 480 pages describing many twists and turns in the politics of cancer research, there are no substantive conclusions to tie it all together. Davis offers broad statements—"we need to open a new front" in the war against cancer (1, p. xviii)—but she fails to offer concrete proposals. In the book's closing pages, she briefly suggests the need for an independent commission for the assessment of toxic hazards and medical monitoring programs for exposed populations, but these suggestions are not developed. "I am not smart enough," she claims, "to know what kind of system will best identify and address the preventable causes of cancer in our environment" (1, p. 430). On this point, she is clearly wrong. As her own autobiographic accounts illustrate, there are few people privileged with the range of scientific and real-world policy experience Davis has to be in a better position to offer some potential solutions. Indeed, this is what makes her failure to do so, so disappointing.
ACKNOWLEDGMENTS
Conflict of interest: none declared.
References
- Davis D. The secret history of the war on cancer (2007) New York, NY: Basic Books.
- Proctor RN. The Nazi war on cancer (1999) Princeton, NJ: Princeton University Press.
- Office of the Surgeon General. Smoking and health: report of the Advisory Committee to the Surgeon General of the Public Health Service (1964) Washington, DC: Office of the Surgeon General, Public Health Service, Department of Health, Education, and Welfare. (DHEW publication no. (PHS) no. 1103).
- Davis DL, Schwartz J. Trends in cancer mortality: US white males and females, 1968–83. Lancet (1988) 1:633–6.[Web of Science][Medline]
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