Cancer Treatment is a Self-Serving Industry

[NW-Bound]

... you really have to experience this stuff first hand to appreciate the little nuances of the horrors of cancer treatment which have allowed this stage 4 survivor to celebrate 10 years of life post diagnosis...

Yes, I have heard of people who live for many years with a stage 4 cancer while taking maintenance medicine.

On the other hand, there are more often stage 4 cases that do not respond to treatments. These are more common, I think.

 

[DallasGuy]

Pretty sure I would not treat stage 4 cancer. It is not going to change the outcome for a lady I know but she is suffering all along the way from all this "treatment".

It depends on the type of cancer.

Half of the people diagnosed with stage 3 multiple myeloma (stage 3 is the highest stage for this cancer) live at least of 3 1/2 years with treatment. That means that half of them live longer than 3 1/2 years. I'm guessing that most people would take the treatments and take a shot at another 3 1/2 + years of life.

I have multiple myeloma and the treatments for me were not that bad, compared to other types of cancers. I was diagnosed with stage 2 multiple myeloma and half of the people diagnosed at that stage live 7 years or longer. I'm currently at 7 years and still in remission. I will most likely relapse at some point in time because there is no cure for this cancer. But the treatments for me have definitely been worth it.

When I was diagnosed 7 years ago, life expectancy was about 3 years. It is now 5-10 years. The development of new treatments has made the difference. My one big complaint though is that the pharmacy industry makes $billions off the backs of cancer patients and our health care system...way more than I consider reasonable.

I also want to comment on a stmt made in the article:

"But as a 2015 analysis points out, in general people do not live longer as a result of early detection. They simply live longer with a diagnosis of cancer, with all its harmful emotional, economic and physiological consequences."

With multiple myeloma, this statement is simply not true. Almost everyone that is diagnosed with multiple myeloma will live longer with treatment and will live longer the earlier they are diagnosed. Not only that but if diagnosed early, kidney and bone damage can be minimized. I was diagnosed as a result of a routine annual physical examination. Had I not had an early diagnosis, I probably would have ended up with kidney and bone damage and that would have surely resulted in a shorter life expectancy.

 

[Midpack]

Let’s hope advances in gene therapy/targeted therapy improve outcomes over chemo and radiation - which could substantially change the landscape in the OP link. There have been some astounding successes already that wouldn’t have been possible with chemo or radiation alone, but targeted therapy is still a developing field as I understand it. However I haven’t heard or read anything about what it costs. Like it or not, what society can afford just isn’t unlimited and we’re pushing those limits with some treatments today, and we sometimes lose sight of that.

There are much better articles but basically https://www.cancer.gov/about-cancer/treatment/types/chemotherapy

 

[PoorOldCountryBoy]

True

Tough topic. My first wife had less than 2 years from cancer diagnosis to passing. I often wonder if we could have enjoyed our limited time together better than the hell of chemotherapy, heart damage and pain of sudden loss.

https://blogs.scientificamerican.com/cross-check/the-cancer-industry-hype-vs-reality/



"A 2015 meta-analysis by epidemiologist John Ioannidis (renowned for bringing the scientific replication crisis to light) and others found no reductions in all-cause mortality from tests for cancer of the breast, prostate, colon, lung, cervix, mouth or ovaries for asymptomatic patients."

My sympathies to you and yours. Losing someone is always tough.

I'll try to minimize another long winded series of anecdotes, but in the end
it is really a flip of the coin in general. If caught early enough there are true cures, most in Stage 1/localized. So most will decide to go for it, of course. When things have spread, then it gets much tougher.

One problem I see is the clinical tendency to soft sell the side effects of the treatments. Doctors don't spend time living with it, nurses tend to be team players and want to push people to be people better ASAP. Before going through a treatment insist on talking to more than one survivor about long term side effects.

Another is outright medical/insurance fraud. We had one of those in our extended family. The (place your choice of adjective here) doctor is now serving time, and fortunately the patient is still with us if a bit slowed down.

The clinicians who were doing the chemo treatment should have been responding daily to any discomfort issues with your loved one. I hope they were as responsive to quality of life issues as humanly possible.

 

[Amethyst]

Ratface, I remember your detailed descriptions, with pictures, of your cancer treatments and am glad every time you post again, showing you are still with us. I seem to recall you experienced side effects from chemo - have those subsided?

Let me preface my comments by stating that I find the members of this site to be among the very brightest and well informed on many different subjects. I however find many of your views lacking by a group that typically is spot on. I personally take issue with anyone who flat out stated that any stage 4 cancer is a certain death sentence. It shows a clear misunderstanding of the standard cancer staging system which incorporates size of a tumor, location of a tumor, and spread of a tumor, all of which combined or alone can delineate staging. Sometimes a cancer has an unknown primary which in itself can cause a stage 4 classification. Then there is the chemical analysis of a tissue sample which can determine treatment options based on what caused the cancer in the first place. Some have more favorable treatment options and better survival rates than others, for instance, I'll speak to head and neck cancer, specifically base of the tongue cancer, which was my affliction. In this type of cancer caused by the HPV virus, specifically #16 and #18 have much better survival rates than the traditional drinking and smoking causative factors. Now consider that almost all cervical cancers are HPV related. Cancers are very individualized and treatments are tailored to that individual, by age, weight, and any other health variables of the individual. Chemotherapy and radiation is also tailored using all those variables and closely monitored and adjusted, some are given infused every 30 days in powerful brink of death doses and others are given daily in small tolerable doses to weaker individuals. Treatment options are constantly evolving to the point that head and neck cancer of HPV origin has gone from surgery, radiation, and chemotherapy to just one modality now yielding the same outcome. There is progress, I can speak to only a few minute strides, for instance radiation has come a long way from Cobalt, to Intensity modulated beam, and now proton, each successive one doing less and less damage to nearby tissue. These little improvements exist in every type of cancer treatment and are evolving in imperceptible increments to which the posted article does not reference probably because you really have to experience this stuff first hand to appreciate the little nuances of the horrors of cancer treatment which have allowed this stage 4 survivor to celebrate 10 years of life post diagnosis. To anyone diagnosed with cancer, it's an individual disease with a multitude of variables and blanket conclusions sometimes don't apply.

 

[Turbo29]

It is now commonly known that PSA test is not a good diagnosis for prostate cancer, and prostate biopsy brings other serious risks.

But other cancer biopsies such as for colon cancer (polyp extraction during a colonoscopy), skin melanoma, breast tumor, pap smear, do not have such risks. Why is it a gamble?

Some gambles are better bets than others. Even for a colonoscopy as one gets older that benefit decreases and the risk of harm (such as perforation) increases.



He doesn't say that one should never be screened, the point is that screening tests are not unmitigated goods.



Take the PSA for instance. Any time I have seen it discussed anywhere you will always get at least one individual stating that the PSA is wonderful, it saved their life. I don't argue that it saved their life, but on average people are harmed by it.


Take the gambling analogy. What if an individual came on the site and stated that they went to the casino and hit the big jackpot and were able to retire. Then they stated everyone should give up saving and investing and go the casino for their early retirement. Everyone (I hope) would realize that was ridiculous. Yet a person will say a certain test saved their life and claim everyone should get it when in fact one is more likely to be harmed (lose at the casino) than have their life saved.



Take the P

 

[ER Eddie]

Whether screening tests result in reduced mortality is not the same question as asking if cancer treatment works. It is entirely possible that some cancers are treatable even if found without screening tests and that the screening tests don't add a lot of benefit overall but that treatment is nonetheless effective for many.

That's true, but my interest is in the efficacy of screening, since that was what almost killed me. (partly, anyhow)

 

[LRDave]

It depends on the type of cancer.

Half of the people diagnosed with stage 3 multiple myeloma (stage 3 is the highest stage for this cancer) live at least of 3 1/2 years with treatment. That means that half of them live longer than 3 1/2 years. I'm guessing that most people would take the treatments and take a shot at another 3 1/2 + years of life.

I have multiple myeloma and the treatments for me were not that bad, compared to other types of cancers. I was diagnosed with stage 2 multiple myeloma and half of the people diagnosed at that stage live 7 years or longer. I'm currently at 7 years and still in remission. I will most likely relapse at some point in time because there is no cure for this cancer. But the treatments for me have definitely been worth it.

When I was diagnosed 7 years ago, life expectancy was about 3 years. It is now 5-10 years. The development of new treatments has made the difference. My one big complaint though is that the pharmacy industry makes $billions off the backs of cancer patients and our health care system...way more than I consider reasonable.

I also want to comment on a stmt made in the article:

"But as a 2015 analysis points out, in general people do not live longer as a result of early detection. They simply live longer with a diagnosis of cancer, with all its harmful emotional, economic and physiological consequences."

With multiple myeloma, this statement is simply not true. Almost everyone that is diagnosed with multiple myeloma will live longer with treatment and will live longer the earlier they are diagnosed. Not only that but if diagnosed early, kidney and bone damage can be minimized. I was diagnosed as a result of a routine annual physical examination. Had I not had an early diagnosis, I probably would have ended up with kidney and bone damage and that would have surely resulted in a shorter life expectancy.

My 95-year-old father has multiple myeloma (stage 2) and prostate cancer that has metastazed into bones and lungs, but is responding well to hormone treatment. I am not at all sure that either will kill him.

The thalidomide treatments for MM are price gouging.

 

[athena53]

I hope I never have to find out exactly how does a physician convey, to a patient who's, say, 85 years old, that treatment will make them supremely miserable; may not (probably won't) work; and thus the patient would do well to give up and go into hospice.

Some of the good ones can do it. When DH's doc broke the news that his polycythemia had morphed into acute myeloid leukemia, he told us up front that chemo had a 3% chance of success. (DH was 78 and weakened by years of polycythemia and the meds he took for it.) That made the decision to forego chemo pretty easy. I sometimes wonder if Medicare would have paid for chemo if we'd gone that route. The same doc, when DH asked in August how long he might have, told us, "I'd be surprised if we were still having this discussion after the end of the year". DH died in November.



Maybe it was easier for him to talk to us because we were practical people who wanted as much of the facts as we could get, but I sent him a note afterwards and told him how much DH and I had appreciated his straightforward answers.

 

[Midpack]

I hope I never have to find out exactly how does a physician convey, to a patient who's, say, 85 years old, that treatment will make them supremely miserable; may not (probably won't) work; and thus the patient would do well to give up and go into hospice.

Some of the good ones can do it. When DH's doc broke the news that his polycythemia had morphed into acute myeloid leukemia, he told us up front that chemo had a 3% chance of success. (DH was 78 and weakened by years of polycythemia and the meds he took for it.) That made the decision to forego chemo pretty easy. I sometimes wonder if Medicare would have paid for chemo if we'd gone that route. The same doc, when DH asked in August how long he might have, told us, "I'd be surprised if we were still having this discussion after the end of the year". DH died in November.



Maybe it was easier for him to talk to us because we were practical people who wanted as much of the facts as we could get, but I sent him a note afterwards and told him how much DH and I had appreciated his straightforward answers.

One more reason the patient can benefit by doing their homework beforehand. If the patient knows the odds and treatment options, it should make it easier for the doctor to be completely candid.

I’ve heard many doctors say most patients want them to do something-everything to save them regardless of the odds. And with the risk of litigation today, doctors treat so they can say they did everything they could even if it’s not what they’d otherwise recommend. If the patient demonstrates they want all their options, and they’re open to not treating, the doctor may be willing to discuss that option.

We all have to balance longevity versus ending quality of life. It would be nice if patients considered cost too, but many don’t.

 

[Car-Guy]

The same doc, when DH asked in August how long he might have, told us, "I'd be surprised if we were still having this discussion after the end of the year". DH died in November.

A relative, who worked in the medical field all of his adult life, was told by his doctor(s) that without treatment for his cancer, he had 6 to 9 months to live. With treatment maybe 9 to 12 months. He had all the testing "redone" and then elected to do nothing except to take pain meds. He live almost exactly 9 months from the date the doctors told him that.

He was a relatively wealthy man, so money would not have been an issue. BTW, he had gone thru chemo for a different cancer some years earlier so he had some direct personal experience. I asked him why he decided not to take any treatments this time. He said it's was all about "time" and "quality of life".

 

[athena53]

We all have to balance longevity versus ending quality of life. It would be nice if patients considered cost too, but many don’t.

This Freakonomics podcast was made a few years ago but it was a great thought exercise. It was a tongue-in-cheek proposal for an insurance company that would give you a large lump sum as a portion of the savings if you elected palliative care. Unconscionable, of course- poorer people would be more likely to elect palliative care so their families would be left with something (and the podcast notes that)- but I agree that there's more choice of aggressive treatment when there's little out-of-pocket cost to the patient.

Are You Ready for a Glorious Sunset? (Ep. 217) - Freakonomics Freakonomics

 

[Teacher Terry]

I am 66 and had a colonoscopy 11 years ago. The doctor wants me to have another one and last time I had no polyps although my 2 older siblings have had them. I also read that at age 66 and up the test might save you one day of life and of course the risk is higher. I also am debating mammograms as a friend of mine had one and 3 months later found a big lump herself. From reading articles it doesn’t appear that they are big lifesavers either.

 

[PatrickA5]

I am 66 and had a colonoscopy 11 years ago. The doctor wants me to have another one and last time I had no polyps although my 2 older siblings have had them. I also read that at age 66 and up the test might save you one day of life and of course the risk is higher. I also am debating mammograms as a friend of mine had one and 3 months later found a big lump herself. From reading articles it doesn’t appear that they are big lifesavers either.

Obviously, if it were true that a colonoscopy only saved you one day of life NOBODY would do one. It's probably one of those (making this up) things that take into account the 100's of thousands of colonosopies done vs. the amount that actually have cancer and the extra months/years getting treatment got them. I'd have to see the study. Those that actually end up with treatable cancer live more than one day.

 

[daylatedollarshort]

This is a really interesting study on colonoscopies: Scientists have found dramatic effects on risk factors for colon cancer when American and African volunteers swapped diets for just two weeks....Western diets, high in protein and fat but low in fibre, are thought to raise colon cancer risk compared with African diets high in fibre and low in fat and protein. The new study, published in Nature Communications today, confirms that a high fibre diet can substantially reduce risk, and shows that bacteria living in the gut play an important role in this effect.

https://www.sciencedaily.com/releases/2015/04/150428125038.htm

I don't know anything about the efficacy of screening but it seems like the biggest factor in avoiding colon cancer would have more to do with prevention via a healthy diet and healthy gut microbiome, rather than eating a standard Western diet and having frequent screenings.

ETA - African Heritage Diet (similar to the one with the improved colonoscopy test results after just two weeks) here: https://oldwayspt.org/traditional-diets/african-heritage-diet/african-heritage-diet-pyramid-0

 

[NW-Bound]

When a person is old enough, even cancer screening will not change the outcome much, because he may not stand up to the treatment of surgeries and chemo. Of course, it is debatable where that age threshold is.

So, one waits until he has some symptoms. If you pass blood in your stool or urine, you simply cannot just wait to die of that unknown cause. Now with the symptom, they have to find the cause to see if it is something else not cancer at all and treatable.

My 93-year-old mother stopped having colonoscopy and mammogram long ago. I think it was some time in her 70s. It just makes sense.

 

[SpinDoctorTX]

Early diagnosis helped us

Early diagnosis helped me, DH and DM.

Me- cervical cancer stage 1. lazered out in 1983 with no residual issues (just monitored pap smears yearly).

DM- Stage 1 breast cancer- in situ- radiation course & tamoxifen (sp?) from 2004- 2009. Nothing since.

This is the most astounding one. DH had psa 4 which had doubled from one year to the next. He was referred to urologist & one gland was full of cancer with a gleason score of 9- which is bad. Removed with robot assisted surgery to remove both sides. Meds for follow-up were lupron (for a year- finished now) and Zometa ongoing therapy to prevent spreading to the bones (it had started to spread from the prostrate "floor"). He is 2.5 years past it, with some residual effects (lower energy mostly). After the surgery, if they see the psa doubling from one test to the next, that means there are cancer cells doubling, so the meds are used to control it.

One has to do their own research to see what treatment plan is best for them. I'm eternally grateful to the medical staff/ procedures & meds that bought us some more time together.

 

[Rambler]

I had prostate cancer 2.5 years ago. I had surgery by a renowned DaVinci surgery specialist. I was 55, and my Gleason score going in was 4+3, Which is relatively aggressive. Post op pathology showed 3+4, which is still relatively aggressive but not quite as bad as 4+3. My dad also had it 22 years prior. His was 4+3 post op, with the prostate full of cancer. Had he waited, his would have been a very painful demise, as prostate cancer most often metastasizes to nearby bone, ie, the pelvis and spine, later attacking the lungs and brain. Once it gets into the bone, your time is limited to months, and without some advanced and very costly treatment, you are in for some serious pain.

But the upside is, my dad’s was caught in time. He’s still kicking at 84 with no recurrence. No recurrence yet for me either. Dad never regained continence, and back then, I don’t think there were ED drugs. But, he had open surgery from the local urologist (almost died during the surgery). I had a top surgeon, with the DaVinci robot. I don’t have the issues my dad had.

So I know some folks are against regular PSA testing, but I am very grateful for it. It saved my dad’s life, and mine so far, and even if I have a biochemical recurrence, it’s likely that salvage radiation will knock it out. After 24 years for my dad, I no longer think he has to worry about it.

Men, please get your PSA tested regularly. If you get a high reading, wait a month and test again after making sure to abstain from any sexual activity, bicycle, motorcycle or horse rides (anything bumpy like that) for at least 72 hours. Based on my pre op and post op results, along with age, my likelihood of a recurrence is less than 10%, and dying of the disease is less than 5%. Had I waited much longer, those probabilities would not be so good.

 

[NW-Bound]

When a person is old enough, even cancer screening will not change the outcome much, because he may not stand up to the treatment of surgeries and chemo. Of course, it is debatable where that age threshold is.

So, one waits until he has some symptoms. If you pass blood in your stool or urine, you simply cannot just wait to die of that unknown cause. Now with the symptom, they have to find the cause to see if it is something else not cancer at all and treatable.

My 93-year-old mother stopped having colonoscopy and mammogram long ago. I think it was some time in her 70s. It just makes sense.

Meant to say "93-year-old mother-in-law". My own mother is a few years younger, and has also forgone some screening tests, but I am not sure.

 

[FLD3C]

A few thoughts:
1 Physicians as a group make different treatment decisions vs non physicians
The essay "How Doctors Die" by Ken Murray MD is a useful read
2 Cancer is not a monolithic illness. Cancers of a specific organ are not monolithic.
For example Breast cancer has at least 6 subtypes and each subtype has different subtypes(estrogen receptor positive or negative , progesterone receptor positive or negative, HER-2 positive or negative). Every subtype has different treatments and different probable outcomes.
3. Many (?most) physicians have a bias to do something vs do nothing. This is exacerbated by fear of litigation.

 

[Rambler]

My grandmother was a wise old lady. She had breast cancer in her mid 70s. Later on, doctors found a largish discolored spot on the back of her calf, at around 78. It turned out to be melanoma. They took it off, but melanoma has a tendency to spread if you cut into it, as they did for the biopsy. And spread it did. It got into her bones and lungs. Doctor started rattling off treatment options from chemo to radiation, but we all knew what that would do to her. She looked the doctor straight in the eye, and said, “if I was your mother, at 79 years old, what would you tell me to do?” He told her that the best thing to do, given her condition, was to live her life the best she could until the end, because it wouldn’t be long, and chemo and radiation would not give her much if any time, but that she’d be miserable from the time she started treatment until she died. So, that’s what she did. She was gone in about 6 months, but she had lost her husband, my grandpa, and thought she was ready. She always said she wanted to live until she was 80. She died just a couple days after her birthday, 36 years ago this week.

 

[daylatedollarshort]

The Ornish diet / lifestyle program has been proven to reverse heart disease and is now being studied to see if it can reverse prostate cancer, with promising initial results:

"Initially, the treatment and control groups had identical PSA levels, which averaged 6.3 ng/ml. At the end of the year, a small but significant difference was evident. The average PSA in the intensive lifestyle group fell to 6 ng/ml whereas the average PSA in the untreated men rose to 6.7 ng/ml. And tests of how the men's blood affected the growth of prostate cancer cells showed similar changes. Blood samples from the lifestyle treatment group inhibited prostate cancer cell growth by 70%, while samples from the control group inhibited growth by only 9%."

https://www.health.harvard.edu/mens-health/lifestyle-therapy-for-prostate-cancer-does-it-work

 

[razztazz]

But the take-away here is the "?" at the end of the headline. As usual

No diet or regimen has been "proven" to do anything.

The Ornish diet / lifestyle program has been proven to reverse heart disease and is now being studied to see if it can reverse prostate cancer, with promising initial results:

"Initially, the treatment and control groups had identical PSA levels, which averaged 6.3 ng/ml. At the end of the year, a small but significant difference was evident. The average PSA in the intensive lifestyle group fell to 6 ng/ml whereas the average PSA in the untreated men rose to 6.7 ng/ml. And tests of how the men's blood affected the growth of prostate cancer cells showed similar changes. Blood samples from the lifestyle treatment group inhibited prostate cancer cell growth by 70%, while samples from the control group inhibited growth by only 9%."

https://www.health.harvard.edu/mens-health/lifestyle-therapy-for-prostate-cancer-does-it-work

 

[GlitterGirl]

I am a retired RN who has worked a lot in oncology, oncology research and hospice so I’ve seen a lot of facets of cancer care. A huge problem in discussing any cancer treatments and options is that cancer is not one disease. It is many, many diseases with vastly different treatments and outcomes. Just as we wouldn’t say that all automobiles have the same capabilities and that they should be driven and cared for in the same way; we shouldn’t expect that the broad disease category called cancer will tell us much.

Even within one “category” of cancer, for instance breast cancer, there are multiple types that have different treatments and can have a highly variable prognosis. That doesn’t even factor in staging which tells us if the cancer is contained or has spread, along with other indicators. My sister’s diagnosis of triple negative breast cancer has a vastly different prognosis than a similar stage breast cancer that is HR/ER positive.

Many here have suggested that you have to educate yourself about the particular cancer you or someone you love has been diagnosed with and not listen to what your neighbor or friend thinks is appropriate and I agree completely. My sister with triple negative breast cancer had to walk a relationship tightrope with her mother-in-law who was SURE she knew more than the doctor because she’d once had a completely different type of breast cancer. Sigh.

Finally, I’d encourage OP to not beat himself up over encouraging his wife to have chemo. If she had survived the ordeal, then you’d be thrilled that you pushed her. You can’t know in advance how the story will end. I’ve seen all of the possibilities from people who die quickly from treatable cancers to people who survive despite the odds which were incredibly grim. Remember that physicians who “give” you six months, two months, two years to live are making their best GUESS. None of us come with an expiration date stamped on our heel.

 

[urn2bfree]

This discussion is not dissimilar to those we often see on these boards about ACTIVE VS PASSIVE Investing. The data overwhelmingly shows that most people will do better with PASSIVE investing, yet there are those who will point to Warren Buffet or whatever strategy they use that has worked for whatever anecdote they tout to say that Active is better.

With cancer treatment, people often think they are smart enough to know when to treat, how much to treat. They can outsmart the statistics, they think.



Furthermore, the treatments, even for incurable people are indeed developed in a foolish but necessary way.

You try to find the highest doses of stuff to give that won't kill the patient or cause intolerable side effects. Maximum Tolerable Dose. The idea being to give the cancer maximal exposure without harming the patient. But in a perfect world, if you KNEW that half that amount was just as effective and much less dangerous you would never push it to the MTD. But how can you test for the Minimally Effective Dose? You have to go lower and lower from the MTD until you don't cure as many patients....so your study will end when you discover that -oops, you were randomly assigned to the group that turns out could have been cured if only we had given a little more drug. How many people sign up for studies like that? Well how many people sign up for any study right now that don't even threaten to undertreat? The overall enrollment in clinical trials is 3% of patients.

With cancer screening, I think the evidence is overwhelming that PAP smears done for YOUNGER woman, on a regular basis- not necessarily every year, but regularly- have reduced cevical cancer deaths tremendously. Advanced cervical cancer once was common, then dropped from the 1930's on--(it's called uterus cancer in the chart below):

https://ourworldindata.org/grapher/cancer-death-rates-in-the-us?time=1930..2011" style="width: 100%; height: 600px; border: 0px none;"></iframe
Dr. Papanikolaou introduced his test (Pap for short) in 1928. It was tested and confirmed effective in the 50's...look at the chart. It also makes sense- because the test is safe and it detects PRE CANCER - not cancer-not invasive-not spread anywhere--it hasn't learned that yet-- by the time it has become cancer the horse is often out of the barn and early testing is just early diagnosis of later stage--
So good screening tests have to be safe and good at detecting PRECANCER-

If the test is mostly picking up cancer- it is not going to be a great screening tool like the Pap smear.
EDIT- chart won't show--basically slow fall in uterine cancer deaths from 1930 (36.3/100,000) to 1950's(23.8/100K) then sharper drop to much lower lever over next 50 years (down to 6.8/100K) or from number 2 cause of cancer death to around 9th nowadays.