Thanks to President Barack Obama's final State of the Union address, we can add moonshot to the lexicon of the war on cancer. They're both lousy metaphors.
Our political leaders' penchant for seeing cancer care through the prism of technology and drug development ignores other paths to progress. Greater investment in prevention and better use of existing technologies would reduce cancer incidence and mortality much faster.
I'm not saying the president's call “to make America the country that cures cancer once and for all” won't have positive effects. Funding more scientific research will deepen our understanding of the genetic and molecular causes of cancer and provide more targets for chemotherapeutic and other interventions.
But the race for better cancer drugs is a marathon. It took more than 30 years before the genetic understanding of chronic myeloid leukemia led to the first drug (Novartis' Gleevec) that targeted a specific mutation.
In the 15 years since the mapping of the human genome and the application of its tools to cancer tumor analysis, we have added a few similar drugs to oncologists' toolkit for treating the more than 200 forms of the disease. The number of targeted drugs is growing, which the president's precision medicine initiative highlighted in last year's State of the Union address.
The latest hot area in cancer research involves immunotherapy—using drugs and monoclonal antibodies to mobilize the power of an individual's immune system to fight errantly programmed cells. We've seen this play before.
In the 1970s, after the first huge infusion of cash into cancer research, the viral cause of cancer was the hot topic. A few, like the relationship between the human papillomavirus and cervical cancer, were identified. But discovering the cause never led to a cure—other than preventing infection.
The field has always been susceptible to “magic bullet” hype. In 1998, when the late Dr. Judah Folkman's anti-angiogenesis drug eliminated tumors in mice, a front-page story in the New York Times hailed the breakthrough. It even quoted DNA co-discoverer James Watson predicting it would lead to a cure for cancer within two years. Today, anti-angiogenesis drugs such as Avastin (bevacizumab) have a limited impact on a few cancers.
And that, unfortunately, foreshadows what will happen if we take a purely technological approach to treating the 1.6 million Americans diagnosed with cancer every year and the more than half million who die from metastatic forms of the disease. Each new drug makes some incremental progress against some forms of the disease. But the hunt for “the cure” is a chimera.
That's not to say the war on cancer hasn't made tremendous progress. Over the past quarter century, the U.S. has reduced cancer mortality by more than 20%. But our rate of progress is slower than other countries.
Why? First, we under-invest in prevention. Smoking rates in states with the highest cancer incidence approach 30%. Obesity is poised to become the No. 1 cause of cancer over the next two decades.
We invest next to nothing in understanding the behavioral or environmental causes of cancer. We do next to nothing to address disparities in care, where minority patients or people in some areas of the country get suboptimal treatment after an initial cancer diagnosis.
Treatment patterns are a major issue. Insurers and oncologists fight over clinical pathways with doctors claiming they fail to address the individual patient's experience. Yet many oncologists do not follow clinical practice guidelines, which would lead to the best outcomes for most people.
Meanwhile, we learn next to nothing from the more than $90 billion we spend on direct cancer care each year. Dozens of cancer treatment centers cite privacy concerns for their refusal to participate in the American Society of Clinical Oncology's CancerLinQ, which gathers data on treatments and outcomes.
Studying those de-identified data, which electronic health records makes possible, could identify which patients benefit most from which existing technologies. It is a different form of personalized medicine, and, if the findings were disseminated and used, could lead to relatively rapid improvements in outcomes.
I've written this before. Care for patients with cancer is a vast, unobserved and uncontrolled science experiment where the outcomes are never gathered, the data are never analyzed and the findings are never disseminated. Until the research paradigm changes, we will make only marginal progress against the disease.
