A new report shows overall cancer rates are on the decline. Diane discusses the latest on cancer in America and the challenges of funding breakthrough research with Dr. Harold Varmus, director of the NIH’s National Cancer Institute.

Guests

  • Dr. Harold Varmus director, National Cancer Institute

Trends in Human Papillomavirus (HPV)–Associated Cancers and HPV Vaccination Coverage Levels

HPV rates
Three-dose human pappilomavirus (HPV) vaccination coverage among girls (aged 13 to 17 years), by state, in the United States, 2010. Source: National Immunization Survey-Teen (NIS-Teen) 2010, National Center for Health Statistics, Centers for Disease Control and Prevention, 2011. Girls in the 2010 NIS-Teen were born during the period from January 1992 to February 1998 and received either quadrivalent or bivalent human papillomavirus vaccine (some girls received more than three doses). Image source: Journal of the National Cancer Institute

Transcript

  • 11:06:56

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. The National Cancer Institute released their annual report to the nation on the status of cancer of this week. Some positive news, overall cancer death rates have declined for some of the most common cancers like lung, colon, breast and prostate.

  • 11:07:18

    MS. DIANE REHMBut some bad news, rates of cancers associated with the Human Papillomavirus increased even though there is a vaccine. Here to talk about the latest cancer data and impact of funding on research, Dr. Harold Varmus, director of the National Cancer Institute, which of course is part of the National Institutes of Health.

  • 11:07:43

    MS. DIANE REHMI hope you'll join us throughout the hour, 800-433-8850. Send us your email to drshow@wamu.org, follow us on Facebook or send us a tweet. Good morning to you, Dr. Varmus, good to see you.

  • 11:08:02

    DR. HAROLD VARMUSThank you, always nice to be here, Diane.

  • 11:08:04

    REHMI must say we used to hear the phrase, "the war on cancer," over and over again. We don't hear that so much anymore.

  • 11:08:13

    VARMUSWell, in part we don't use that metaphor because I don't think it's a terribly appropriate one, for several reasons. One is that cancer is not just one disease, its many diseases. Secondly, well yes, we do want to defeat it. the notion of war suggests that all we have to do is shoot and the fact is that we need to figure out a very complex biological puzzle that affects many of our cells in our bodies and simply making a military metaphor seems to me to oversimplify the problem.

  • 11:08:45

    REHMIt really is interesting to learn how many different ways cancer can come into the body and therefore how different each cancer can be.

  • 11:09:02

    VARMUSRight, well I don't, I think it's useful to point out that, without being critical, it's not that cancer comes into the body but cancer arises from our own cells as a result of misfiring, misdirection's of our normal cells processes. So cancer is a disease which is sort of inherent in the biological situation and it results from damage to our chromosomes, damage to specific genes and it's understanding the nature of that damage, why it occurs, what it affects physiologically in cells and how we can counteract that damage that is so influential in our thinking about cancer.

  • 11:09:42

    REHMI think I was thinking about cigarette smoke, for example.

  • 11:09:47

    VARMUSWell, as...

  • 11:09:48

    REHMAnd that coming into our bodies.

  • 11:09:51

    VARMUSYes, of course that is the cancer is a result of a variety of risk factors, some of those are factors that we inherit that is damaged genes that come from our parents. but some of it, as you point out, comes from our environmental exposures to certain viruses that we'll talk about during the program, to cigarette smoke to other so-called mutagenic, DNA damaging agents that affect our genes and then make cells go awry when the right constellation of changes occur.

  • 11:10:24

    REHMWhat would you say are the biggest challenges that the National Cancer Institute faces today?

  • 11:10:33

    VARMUSWell, there are many that -- the biggest problem, of course, is trying to reduce cancer mortality and cancer incidence but you have to go about that in a variety of ways and that's where things become difficult. We have a very large portfolio because we're trying to understand how cancer arises in many different cell types and many different organs in, as a result of many different kinds of mutations.

  • 11:11:01

    VARMUSSo I would say our biggest overall challenge in some sense, perhaps not in the public health sense, but in the fundamental sense of trying to understand this vast and complex array of diseases is to understand those diseases at a fundamental level so that we can take appropriate action. but from the public health point of view, which is something we keep in mind all the time, the challenge is saying how do we take a disease that is one of the major killers in our country and around the world and turn it into a much less devastating set of conditions.

  • 11:11:33

    REHMTell me about the good news, as far as cancer is concerned?

  • 11:11:37

    VARMUSAll right. Well, the report that was just issued and I should probably add that it was not just from the National Cancer Institute but also from the Centers for Disease Control, the American Cancer Society and the cancer registries around the country, shows two things. One is that, as you point out, it shows that there's a continuation of an overall good, but not astounding trend that is, there's been about a 1.5 percent reduction in age adjusted mortality rates for cancers overall and for most of the important cancers.

  • 11:12:12

    VARMUSThere are a few exceptions because, as I mentioned, cancer is a complex set of diseases and for some diseases, we're not making the kinds of gains. In fact, things are getting worse so we can talk about that. The other major point that it makes, and one that I think is important to bring to public attention because there's something we can do about it, all of us regardless of whether we're working at laboratories or have medical degrees.

  • 11:12:35

    VARMUSAnd that is the increase in the so-called human papillomavirus associated cancers that have shown some of the biggest increases in incidence over the last few years and yet we have the tools to protect against those cancers because we have a vaccine that's safe and effective that is being dramatically underused in this country by both boys and girls.

  • 11:12:58

    REHMTell me why that human papillomavirus is becoming so widespread?

  • 11:13:07

    VARMUSWell, I think we don't know exactly why it's increasing in incidence, maybe due to changing sexual practices because the virus is generally transmitted through sexual activity. There is, of course, improved detection of the virus that's important, but the thing that to me is so striking is that we have an effective agent, a vaccine, to protect against infection by the most cancer causing strains of the virus and yet a very small fraction, only about a third of girls and a very, very small fraction of boys, are being vaccinated to protect them against cancers.

  • 11:13:47

    REHMAnd at what age is the recommendation for vaccination?

  • 11:13:51

    VARMUSYes, well, this is a little complex, but the best time to vaccinate is just before people become sexually active. We don't know yet because the vaccine is only about a decade old, how long the immunity conferred by the vaccine will actually last. So it is imperative to vaccinate at a time that provides optimal benefit, not at infancy but just before the virus is likely to be infecting individuals who begin sexual activity.

  • 11:14:23

    REHMAnd yet at the same time, you have greater and greater resistance in a certain portion of the population to vaccines of any kind.

  • 11:14:36

    VARMUSYes, that is true. I would point out, however, that this vaccine is now been given to many millions of people with minimal side effects. The vaccine is not a live virus, the vaccine is just viral protein. There are no viral genes in the vaccine which means the virus can't grow and cause damage in individuals and people who are being vaccinated are generally in the adolescent age group, age 11, 12, 13 and therefore, you know, there's a myth out there that's founded, frankly, on nothing but misrepresentation that certain viruses are linked to developmental anomalies, like autism and that is been completely debunked and of course it would not apply despite the claims made by some of our politicians, to individuals who are in the adolescent age group.

  • 11:15:33

    REHMSo are, is the recommendation from the CDC, for example, that pediatricians as an entire group, recommend to parents that their youngsters receive this vaccine?

  • 11:15:51

    VARMUSYes, there are very strong recommendations from the CDC and from the United States Preventative Services task force that both boys and girls in the adolescent age group should be vaccinated and there are tools to help make vaccination. There are a number of reasons why people don't get vaccinated, it's not just fear of complications that are not credible.

  • 11:16:15

    VARMUSOne, is that the vaccine is not cheap but there are provisions by the CDC, for example, under their vaccines for children program, if one's qualified, one can get vaccinated and we believe that physicians can be more active in reminding people it's not just one vaccination.

  • 11:16:36

    VARMUSWhat's recommended currently is three successive vaccinations.

  • 11:16:40

    REHMI see.

  • 11:16:42

    VARMUSWe don't know how long immunity is going to last and it seems reasonable to try to optimize the chances of persistent protection against this virus, which is a cancer causing virus.

  • 11:16:52

    REHMThere are a number of other cancers on the rise, kidney, pancreatic cancers?

  • 11:17:01

    VARMUSWell, especially, the cancers that have shown increased mortality rates after age adjustment in the last few years include melanoma in males, very slight increase in mortality and a fairly dramatic increase in incidence. Cancer of the pancreas, cancer of the liver and in women, cancer of the uterus, not the cervix but the rest of the uterus.

  • 11:17:24

    VARMUSAnd we don't really understand the reasons for these increases in mortality and in these cancers frequently we don't have very good therapeutic options, that's certainly true for pancreatic cancer and the diseases are frequently found at a time, that it's diagnosed at a time when they're too far advanced to be responsive to surgery, which of course, is always our best tool for treating cancers.

  • 11:17:50

    REHMWhat about colon cancer?

  • 11:17:52

    VARMUSWell, colon cancer is a success story, I think it could be much greater one. But perhaps the most important tool that we have is early diagnosis by or early detection of what we call premalignant lesions. And that means is we can use either a sigmoidoscope, which looks at the rectum and the lower colon or a colonoscope which goes all the through the colon.

  • 11:18:18

    VARMUSOr we can simply do a regular and frequent testing of stool for blood and those screening tests all provide reduction in mortality rates by finding cancers either in early staged or finding the premalignant lesion we call an adenoma and if applied properly these are life saving and they've reduced the mortality rates by about three percent.

  • 11:18:43

    REHMDr. Harold Varmus, director of the National Cancer Institute, part of the National Institutes of Health. Do join us after a short break.

  • 11:20:06

    REHMAnd welcome back. In this hour Dr. Harold Varmus, he's director of the National Cancer Institute which was actually created in 1936. Is that correct?

  • 11:20:21

    VARMUSWell, '37, but that's close enough for government work.

  • 11:20:22

    REHM'37. All right. Close enough. And of course, for many years, and certainly as I recall from President Nixon's time on, there was the so-called war on cancer. It is no longer -- that phrase is no longer used because there is such a multidimensional process to be approached to cancer, to what causes cancer, how it arises. And that's why the National Cancer Institute is there.

  • 11:21:01

    REHMFrom our website, Dr. Varmus, a point made. "We need to direct money and focus on the cause of cancer not the cure. Without knowing the cause we will never find a cure, the cure that works without killing people. I would love to know what Dr. Varmus has to say about this."

  • 11:21:30

    VARMUSWell, first of all, I would pluralize those words, that is there are many causes. And one has to also be careful about the use of the word cause. There are what we call risk factors, like smoking, like very pronounced obesity, like inheriting certain abnormal genes from your parents that predispose to cancer.

  • 11:21:58

    VARMUSThen there are the ways in which those causes work, which we think largely is through changes in our genes, mostly what are called mutations, change in the sequence of the basis and DNA that dictate how our proteins are made. But also other kinds of changes that affect the way in which genes are read out or expressed. And then we have to use the word -- the word cure is -- first of all, it shouldn't be singular because we have different approaches to different cancers.

  • 11:22:27

    VARMUSAnd secondly, we have to face the face that while cures are highly desirable and in fact achievable in quite a few cases, that we would also consider it to be a tremendous step forward to be able to control the disease so that it doesn't progress and people can live normal lives. And we have some remarkable examples of that in just the last decade.

  • 11:22:49

    VARMUSFor example, the one that is sort of the poster child for explaining this in a disease that is the most common leukemia in adults in this country, chronic myeloid leukemia, indeed throughout the world, we know that that is a relatively homogeneous disease that is virtually every patient has a change in one important gene. And we have a drug that inhibits the activity of that gene. So virtually everybody who receives that drug for that disease goes into a dramatic remission, that is the disease is held in check. Most of the leukemic cells go away.

  • 11:23:28

    VARMUSIt's not a cure. People can't come off the drug. A small fraction of patients become resistant to the drug but we have backup drugs so that it's now possible to overcome drug resistance in most cases. And we can now say that the disease that was lethal within five years in virtually all patients is now a disease that's consistent with a perfectly normal life expectancy.

  • 11:23:51

    REHMNow on the other hand, there are -- sometimes there the so called treatments that are so damaging to the body in the attempt to ameliorate the cancer that they can kill you.

  • 11:24:15

    VARMUSWell, it is absolutely true and something that we work hard on that many of the traditional chemotherapies -- not all but most -- and radiation therapy and even sometimes surgery are debilitating and cause other symptoms that are very difficult to cope with. One of the successes that's often not talked about in discussions about cancer are the advances that we've made against the side effects of chemotherapy. There's much better control of bone marrow suppression by chemotherapy. There's better control of pain and of nausea and vomiting.

  • 11:24:53

    VARMUSI'm not saying that cancer is a walk in the park. It's not but we have a very active program that deals with efforts to ameliorate the side effects of many kinds of therapy. And it's been dramatically successful. And I think one of the reasons why people have a different approach to dealing with their own cancers now than they did before is because it is possible to talk about it.

  • 11:25:20

    VARMUSPeople -- I've seen many patients in my time, as director of Memorial Sloan and Kettering patients who are in active cancer therapy but they're at work and leading normal lives because we're able not only to successfully hold off their cancer but also to control many of the side effects of treatment.

  • 11:25:39

    REHMAre there some promising non-chemotherapy treatments that are out there?

  • 11:25:46

    VARMUSOh, absolutely. And of course, one of the goals of contemporary cancer research is to design these so called targeted therapies, one example of which I mentioned earlier in talking about chronic myeloid leukemia. But there's also been progress in using the immune system to help overcome cancer. Just in the last couple of years treatments of certain leukemias and treatments of melanoma have been tested and shown to be effective. Not universally effective and not necessarily effective in the very long term, but these are promising developments because 20 years ago the attitude was that we can't use the immune system to counteract cancers.

  • 11:26:31

    VARMUSBut now I think there's general agreement that we know enough about how the immune system works, what the accelerators and brakes on various cellular components of the immune system are so that we can try to direct immune cells against specific cancers in meaningful ways. Indeed, we use antibodies routinely in certain therapies, for example Rituximab in certain lymphomas, Herceptin in breast cancer. These are antibodies. They are products of the immune system. They have some toxicities admittedly, but they are quite effective in controlling, as you know, breast cancer and lymphomas.

  • 11:27:09

    REHMI want to go back for a moment to the human pappiloma virus because we may have left the impression that it's really only girls who need to get this vaccine. As you pointed out to me during the break, young boys are particularly vulnerable as well.

  • 11:27:34

    VARMUSWell, it's not necessarily young boys. The vaccination should be administered before boys and girls become susceptible. But I think it's important for people in the audience to understand that while cervical cancer worldwide is still the major cancer that is induced by the human pappiloma viruses of certain types, that especially in this country there is a growing incidence and the predominance of other kinds of cancers. Cancers of the mouth and throat, we call oropharyngeal cancers, cancers of the vulva, cancers of the penis, of the anus.

  • 11:28:08

    VARMUSAnd these cancers are growing in incidents in general and associated with a virus that can be defended against by using the current vaccine. So I'm a major enthusiast for widespread use of the vaccine. And it is notable that the U.S. has such low rates of vaccination. In Australia, in the United Kingdom, even in parts of Africa like Rwanda where the vaccine is being provided with financial assistance, the vaccine uptake rates are much higher. And this is going to have a major effect worldwide on the rates of the HPV-associated cancers.

  • 11:28:50

    REHMYou mentioned financial assistance. Here's an email from Marion in Louisville, Ky. "Please comment on the pending cuts to the NIH budget should the sequester go through. Also if the sequester's actually not implemented, what are the prospects for the NIH budget going forward?"

  • 11:29:19

    VARMUSRight. Well, the NIH has always been strongly supported by the public and by Congress. And when I was the NIH director in the 1990s I lived in very good times when the congressional support for the NIH and the growing economy allowed the NIH to expand its activities dramatically with a doubling of the NIH budget over five years. Since about 2003 there's been minimal increase and for the last few years flat budgets, or actually even one year of 1 percent decrease in our budget.

  • 11:29:55

    VARMUSOur community is large. It's very active. It's got a lot of great ideas. And we're at the point now where we fund at the cancer institute about one in seven of the applications that come through our doors. So this is a situation which is limiting our ability to make progress. Obviously we have a $5 billion budget. We do a lot of work and I believe that we are making advances. We're trying to use our money as judiciously as possible, so we're funding the very best science. And the science is likely to lead to improvements in our ability to control these diseases we call cancers.

  • 11:30:35

    REHMBut are you suggesting that there could be a reduction in the amount of investigation into new drugs, new treatments?

  • 11:30:44

    VARMUSWell, it's obviously the case that if we have less money we're going to support fewer grants. And we're always trying to do some new things and yet some of the old things are not brought to satisfactory conclusions. So I think it's a statement of obviousness that we can just do less with less money. I also point out, of course, that the key thing in all this is talent and ideas. Money is essential but not sufficient.

  • 11:31:16

    VARMUSBut we do have a remarkably active and -- community of scientists. Many of them recruited by the excitement of growing interest in medical science, the altruism of improving health of individuals around the world and making discoveries about how life forms work. So many reason to join this enterprise but now many of our scientists, even the best and youngest, are definitely threatened by budgetary reductions.

  • 11:31:52

    REHMDr. Varmus, as the former director of NIH overseeing the entire program, I wonder -- now you are focused on cancer, I wonder in your own mind how concerned you are about the rise in cases of Alzheimer's as the population ages and the money being allocated for research into Alzheimer's as opposed to the money allocated for research into cancer.

  • 11:32:33

    VARMUSWell, Diane, first of all, it's very difficult to say whether there is an appropriate level of funding for any single thing. After all, much of what we do is directed to basic biological processes. And there is cross sharing of information.

  • 11:32:49

    REHMI'm sure.

  • 11:32:49

    VARMUSThere is substantial allocation for Alzheimer's. Is it enough? No, but that's also true of the funding for many other diseases, diabetes and heart disease and infectious diseases. There are more ideas than we can support. Of course we're all quiet concerned about Alzheimer's, a devastating disease which currently is going to affect nearly 50 percent of all of us at the age of 85.

  • 11:33:16

    REHMExactly.

  • 11:33:17

    VARMUSSo this is a major threat. And we have some new tools. There have been advances but no advances that -- there's advances in our understanding, our ability to diagnose the disease. And indeed all of us who are approaching the age at which Alzheimer's disease becomes more frequent are beginning to see individuals who are encountering the early stages of the disease. One of my hopes is that by using early diagnosis, which is a devastating piece of news at this stage, we will have the ability to use treatments, which I believe are going to be much more effective very early in the disorder than they will be later on.

  • 11:33:58

    VARMUSSo I think there are significant changes that have occurred in our approach to Alzheimer's but nevertheless it's a terrible diagnosis. And it's one that I see neuroscientists working on with great ardor.

  • 11:34:13

    REHMAnd you're listening to "The Diane Rehm Show." We've got lots of callers. I'm going to open the phones, 800-433-8850. First to Cape Code, Mass. Hi there, Gail, you're on the air.

  • 11:34:32

    GAILYes. Good morning, Diane. My question, I guess I'm interesting in the discussion -- I'm interested in the whole program of course but I would question about the HPV virus vaccine. It's my understanding that the Gardasil Company produced that. I'm not sure if they're the only provider at this time. But my information was that it only protected against 15 to 16 approximately of the HPV virus attack. And I wondered if the doctor could comment on that.

  • 11:35:08

    VARMUSYes, thank you. Hi, Cape Cod. There are two vaccines currently available. One -- and let me backtrack a second by saying that there are many strains of human papillomavirus, probably about 100. But only two account for most of the cancer-causing properties, strains 16 and 18. Both of the available vaccines protect individuals who are vaccinated against those two highly cancer-causing strains. One of the vaccines also protects against two other strains, strains 6 and 11, if you care to know the numbers, that cause genital warts in addition to cancers.

  • 11:35:49

    VARMUSThose two strains, the two highly so called oncogenic strains, 16 and 18, account for 70 percent of cervical cancer. And they account for about 90 percent of all the other cancers that are HPV, human pappiloma virus associated that I mentioned earlier, cancers of the vulva, penis, mouth and throat and the anus. So these are very effective vaccines but they're not perfect. And your call is -- one of the points that's worth raising here is that it's not completely protective because there are 30 percent of cervical cancers that won't be defended against by this vaccine.

  • 11:36:28

    VARMUSThere are new forms of the vaccine that are being developed that will cover more strains. And my hope is that research being carried out at the NIH and elsewhere will enable us to provide vaccines ultimately that protect against all of the cancer-causing strains, indeed all the strains as far as...

  • 11:36:45

    REHMSo let me understand. Are you saying an individual would have to have two different forms of the vaccine...

  • 11:36:54

    VARMUSNo.

  • 11:36:54

    REHM...or just one?

  • 11:36:56

    VARMUSOne at this point. And my hope is that we will develop even better versions of vaccine. But it takes time because these strains -- these new vaccines need to be developed and they need to be tested both in preclinical and clinical settings. And it will be a while before we have a vaccine that's universal.

  • 11:37:15

    REHMDr. Harold Varmus. He's director of the National Cancer Institute. When we come back more of your calls, your email. I look forward to speaking with you.

  • 11:40:03

    REHMAnd here's an email from Don in Bethesda, Md. saying, "Diane, you should mention that in addition to currently being head of the National Cancer Institute, Dr. Varmus is a Nobel laureate and director of the National Institutes of Health during the Clinton administration. It's also been publicized he is a very fit athlete and rides his bicycle to work from D.C. to the NIH in Bethesda." Is that still the case?

  • 11:40:41

    VARMUSDon, thank you for that comment and all these things remain true. Although Nobel Prize was a long time ago. We've simply forgotten that.

  • 11:40:48

    REHMWell, it's for life, Doctor, really for life. Tell me about your diet.

  • 11:40:57

    VARMUSMy own diet, well...

  • 11:40:57

    REHMYes.

  • 11:40:58

    VARMUS...you know, I -- because I do a lot of sports, I try to keep myself pretty fit and low fat diet, but I enjoy food and I eat out and I -- but I don't want to gain excessive weight for a lot of reasons.

  • 11:41:14

    REHMAre you a vegan?

  • 11:41:15

    VARMUSNo.

  • 11:41:16

    REHMYou are not?

  • 11:41:17

    VARMUSI'm not.

  • 11:41:17

    REHMYou do eat beef, chicken?

  • 11:41:19

    VARMUSI eat vegetables, fruits and I eat chicken and other things, but in moderation.

  • 11:41:24

    REHMAbsolutely.

  • 11:41:24

    VARMUSAll things in moderation.

  • 11:41:25

    REHMAbsolutely.

  • 11:41:25

    VARMUSA balanced diet and -- but I happen to have the advantage of enjoying fruit and vegetables and eat a lot of them.

  • 11:41:32

    REHMAs do I.

  • 11:41:33

    VARMUSAnd I don't mind skim milk, unlike my wife, so...

  • 11:41:39

    REHMYou don't drink...

  • 11:41:40

    VARMUSMind skim milk, right?

  • 11:41:41

    REHMYeah, yeah. Okay.

  • 11:41:42

    VARMUSSo I keep my fat content down. And I try to control my cholesterol levels and watch, you know, watch my glucose levels and, you know, I'm conscious of the fact that what we do with ourselves, maintaining adequate exercise pattern, a balanced diet, is important. And I also am sensitive to the idea of trying to prevent disease in other ways, by monitoring one's blood pressure and by taking a daily aspirin, which is protective not just against cardiovascular disease and stroke, but it's also -- there's very strong evidence to suggest that taking a daily small aspirin is protective against all of the gastrointestinal cancers and lung cancer. This is something which is not widely appreciated...

  • 11:42:35

    REHMInteresting.

  • 11:42:36

    VARMUS...has not yet been endorsed by some of the major organizations that make suggestions about prevention like the United States Preventive Services Taskforce. But the evidence is increasingly strong that one can achieve, especially in individuals in the middle age range, 50 to 65 or so. As much as 30 percent reductions in cancer mortality caused by cancers of the esophagus, stomach, colorectal areas and lung, and perhaps some other cancers as well.

  • 11:43:11

    REHMAnd you're talking about a baby aspirin.

  • 11:43:14

    VARMUSI'm talking about 81 milligram doses every day.

  • 11:43:15

    REHMEight-one.

  • 11:43:16

    VARMUSMm-hmm.

  • 11:43:16

    REHMAll right. Let's go to Miami, Florida. Hi there, Ray, you're on the air.

  • 11:43:22

    RAYOh, hi, Diane. You're a national treasure.

  • 11:43:24

    REHMThank you.

  • 11:43:25

    RAYAnd I'm a Diane Rehm addict.

  • 11:43:28

    REHMOh, I'm glad to hear that.

  • 11:43:30

    RAYAbsolutely. My question for the doctor is, well, my wife of 59 years died of brain cancer, the glioma. And that's the same cancer that Ted Kennedy died of. I have a -- one question is what progress has been made as far as glioma's are concerned? And the other is a statement. And she was in an early music group that played replica instruments out of which a group of seven, five died of brain cancer. I don't know if they were all primary. I know three were. And how do I go about trying to find any information that there may -- it maybe had been attributed to a particular double reed instrument that -- it sounds farfetched, but...

  • 11:44:30

    REHMA double reed instrument. What instrument are you talking about?

  • 11:44:36

    RAY(unintelligible)

  • 11:44:36

    VARMUSOboe probably or bassoon.

  • 11:44:37

    REHMThe oboe. Okay.

  • 11:44:38

    VARMUSAs an oboe player, I listen to this carefully.

  • 11:44:42

    REHMI'm sure you do.

  • 11:44:44

    VARMUSBut, first of all, let me offer my condolences on your loss.

  • 11:44:50

    REHMI should say.

  • 11:44:51

    VARMUSBrain cancer of the kind you're referring to, a form of glioma, called glioblastoma is one of our most horrific illnesses, and one of which we made very little progress in control. There has been progress in understanding the disease in that glioblastoma was one of the first cancers that has been subjected to analysis as part of what we call the Cancer Genome Atlas, an effort to catalog all the changes in genes and gene expression that occur in that disease. And one of the things that's emerged from that is a sub classification of glioblastoma so that we recognize that there are several different types that have different patterns of mutation and gene expression.

  • 11:45:41

    VARMUSAnd that's obviously helpful in thinking about the disease and trying to use new treatments in a way that's appropriate for the different categories. But I'm sorry to say that at this point there is not a tremendous to offer. We have improved surgical methods. There is radiation therapy that can offer some benefits. There are some drugs that offer some help in some cases. But as you undoubtedly have experienced with your wife's disease and with cases in her music group, that there isn't a tremendous amount to be done. We don't have the kinds of tools we have for many other cancers.

  • 11:46:21

    VARMUSThat being said, your point about the high incidents in one small group is something that is worth looking at, but is also a fact that ought to be stressed that if you look at the distribution of any disease, including cancers, you will find certain sporadic clusters of disease that usually don't hold up with greater scrutiny because there just will be a random cluster here and there. And unless there's some potential risk factor that this group was practicing in a room that was -- that had some other kind of mutational agent, maybe that could be an explanation. But in general these coincidences, because cancers are not infrequent diseases, that simply don't bear up on further scrutiny.

  • 11:47:22

    REHMRay, I'm so sorry for your loss. Thank you for calling. Here's an email from Mike in Missouri, who says, "We have a friend receiving alternative treatment for a brain tumor in Mexico. It's a vegan diet with juicing and coffee enemas. Please comment on what research is being done with alternative treatments, especially diet."

  • 11:47:55

    VARMUSYes. Well, of course, alternative treatments represent a large selection of approaches. And in general they have not been validated. It is important to know what alternative therapies patients are taking, because frequently they conflict with, cause adverse reactions when used in the context of traditional therapy. So it's important that people be honest with their physicians about the things that they're doing. Some alternative therapies do pose dangers. And I would say that coffee enemas is one of them. There is, of course, a widespread interest in the role of nutrition in either cancer causation or cancer therapy.

  • 11:48:40

    VARMUSThe evidence at this point is generally fairly weak and is why you read in the newspaper with great regularity that one day coffee is -- you know, oral coffee is good for you and one day it's not good for you. And that's why there are different levels of credibility associated with claims that one fruit or one vegetable or something of the sort has protective powers.

  • 11:49:06

    REHMDidn't NCI for a while have an alternative therapy...

  • 11:49:10

    VARMUSOh, we still do.

  • 11:49:11

    REHM...investigation?

  • 11:49:12

    VARMUSI'm trying to say -- I know that -- I'm suggesting there are studies being done on...

  • 11:49:18

    REHMGood.

  • 11:49:18

    VARMUS...alternative approaches, both in the NCI itself and in the center that NIH has for complementary and alternative medicine.

  • 11:49:27

    REHMWhat kinds of...

  • 11:49:29

    VARMUSWell, they vary dramatically. And one of the things that's a problem here, and you're appropriately raising it, is there are thousands of alternative therapies that are suggested. Every study that one carries out, especially if it's a clinical study, is expensive and requires a lot of attention, a lot of man power. So we have to be very selective about what we're going to undertake because we can't study everything. So when there's evidence, sometimes anecdotal, sometimes from a preliminary study that something is worth looking at in detail, that's done. In general, the studies that have been undertaken by the Center for Alternative Medicine for all diseases have failed to validate claims for efficacy, for alternative practices.

  • 11:50:11

    VARMUSBut, you know, I take the point of view that everything was once an alternative medicine, even digitalis and aspirin. At one time these were new. And what I like to do is not distinguish between conventional and alternative, but can distinguish between what works and what does not work.

  • 11:50:29

    REHMAll right.

  • 11:50:29

    VARMUSAnd the only way to figure that out is to do a controlled clinical trial and to...

  • 11:50:33

    REHMOf course.

  • 11:50:33

    VARMUS...look for an explanation for why something would work or not.

  • 11:50:36

    REHMLet's go to Baltimore, Md. Jenny, you're on the air.

  • 11:50:43

    JENNYHello. Thank you so much for bringing attention to this issue. You and Dr. Varmus are doing enormous good by bringing attention, especially I feel, to the HPV vaccine issue. So I have a comment and a question and I'll take my answer off the air.

  • 11:51:01

    REHMAll right.

  • 11:51:02

    JENNYI lived in Austin during the time when Rick Perry in 2007 actually tried to get the HPV vaccine mandated. Sadly this degenerated. I had never been on the same side of an issue as Rick Perry, so it was kind of surprising. But it turned out that there were some accusations of chronism, that he had support from Merck and it kind of ended up really not going anywhere, which is a great disservice to the kids in Texas. As the mother of a 9-year-old, I want my child to be vaccinated.

  • 11:51:34

    JENNYAnd I feel that conflating the idea of vaccinating a child against a potential life threatening disease that leads to many types of cancer and which they can also pass on to others through sexual contact is inadmissible. It's crazy that we wouldn't vaccinate a child. And I really wish that -- I mean, this is kind of due for a makeover in terms of a public service campaign, because you wouldn't say that a child -- that giving a child the polio vaccine is tacit approval for them to get polio. I mean, you want to give them the vaccine before...

  • 11:52:14

    REHMSure.

  • 11:52:15

    JENNY...they're ever exposed to the disease.

  • 11:52:16

    REHMSure.

  • 11:52:17

    JENNYAnd I think that most parents if approached in that spirit, I mean, this is really -- it's a perception problem and needs to be addressed as such. And I think that community health organizations are a good place to start, whether in terms of diseases like diabetes that can be modified by diet, cancers that come from obesity, all of these lifestyle changes can be addressed there. And also the vaccination issue because not vaccinating our child against HPV and conflating this with some kind of, you know, other morality issue is crazy to me.

  • 11:52:54

    REHMAll right.

  • 11:52:55

    JENNYSo my question is really why can we not mandate an HPV vaccine in the same way that we say that if you are going to attend school, you have to have measles, mumps vaccinations?

  • 11:53:06

    REHMAll right. All right. Dr. Varmus.

  • 11:53:08

    VARMUSSo briefly, yes, mandates are possible. There is a mandate in the District of Columbia and one other state. These are not perfect. We still don't have complete compliance in the District of Columbia because the mandates are not hard wired. I would also point out that the president's cancer panel, a panel created by the National Cancer Act of 1971, is currently studying the human papillomavirus issues, including vaccinations in the U.S., and will be issuing a report in this year. I'm hope that further public attention by you, by the president's cancer panel and others will bring more attention to this very important issue.

  • 11:53:49

    REHMAnd you're listening to "The Diane Rehm Show." Here is a question that's come up several times. This from Kathy in Raleigh, N.C., who says, "I'm almost 60 years old. I have not been sexually active for over 12 years. Recently my gynecologist routinely screened me for HPV. I was found to be positive. She said this meant I needed to get a pap smear every year. I'm totally dumbfounded about the finding. How long can this virus be dormant? How can this be explained, if at all?"

  • 11:54:34

    VARMUSWell, this is one of those viruses that can inhabit your cells for many, many years. And it does cause cancer very slowly. One of the reasons we've been so effective in this country in reducing cervical cancer death rates down to under 3,000 per year is because there has been very high level of compliance with the recommendation to have pap smears done. In fact, we probably do too many pap smears in this country, too frequently, too early, too long. But that will change with both the vaccination coming into great use and with other kinds of tests like the test that you're doctor advised, namely a test for human papillomavirus in your cervical cells.

  • 11:55:19

    VARMUSBut the virus is one that can be quite quiescent and can be carried for very long periods of time, so you're story is not atypical.

  • 11:55:28

    REHMBut certainly frightening. To what extent is the vaccine recommended for older people?

  • 11:55:37

    VARMUSWell, let me be clear, Diane. The vaccine does not have any effect once you've been infected.

  • 11:55:42

    REHMI see.

  • 11:55:42

    VARMUSThe vaccine is intended to protect you against initial infection, which is why it's so important to recommend that the vaccine be used before sexual activity commences or very early in one's sexual activity. Not every sexual encounter is going to lead to an infection. And indeed one of the reasons to sterilize both boys and girls is to try to decrease the...

  • 11:56:07

    REHMYou don't mean sterilize, you mean vaccinate, don't you?

  • 11:56:09

    VARMUSSorry, vaccinate. But, yes, I'm sorry, vaccinate, thank you. But to keep the vaccine -- the virus from infecting individuals is that if you reduce the virus -- the prevalence of virus both in boys and girls...

  • 11:56:24

    REHMRight.

  • 11:56:24

    VARMUS...you reduce the chances that the virus will be transmitted.

  • 11:56:27

    REHMBut say that one is 40 years old and one has been sexually active, but has not had any incidents of HPV, could one decide at 40 that I want this vaccine? Would it do some good?

  • 11:56:49

    VARMUSWell, in general, that's not recommended, but...

  • 11:56:53

    REHMBecause?

  • 11:56:54

    VARMUSWell, because, in general, people have been exposed to the virus by then, and if they haven't been, they're probably not going to be exposed at that age. But, you know, you're making a useful point. But as a public health measure we recommend vaccination up to the age of about 26 for those who never --

  • 11:57:11

    REHMAll right.

  • 11:57:12

    VARMUSBut hopefully we'll vaccinate everybody in adolescence and won't be required later in life, in the future.

  • 11:57:18

    REHMNobel Prize winning scientist Dr. Harold Varmus. He's director of the National Cancer Institute. Thank you so much for the hour.

  • 11:57:30

    VARMUSMy pleasure. I'm surprised it's done already. Thank you, Diane.

  • 11:57:31

    REHMAnd thanks for listening all. I'm Diane Rehm.

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