President Joe Biden's pledge to "end cancer as we know it" is a rare sliver of common ground between Democrats and Republicans.
Congress has appropriated $1.8 billion for the “cancer moonshot” Biden began in 2016, and the positive reaction to Biden’s request for more during Tuesday’s State of the Union suggests it’s eager to maintain the momentum.
But cancer researchers are less unified about the moonshot than Washington policymakers. A contrarian cadre question whether the money appropriated is being well spent. Cancer research is funded well enough, they said, and investing more in high-tech individualized treatments is more likely to help the wealthy live longer than it is to save those most likely to die of the disease: the poor and people of color.
"It's a lot harder than getting a man to the moon," Gilbert Welch, an internist and senior investigator at the Center for Surgery and Public Health at Brigham and Women’s Hospital in Boston, said of curing cancer. "It's a very complex set of diseases. You need to think of it as a family of diseases. The moon is just one thing. Just gotta get there. This is hundreds of different things."
Biden wants to press ahead on a bipartisan initiative. In his State of the Union, he called on Congress to reauthorize the 2016 law that launched the moonshot, the 21st Century Cures Act. He pledged to cut cancer death rates by 50 percent in the next 25 years and to turn fatal cancers into treatable diseases.
Biden also has asked Congress to reauthorize the National Cancer Act, signed into law by President Richard Nixon in 1971. Reauthorization would help the National Cancer Institute support researchers around the country by building clinical trial networks and more robust data systems, according to Danielle Carnival, the White House’s moonshot coordinator.
But some experts, such as Ezekiel Emanuel, an oncologist, a professor at the University of Pennsylvania and former White House adviser, said there's plenty of money devoted to cancer research. The National Cancer Institute had a nearly $6.4 billion budget for cancer research in 2021 and its annual spend has been growing since 2015. Cancer non-profits like the American Cancer Institute also raise hundreds of millions of dollars every year.
Additionally, the pharmaceutical industry is incentivized to put money behind increasingly lucrative cancer diagnostics and therapeutics. Research shows that from 2010 to 2019 revenue generated from cancer medicines increased 70 percent among the top 10 pharmaceutical companies to reach $95 billion.
And not everyone thinks more funding is a good thing. "There's so much money sloshing around," Welch said of the cancer industry, adding, "Both academic and biotech or industry are excessively enthusiastic and just trying to put out as many products as they can."
We've overinvested in cancer, according to Welch, especially in expensive cancer drugs with modest or unproven benefit for patients and in screenings — Welch's research area. He's particularly opposed to the Medicare Multi-Cancer Early Detection Screening Coverage Act, sponsored by Sen. Mike Crapo (R-Idaho) and Rep. Terri Sewell (D-Ala.), which would require Medicare to cover cancer blood tests if they're approved by the FDA. From Welch's vantage point, benefits from screenings have been exaggerated, while its harms have been minimized.
Other critics, such as Keith Humphreys, a public health professor at Stanford University who has published academic articles on the link between alcohol use and cancer, see cancer prevention as a more immediate way to save lives.
Managing disease and curing it
The president's agenda goes beyond money, Carnival told POLITICO, emphasizing prevention efforts, such as improving nutrition for kids, discouraging smoking, and decreasing environmental risks.
"We're going to have to reach more people with the tools we already have and those we develop along the way," Carnival said. "The purview is much broader than research. I don't think anyone would say we have all of the research advancements and knowledge and treatments that we need today to end cancer as we know it."
Those closely involved in developing cutting-edge cancer therapeutics said the field has shifted dramatically in recent years. It's gone from treating cancer as a chronic disease, to trying to cure patients.
During his medical fellowship in the early 2000s, improving patient survival by months or years was the goal, explained Marco Davila, a physician-scientist at Roswell Park Comprehensive Cancer Center in Buffalo, N.Y., who helped pioneer some of the first CAR-T cell therapies for patients with blood cancer.
Since then, treatment breakthroughs for some previously incurable cancer have upended the cancer-as-chronic-disease philosophy. Now, doctors and researchers believe cancer-curing therapies are within reach. "It's changed the nature of how we manage patients. There's that option there. It's on the table," Davila said.
For Davila, moonshot funds earmarked for cancer research and therapies created a new pool of money for his work. It doesn't fix the problem of underfunded science as a whole, he said, but it makes his work as a cancer researcher a priority.
"It's great for us, because that's our field. It's also great for patients, because cancer is still going to be one of the most common causes of people's death in the United States," Davila said. (In the U.S., it’s second behind heart disease, taking more than 600,000 lives in 2020, the most recent year for which there are statistics.)
Indeed, since the late 1980s, scientists have developed effective treatments for lung cancer, breast cancer and Hodgkin's lymphoma. There are caveats, of course. They don't work for all patients.
"It's maybe 20 percent, 30 percent," Davila said. The goal now is to keep improving those cure rates over time — to 50 percent or 60 percent, for example.
"Will it get to 100 percent in your lifetime? I don't know," he said.
What Davila does know is that each 10 percent cure-rate increase means saving tens of thousands, or even hundreds of thousands of lives.
‘Prevention takes action’
But some cancer experts said there's a downside to the shift toward precision medicine and individualized treatments. Attempting to test everyone or characterize every tumor more precisely is a bit of magical thinking, according to Welch.
"The more you subset people, the more difficult it is to know whether your treatments help. It's too small of a group," Welch said. "It used to be just lung cancer. Now we've got eight genetic variants we're testing in adenocarcinomas of the lung," he added.
"Ironically, the more precise we get, the more types of cancer there are, as we genetically signature each cancer, all of a sudden we don't really know what to do with any one of them."
Others think there needs to be a fundamental shift away from screening and treatment and toward preventing cancer in the first place.
"It's terrific when we develop new treatments for cancer, but it certainly is always better to prevent something than to treat it," said Humphreys, who served as a drug policy adviser under Presidents George W. Bush and Barack Obama.
"Very high-end, complicated treatments are never going to be accessible to the whole population," he added. "Congress could definitely do more.”
Tobacco taxation is widely considered one of the most effective practices in preventing people from starting to smoke in the first place, leading existing smokers to quit, and reducing deaths from tobacco-related cancers. Humphreys said Congress could take the same taxation approach to the alcohol industry. “We have very good evidence that when we raise the federal alcohol tax that fewer people die,” he said.
While broad blood-based cancer screening may not be a cost-effective strategy for stopping cancer early, targeted cancer screening for colorectal, breast, cervical, prostate, and lung cancers could be. Rules could stoke participation or ensure that patients on Medicaid, who are more likely to be at risk of cancer, are getting regular screenings.
"It's important to acknowledge that our biggest success in cancer really reflects prevention," Welch said. "It's nothing fancy. It's discouraging cigarette smoking."
Following a surgeon general warning in the 1960s about the health risk of smoking, and subsequent anti-smoking campaigns, tobacco use — and later lung cancer rates — plummeted.
The White House touts prevention in its moonshot agenda. In 2022, the first year of the reignited moonshot, the FDA proposed rules to prohibit menthol cigarettes. Among other agenda items, the moonshot program plans to increase cancer screenings in at-risk communities and facilitate donations of sunscreen to schools and youth organizations.
But prevention is a trickier cancer-prevention mechanism than treatment. It could mean cleaning up Superfund sites or removing lead pipes to reduce environmental cancer risk. It often requires people to change their behavior — to drink less alcohol and exercise more or stop smoking — a more challenging mission at the population level than directing patients to take a pill or offering them a diagnostic test.
"It's not necessarily clear how one spends money on prevention," Welch acknowledged. "It's much easier to sell a test or a drug. It's a concrete thing. Prevention takes action on the part of individuals," he said. "You gotta say, that's harder."
More funding wouldn't necessarily solve the problem, according to Emanuel.
There's a lot of money already in the system. It just needs to be redirected and allocated differently, Emanuel explained.
Who is spending that money also matters. The government sponsors roughly one-third of clinical cancer research, according to Emanuel. Industry accounts for the remaining two-thirds of funding. "It's good that they've got a lot of drugs that they're testing. What's bad is having industry shape the clinical research agenda, because industry has a bias."
Emanuel's solution: stronger government leadership and more non-industry sponsors.
"The NCI [National Cancer Institute] is the biggest NIH institute," Emanuel said. "It's not exactly like they're starving."
Ruth Reader contributed to this report.
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