Decades into the war on cancer, the United States is once again redrawing its battle plans — a tacit acknowledgment of the disease’s overwhelming complexity, despite major progress in recent years.
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Both are a far cry from the promise of curing cancer in five years that characterized the start of federal investment in cancer research in the 1970s. That’s a reflection of our increasingly nuanced understanding of cancer itself. “Ironically, when it comes to discovery in oncology, the smarter we get, the more cancers we have,” said Karen Knudsen, CEO of the American Cancer Society. Cancer is not one disease, but over 200, she said, “each arising from a different underlying cause, and each responding to a different kind of treatment.”
That understanding has helped transform some forms of cancer from a virtual death sentence into something more manageable. But meeting Biden’s goal will take more than continuing to uncover cancer’s biological complexities; it also necessitates ensuring that everyone has access to the screening and treatments borne of recent advances.
For worrying tumors, genetic testing of the cancer cells can help doctors choose among dozens of different drugs used to treat breast cancer. Tamoxifen, for instance, effectively stifles the growth of cancer cells, but only a subset with certain characteristics. “If we ran a clinical trial on tamoxifen in all breast cancer patients, it’d be a failed therapeutic,” Knudsen said.
“Cancer is a complex, emergent system, and we’ve treated it reductively,” said David Agus, a medical oncologist and CEO of the University of Southern California’s Lawrence J. Ellison Institute for Transformative Medicine. A multitude of factors — body part, genetics, environmental factors, even the bacteria and fungi in your gut — conspire to determine the course of disease. “You can’t just look at one gene, you can’t look at one pathway, you know, it’s the body intersecting with itself,” he added.
That multifaceted understanding has helped develop promising treatments. For example, researchers can now tweak a patient’s immune cells to attack cancer cells, harnessing the body’s innate defenses. The approach is called CAR T-cell therapy. “It’s not targeting the cancer, but what it does is it reactivates the immune system to then target the cancer,” Agus said. “These are new ways of looking at that complex system” and using it to fight cancer.
“We’re in a new era now where we can use data, and every patient’s experience, to improve not just their experience, but the next person’s experience,” he said.
Vast amounts of clinical data already exist, spanning decades of electronic medical records, diagnostic scans of tumors, genomic data from patients and cancer cells, and results from drug trials. Hidden within this data might be hints of how best to treat a patient of a certain background for a specific tumor type. Increasing access to this data, coupled with artificial intelligence and machine-learning methods, can help researchers and clinicians make better decisions. “We’ve got amazing cancer drugs, and what the data will do is enable us to use them better in the near term,” Agus said.
But those recent scientific advances have not been able to eliminate stark disparities in cancer outcomes. For example, Black Americans have higher cancer death rates than other groups, and rural Americans die at higher rates from all cancers than those who live in metropolitan areas. “These gaps are not due to lack of knowledge, they’re due to lack of access to care,” said Ronald DePinho, an oncologist at MD Anderson Cancer Center.
“The level of disparity in survival outcomes and diagnostic accuracy is staggering,” he said. At MD Anderson Cancer Center, where people often travel seeking specialized treatment, “about 24 percent of cancer patients are misdiagnosed when they come to see us,” DePinho said. That reflects a fundamental failure in ensuring equitable access to the best care.
“We know how to prevent so many cancers,” said Chi Van Dang, scientific director of the Ludwig Institute for Cancer Research. “Focusing more on prevention and early detection is going to save a lot of lives,” he said, especially if such efforts reach communities with less historical access.
But there is one key ingredient missing from Biden’s “reignition” of the cancer moonshot: money. It will be up to Congress to decide whether or not the government funds the program — and to what extent. “It’s not clear we’ll make it to [Biden’s goal] without further investment,” Knudsen said. Biden’s annual budget request, to be released next month, may clarify the administration’s ambition for the program.
Assuming adequate investment, “I think the new goal is actually a modest one,” said Larry Norton, a medical oncologist at Memorial Sloan Kettering Cancer Center. “I personally think we’re going to do better than that.”
Norton is heartened by recent scientific advances, even if cancer’s proliferating forms and causes have dashed early hopes for simple cures. “Science always gets more complex before it gets simple,” he said.
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