Same old, same old in the war on cancer

Prevention again slighted as Biden bets on technology

Is pouring more money into research the best way to cut the cancer death rate in half over the next quarter century? President Biden outlined that ambitious goal in calling for new funding for his Cancer Moonshot program.

Like the president, most people have lost someone near and dear to their hearts to cancer, the emperor of all maladies to use Siddhartha Mukherjee’s piquant phrase. Since 1971, when philanthropist Mary Lasker convinced Richard Nixon to launch the original war on cancer, the federal government has poured more than $150 billion into the National Cancer Institute, far more than any other group at the National Institutes of Health. Adjusted for inflation, that figure is well beyond a half trillion in current dollars.

Yet by the most basic measure for a desired health outcome – a reduction in mortality – progress in the war on cancer has trailed far behind other leading causes of death in the U.S.: heart disease, which is still the number one killer, stroke and, even before COVID, infectious disease. Over the past half century, the mortality rates from those diseases have been cut by more than half thanks to better diets, drugs for treating high blood pressure, more effective surgical interventions, and, in the case of influenza and pneumonia, vaccines.

The overall cancer death rate, on the other hand, has only inched lower. Most of the small annual reductions since the mid 1990s are attributable to the steady decline in lung cancer incidence, which had nothing to do with better medical interventions. It was entirely due to the decline in smoking that began after the 1964 Surgeon General’s report irrefutably linked that filthy habit to lung and other cancers.

Why not prevention?

Public health approaches to reducing the cancer rate has never been the primary strategy favored by the well-heeled anti-cancer lobby. Organizations like the American Cancer Society, the American Association for Cancer Research and the dozens of cancer-specific patient advocacy groups prefer to work hand-in-glove with the pharmaceutical, biotechnology, and surgical, radiology and imaging equipment industries, whose research and development programs in oncology depend on the basic and applied research funded by NIH.

As I reported in this Washington Monthly article, most patient advocacy groups receive a large share of their funding from drug and device companies. Their leaders rarely raise questions about the exorbitant six- and seven-figure prices slapped on the latest cancer treatments, whose value in terms of increased life expectancy is almost always measured in months, not years.

Don’t get me wrong. I’m all for pouring more money into medical research, not just for the National Cancer Institute, but for all of the 27 institutes and centers that make up NIH. I also like the idea of setting up an Advanced Research Projects Agency – Health, which was included in the president’s original Build Back Better plan. It would be modeled on the Defense Department agency that came up with advances like the Internet and the global positioning system.

But the idea of creating an independent ARPA-H outside NIH, which was floated recently by Rep. Anna Eshoo, the California Democrat who has been a consistent voice for the biotech companies in her Silicon Valley district, would simply replicate a model that’s been used before with little success. In the early 1990s, patient advocates frustrated by underfunding of breast cancer research by the National Cancer Institute successfully lobbied Congress to set up a special medical research unit inside the Pentagon.

Today the Defense Department spends $1.5 billion a year on special medical research projects, including $210 million on breast cancer research. A recent Government Accountability Office report suggested most of its funded projects complemented research conducted at NIH and weren’t different in kind (a few even replicated projects that were already underway).

In other words, the Pentagon program represented a second way for researchers aligned with specific patient advocacy groups to obtain funding if they didn’t make the cut in the NIH peer review process. An ARPA-H outside NIH might easily fall into the same pattern.

Where will new money come from?

White House officials expressed optimism that new money will be found for the president’s reinvigorated cancer moonshot. “There will be robust funding for it because there’s nothing more bipartisan, whatever else you can say about Washington,” Office of Science and Technology policy director Eric Lander told Politico.

But who will determine the priorities? The White House fact sheet did make note of some public health approaches to curbing cancer rates. It called for a renewed effort to reduce smoking. The program also called for investing in new technologies that will make cancer screening for early detection cheaper and more effective.

But when it comes to prevention, the program outline ignored the biggest elephant in the room, which is obesity. Studies show obese people suffer substantially higher rates of numerous cancers, including liver, kidney, pancreatic, ovarian, breast and colorectal cancer.

The U.S. has the highest obesity rate in the world. Yet no White House occupant has used the bully pulpit to raise the issue since Michelle Obama called the place home. Indeed, if the president really wants to achieve his goal of cutting the cancer rate in half as well as address the disparities in cancer outcomes, where African Americans have higher incidence and mortality rates from most cancers, it should put public health approaches to addressing the causes of cancer front and center in his program.

He need look no farther than the Obamas’ home base of Chicago for an example of where his medical innovation-first approach leads. The University of Chicago Medicine this week announced it will build a 128-bed, $633 million cancer treatment center on the city’s South Side. Medical Center President Thomas Jackiewicz, in a letter to the head of the state’s Health Facilities and Services Review Board, justified the expansion by pointing out cancer death rates in that area of the city are twice the national average. Area residents are 29% more likely to receive a cancer diagnosis than those living in other parts of the city.

Hospital officials said the new facility would free up beds in its main hospital, which is nearly always full due after the closure of several neighborhood safety net hospitals. In addition, it would serve as a research center for new therapeutics.

Why the best treatment isn’t good enough

That doesn’t sound like an approach that can make a major dent in the disparate outcomes on the South Side. Perhaps people living there will access get better treatment once they get very sick. That will lead to a marginal improvement at best.

Here’s some advice. If they are going to invest $633 million to improve cancer care and outcomes, why not shrink the size of the new facility somewhat. They can hive off $100 million for neighborhood health centers that can conduct screening, provide dietary education, and call attention to the environmental hazards that cause cancers.

They could use some of that money to invest in food stores that stock fruits and vegetables and other nutritious foods. They could give matching grants to the city if it builds more parks and urban trails in that section of the city, which has been shortchanged for years by the Parks Department.

The best way to reduce cancer disparities is to reduce its incidence — not come in after the fact with more advanced methods of treating a disease that is usually fatal when addressed in its final stages.