Can the Cancer Moonshot do what its advocates promise?

The Cancer Moonshot. It’s a topic that I’ve been meaning to address ever since President Barack Obama announced it in his State of the Union address this year and tasked Vice President Joe Biden to head up the initiative. Biden, you’ll recall, lost his son to a brain tumor . Yet here it is, eight months later, and somehow I still haven’t gotten around to it. The goal of the initiative is to “eliminate cancer as we know it,” and to that end, with $195 million invested immediately in new cancer activities at the National Institutes of Health and $755 million proposed for FY 2017. My first thought at the time was that that wasn’t nearly enough money to achieve the ambitious goals set out by the President. That has now become particularly clear now that a week and a half ago the National Cancer Institute released the report from the initiative’s blue ribbon panel suggesting ten ways to speed up progress against cancer.

Initial thoughts on the Cancer Moonshot

When I first saw the President announce the Cancer Moonshot initiative several months ago, I couldn’t help but think that, although a very catchy title that would grab attention, calling the initiative the Cancer Moonshot was profoundly deceptive, probably unintentionally so but deceptive nonetheless. Why? The analogy between finding cures for cancer and going to the moon in the 1960s is profoundly flawed. The latter was primarily an engineering problem. The science, in particular the physics, necessary to achieve a moon landing was already adequately understood. What was needed was the technology to achieve the ambitious goal and the resources to develop that technology. In the Cold War era of the 1960s, in which the original moonshot was part of the geopolitical competition between the U.S. and the Soviet Union, it didn’t take much to direct resources to this end, resulting in a moon landing less than a decade after President John F. Kennedy, Jr. announced it.

The other reason that the analogy is deceptive is that the original moonshot was a much simpler problem to solve than cancer is. That’s not to say the original moonshot wasn’t a very difficult initiative, but cancer is orders of magnitude more difficult. As I’ve pointed out many times before, cancer is not just one disease. It’s hundreds. Even individual cancers are incredibly complex. Thanks to the power of evolution, tumors evolve into masses of heterogenous cells with different genetic makeups, such that tumor cells from a metastasis might well be resistant to treatments to which the primary tumor is sensitive. Breast cancers, for example, have been shown to harbor at least 1,700 different mutations, but only three of them showed up in at least 10% of patients, with the great majority of them being unique to each patient. Back in 2011, which was the 40th anniversary of President Nixon’s War on Cancer initiative, there were a spate of “Why haven’t we cured cancer yet” articles. I explained why. Cancer is not a single disease, and cancers are different. The mechanisms of carcinogenesis are not simple. Cancers evolve rapidly because of their genetic instability, leading to tumor heterogeneity. There are many more reasons, but those are the top three. Although, thanks to rapid advancements in gene sequencing and computer technology since the 1990s, the last two decades have produced massive quantities of data on the sequences of individual cancers, which genes are mutated and where, and how intracellular signaling pathways controlling proliferation, migration, and invasion are altered in cancer, at least thus far the effect on patient care has been far more modest.

None of this is to say that the Cancer Moonshot itself is a bad thing, only that, as has been the case for so many initiatives to “cure cancer” before, what it is likely to achieve is actually far more modest than what is being promised.

The Blue Ribbon panel’s report

When the news stories started coming out last week about the Cancer Moonshot, I naturally gravitated over to the National Cancer Institute website to get the details. The first thing I did was to look at who was on the blue ribbon panel. There’s no doubt that there are heavy hitters on the panel, whose names I immediately recognized, but there are also a fair number whom I had never heard of before. Be that as it may, the process is described thusly:

The BRP members were announced on April 4, 2016, and the first (virtual) meeting took place on April 11. At this meeting the members agreed to establish seven working groups to focus on major topic areas. The working group members were announced on May 2, and the groups met frequently until mid-July. In addition, the BRP met several more times—in person on April 18 and July 20, and virtually on July 13.

The working groups began with broad discussions of the state of the field for their respective topics and considered ideas from the members and the community at large. The panel considered more than 1,600 ideas submitted by the broader cancer community through a dedicated website, email, and other routes. Some working groups created subgroups with focused expertise in particular areas to carefully craft their recommendations. As the working groups narrowed in on their specific recommendations, the chairs of multiple groups also met to discuss cross-cutting themes and to merge similar topics into joint recommendations.

The BRP reviewed the working groups’ draft recommendations at its June 13 meeting and reviewed their final recommendations at its July 20 (in-person) meeting.

In other words, it sounds like a typical process for producing a white paper or set of evidence-based recommendations. The result was a 100+ page report, Research Opportunities for the Vice President’s Cancer “Moonshot. I didn’t read the entire thing, given how long it was, but did hit some of the highlights, such as the Tumor Evolution and Progression Working Group Report. Each working group report is divided into nice bite-sized sections, including

  • What is the recommendation?
  • Where are we now?
  • Where do we need to be (in 1-5 years)? (with priorities listed)
  • Strategy: What will it take to get there?
  • What does success look like?

The panel’s recommendations are alos summarized in a short version and long version of the report, as well as in a video:

The recommendations include:

  1. Establish a network for direct patient involvement
  2. Create a clinical trials network devoted exclusively to immunotherapy
  3. Develop ways to overcome resistance to therapy
  4. Build a national cancer data ecosystem
  5. Intensify research on the major drivers of childhood cancers
  6. Minimize cancer treatment’s debilitating side effects
  7. Expand use of proven prevention and early detection strategies
  8. Mine past patient data to predict future patient outcomes
  9. Develop a 3D cancer atlas
  10. Develop new cancer technologies

Some of these recommendations are pretty uncontroversial. For instance, although more detail is given, who on earth would be against developing new cancer technologies? The rub, of course, is which new cancer technologies. Similarly, who would be against minimizing the debilitating effects of chemotherapy and other treatments? Or expanding the use of proven prevention techniques? For instance, tobacco use is the single largest cause of preventable deaths, and those deaths aren’t just due to tobacco-associated cancers like lung cancer. If smoking could be eliminated, as I’ve pointed out before, deaths from cancer would plummet because by far the most common cause of preventable cancer is tobacco, causing an estimated 86% of cases of lung cancer, 65% of cases of esophageal cancer and cancers of the oropharynx and head and neck, 37% of cases of bladder cancer, and 29% of cases of pancreatic cancer.

Uncontroversial recommendations aside, most of the recommendations are pretty measured and well thought out, although at least one appears to be a result of a current scientific bandwagon effect. Let’s take a look.

Selected Cancer Moonshot recommendations: Immunotherapy

The first thing I noticed when I read the Cancer Moonshot Blue Ribbon Panel report, is that there wasn’t anything particularly bold about it, the effusive praise heaped on it by the American Society of Clinical Oncology (ASCO) notwithstanding. Personally, if this weren’t called the Cancer Moonshot, I wouldn’t think that was a bad thing, but rather a good thing. In actuality, the report is a synthesis of where cancer research is right now and where it is going rather than any sort of bold vision of where it should go. Again, that’s not a bad thing. Martial rhetoric, exaggerated promises, and analogies to massive scientific efforts of the past have always been at odds with the evolutionary and incremental nature of cancer research; so a report that proposes, in essence, to take the technology and science we have today and to build on it is the best that is likely to be expected, even if it’s a bit boring. In retrospect, I wish I hadn’t skipped this year’s ASCO meeting because I could have seen Vice President Biden give his pitch for initiative.

The first recommendation that leapt out at me was definitely the recommendation for a clinical trials network devoted exclusively to immunotherapy. Yes, that’s the one that’s clearly based on a current scientific fad. My guess is that, if the Cancer Moonshot Blue Ribbon Panel had been convened in the 1990s it would have included an initiative to investigate antiangiogenic therapy (therapy that targets blood vessel development). Is immunotherapy a big enough deal to rate one of the ten major recommendations of the panel and a recommendation for a national clinical trials network devoted solely to immunotherapy? Maybe, but over the years I’ve become a lot more skeptical, remembering all the hype and promise of antiangiogenic treatments in the 1990s and the previous wave of immunotherapy hype in the 1980s. (That’s what happens when you get to be a bit of an old fart.) Those memories temper my enthusiasm.

On the other hand, there’s no doubt that a new class of drugs, immune checkpoint inhibitors, is a big deal. There are lots of other forms of immunotherapy that have been developed. For example, there are humanized monoclonal antibodies against specific cancer targets (like Herceptin), which are more targeted therapy than immunotherapy per se. There are cell-based therapies, some of which I saw when I was a resident in the late 1980s and early 1990s. There are dendritic cell therapies. There are also cancer vaccines, which have had pretty mixed results and are mostly still experimental. There are vaccines to prevent cancer, the most successful of which is, obviously, HPV vaccines such as Gardasil and Cervarix, which prevent cervical cancer by preventing infection by the most common HPV types. To be honest, though, my assessment of these other forms of immunotherapy is that they’ve had fairly limited success over the last 30 years, other than Gardasil and Herceptin, and I consider Herceptin to be targeted therapy more than immunotherapy. Immune checkpoint inhibitors are different, though. These days, when a cancer researcher (and, truth be told, the Cancer Moonshot Blue Ribbon Panel) say “immunotherapy, what they really mean are mainly immune checkpoint inhibitors.

One of the most critical key steps in the immune system is the system that allows the immune system to distinguish between what is “foreign” and “self.” The main job of the immune system is to leave self alone and to attack foreign invaders, such as bacteria. Obviously, it’s a lot more complicated than that, because we have trillions of bacteria that live on our bodies in relative harmony with us, but for purposes of this discussion it’s not necessary to go into that more deeply. The problem with cancer, of course, has always been that cancer at least starts out as “self.” It is our own cells. When they become cancerous, some tumor cells are indeed recognized as no longer being self, but some cancers are very good at evading the immune system, often by tricking these immune checkpoints. Immune checkpoint inhibitors target proteins controlling these checkpoints, such as PD-1, which normally acts as a type of “off switch” that helps keep the T cells from attacking other cells in the body. Immune checkpoint inhibitors are one of the most promising classes of new drugs in the pipeline.

The report states:

The success rates of first-generation cancer immunotherapies, such as checkpoint inhibitors, genetically engineered T cells, and new immune activators have improved remarkably over the last 10 years, resulting in durable, long-term survival—and, in some cases cures—for a subset of patients with advanced cancers such as melanoma, blood, and lung cancers. However, only 10-20% of patients with these cancers have long-term responses to current immunotherapies. We must learn why some patients who have melanoma (such as President Carter) or lung cancer respond to checkpoint blockade immunotherapy, whereas patients with many other types of adult cancers, including ovarian, breast, pancreatic, brain, and prostate cancer—as well as most pediatric cancers—have brief responses or do not respond at all.

Same as it ever was. One could say the same thing about many targeted therapies. I’m not sure I would have devoted a whole national clinical trials network to just immunotherapy. I would have thought bigger and included all targeted therapies, as I tend to agree with cancer researcher Vinay Prasad:

Immunotherapy refers to promising new drugs that harness the body’s immune system to fight cancer, and indeed these have generated impressive outcomes for some patients. But with dozens of immunotherapy studies underway, that rocket has already lifted off, and it’s unclear what Biden’s moonshot can add. And, unfortunately, the bitter reality is that despite immunotherapy’s promise, its benefits will probably remain confined to a minority of patients with certain types of cancer. Immunotherapy is unlikely to be a panacea.

In other words, there is nothing about immunotherapy that is likely to be the “magic bullet” that some portray it as.

Selected Cancer Moonshot recommendations: Clinical trials

I was heartened to see in the panel’s recommendations establishing a network for direct patient involvement, building a national cancer data ecosystem, and mining past data to learn to predict patient outcomes. One of the most pressing problems confronting cancer research is recruiting patients to clinical trials to test new therapies. Thus, I like hearing things like:

This recommendation calls for cancer patients to join a new national network that, with appropriate privacy safeguards, will provide them with a genetic profile of their own cancer and let them “pre-register” for clinical trials, so they can be contacted when a trial for which they may be eligible opens. Researchers will be able to access patient outcomes reported in the network database to conduct studies on what treatments work, in whom, and in which types of cancer.

And creating an ecosystem to facilitate cancer research:

Technology has enabled the collection of a massive amount of patient data. But these data are often stored in proprietary databases or accessible only to a select group of people, limiting their usefulness as a research resource. A national ecosystem that links many of the nation’s largest data repositories would enable one-stop, free access for researchers, doctors, and patients to share data on cancer and fuel faster progress.

Smaller countries, with national health care systems, already have such outcomes data that researchers can mine. The fragmentation of the US health system and a lack of will to make such a database a priority have long been an issue. Also, such a database and encouragement to patients to empower them to be more involved in their own care by having access to their genetic profile could increase patient enthusiasm for research.

Similarly, but what about mining past data for the purpose of hypothesis-generation:

Understanding why some patients with the same type and stage of cancer,
and same treatment may end up with different outcomes continues to be a research challenge. Analysis of existing tumor tissue from patients who received standard-of-care treatment, stored at biobanks around the country, may enable discovery of genetic and other factors that distinguish which individuals would bene t from standard care versus experimental treatment in a clinical trial.

We have an enormous resource in the form of existing patient samples. It just hasn’t been adequately mined. However, I can’t help but echo cancer researcher Vinay Prasad’s skepticism when the Cancer Moonshot initiative was first announced:

Another oft-mentioned proposal is harnessing the power of big data. One such idea is to closely examine what therapies have worked for individuals and which unique genetic traits allowed those therapies to work, and then extend these findings to other patients. Unfortunately, such an approach is fraught with limits. My colleague Andrae Vandross and I recently reviewed the published reports of patients who have had an exceptional response to a cancer drug. In many instances, we found that these patients responded unusually well not only to the studied drug but also to older ones. In several cases, these people had already survived far longer than the typical patient by the time they received the lauded medication. It is hard, then, to conclude which patients have great outcomes because of a drug and which simply have slow-growing cancers — a phenomenon doctors have recognized for years. But this distinction is the very crux of the big-data approach. Observational data — no matter how “big” — will have difficulty overcoming this challenge.

The other trouble with big data is that if we agree that the outcomes we have now are mediocre (and I think we can agree on that), studying these outcomes in greater detail is unlikely to result in truly transformative approaches. It would be like NASA scientists studying old nautical voyages to figure out how to reach the moon.

I’m not as pessimistic about big data approaches a Prasad is, but I do share some of his skepticism. We’ve been trying big data approaches using genomic data for over 15 years now, and thus far we haven’t found anything truly transformational. Again, to me that’s not a criticism of using big data approaches. Such computational approaches are and will be very useful in cancer research. It’s just that they are and will be very useful in an incremental fashion, and they they are prone to pitfalls that have plagued cancer research since cancer research began. In cancer, we frequently point out that biology is king. If you’re lucky enough to get a “good” cancer, chances are that you will tend to do well no matter what treatment is used. (Most alternative cancer cure testimonials consist of patients with “good” cancers.) If you’re unlucky enough to get a nasty cancer, chances are that you will do poorly regardless of treatment. I don’t see anything in the “big data” proposals that will overcome that. However, I also don’t think that better tools for hypothesis generation and to improve patient participation are a bad thing. They’re just not transformational.

The overall problem

I don’t see much reason to go into a lot of detail about the other recommendations. As I said before, most are not particularly controversial. Certainly none of them are transformational, including developing strategies to overcome resistance to anticancer therapies (a research priority that’s been a priority ever since entered the field), minimizing side effects (a long-neglected priority that has come to the fore already in the last five or ten years, no “moonshot” required), expanding the use of prevention and early screening (the latter, of course, is not without risks, such as overdiagnosis and overtreatment), intensifying research into the drivers of childhood cancers (which basically says right there that it’s just ramping up what we’re already doing), or developing new technologies to fight cancer (which is something cancer researchers have been doing since time immemorial).

I will admit that I found the proposal to develop a 3D and 4D cancer atlas to be kind of cool:

Oncologists today rely on past experience, consultation with multidisciplinary teams, published studies, and other sources to make diagnosis and treatment decisions. Providing a web-based catalog of the genetic lesions and cellular interactions in tumor, immune, and other cells in the tumor microenvironment that maps the evolution of tumors—from development to metastasis—will enable researchers to develop predictive models of tumor progression and response to treatment that will ultimately help oncologists make informed treatment decisions for each patient.

The “4D” aspect, discussed in the more detailed report, involves rerecording the same data over time for individual patients. The problem with such an atlas, however, is the same problem with all of “precision medicine,” namely that we don’t yet know what to do with all the mountains of information gathered for them when it comes to applying all that data to individual patients. That leads me to wonder if the effort and expense necessary to build such a tool will pay off.

I realize that to persuade politicians to fund an effort it’s often necessary to sex it up and make it appealing. I also know that slow and steady incremental advancement is far less sexy than a “moonshot”-style effort, as in a massive surge of resources and effort directed at a single focused goal. Unfortunately, the whole concept of a “moonshot,” while well-suited for focused engineering problems such as landing a human being on the moon, is poorly suited to a problem like “eliminating cancer as we know it,” which, by the way, is a poorly defined goal. You might remember the then-director of the NCI, Andrew Von Eschenbach, making the goal of the NCI to “eliminate suffering and death” from cancer by 2015. Well, it’s now 2016, and there’s still plenty of suffering and death from cancer in the US. Indeed, I remember attending a meeting of the American Association for Cancer Research in 2003 or 2004, where I attended a talk by Von Eschenbach and thought, “What is this guy smoking?” That was pretty much the reaction of every research with whom I spoke about his talk. The point is that making promises like that, framing cancer research as a “war” (which implies someday winning), or selling the idea that a concentrated “moonshot”-style effort can eliminate cancer is the wrong message.

Cancer is not a focused problem. It’s many hundreds, if not thousands, of problems, many interrelated, some not, that require many different solutions. Progress in cancer research, like science, will always be incremental, resistant to surrendering to victorious scientists and physicians the way Germany and Japan surrendered to the Allies in 1945, resistant to promises to eliminate it in 12 years, and certainly resistant to focused “moonshot” efforts to solve it. That doesn’t mean that there aren’t some good ideas worth implementing in the Cancer Moonshot, nor does it mean that it wouldn’t be worth increasing cancer research funding significantly, given the decrease in real purchasing power of the NIH and NCI budgets since 2004. Invested wisely, such funding could certainly contribute to real advances. The problem is, as with all science, it’s very difficult to predict where, when, or how such advances will manifest themselves or even what they’ll be. All we do know is that they’ll come about through incremental progress based on prior research. Unfortunately, that message is not one that’s as appealing as that of the Cancer Moonshot.

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I share your reservations. In the end, more money for research is always good, but the rhetoric is reminiscent of Nixon's "war on cancer", and sets unrealistic expectations which absolutely will be exploited by quacks down the road.

By Guy Chapman (not verified) on 18 Sep 2016 #permalink

I don't share your pessimism about new treatment modalities that could be efficient in a majority of cancers.
I also think that big data can be very useful but this requires a change in science communication and evaluation. Big data can be of major importance if used for hypothesis testing. This means that there should be a scientific community able to evaluate the strength of a hypothesis, able to understand biases and confounders and poised to admit that testing a hypothesis is part of science, even if there is no production of new data.

By Daniel Corcos (not verified) on 18 Sep 2016 #permalink

For example, there are humanized monoclonal antibodies against specific cancer targets (like Herceptin), which are more targeted therapy than immunotherapy per se.

Great while it lasts.

There are vaccines to prevent cancer, the most successful of which is, obviously, HPV vaccines such as Gardasil and Cervarix, which prevent cervical cancer by preventing infection by the most common HPV types.

Yeah right. Maybe like 10 cases per year. Merck's own data from the clinical trials showed that Gardasil even accelerated cancer in people that already had it.
Come on Orac, we all know that you oncologists really don't want to cure anything. That is why you ridicule every single effective treatment while promoting every single expensive and dubious treatment that you and your cronies are peddling.
People linus Linus Pauling, William Koch, Max Gerson, and maybe even Burzynski would put you to shame in clinical trials.

Why can't I post here? This is absurd. This is nothing but a shill website.

Use of CRISPR-Cas9-associated screening for studying fusion oncoproteins in childhood cancers is mentioned (pages 27-28) in the report, but the newer CRISPR-C2c2 possibility for targeting RNA was not mentioned. Do you think CRISPR-C2c2 just too new relative to the report deadlines to have made it in? This being a "moonshot" report these newest developments in DNA/RNA targeting seem to be something to "sex it up".

By Chris Hickie (not verified) on 19 Sep 2016 #permalink

It would make a lot more sense (at least to this Australian ID Physician of your vintage) to model the attack on cancer on the biology and control of HIV, Reagan's Bane notwithstanding. T cell biology is more than PD-1 inhibition.

I recently heard a talk by a former NASA employee who had an interesting perspective on the efforts to put a man on the moon. He said that in long-range terms the effort was a failure. By setting a concrete, short-term goal NASA focused their energy and expenditures so narrowly that once they reached the moon there was no place left to go: the foundations weren't broad enough.

Are we running that risk with this "Moon Shot"?

Are we running that risk with this “Moon Shot”?

I don't think so, for roughly the same reasons Orac mentions in the post that "moon shot" is a poor analogy here. Cancer isn't a single disease, it covers a whole bunch of illnesses with some properties (specifically, uncontrolled cell growth) in common. So it's not a narrowly focused goal.

But there are risks of a different kind, precisely because the goal isn't narrowly focused. As Yogi Berra said, "You have to be very careful if you don't know where you're going, because you might not get there."

By Eric Lund (not verified) on 19 Sep 2016 #permalink

Or as Clausewitz put it - “No one starts a war--or rather, no one in his senses ought to do so--without first being clear in his mind what he intends to achieve by that war and how he intends to conduct it.”

For some reason that kept running through my mind during March of 2003.

By shay simmons (not verified) on 19 Sep 2016 #permalink

@ #5:

Why can’t I post here?

You can, but new posters always go into automatic moderation to make sure you're actually a human being. Now that your posts have been released from moderation, you should be able to post live now; I think Orac whitelists people when he releases their posts from moderation. His blog is popular enough it gets hit pretty heavily by spambots.

Also, just as an FYI, links always put posts into automatic moderation, even if your account has been whitelisted. Do feel free to post references when you feel it's helpful, just know that it may take a while for them to show up. Regulars usually post their links, and then a second post to let other readers know there's a post with links waiting in the moderation queue.

By Calli Arcale (not verified) on 19 Sep 2016 #permalink

I don't like the idea of a "cancer moonshot". Mostly because I'm fairly disappointed in how the actual moonshot ended up. Pile a huge amount of resources into it, do some really amazing things, and then once the appropriate bootprints and flags have been placed and we've all patted ourselves on our backs, cancel the whole thing.

Is that really the model anyone should be fighting for with respect to cancer research? Throw a huge pile of money at it, and then, once everybody has their careers really well established and are just starting to make some real progress, cancel most of it?

By Calli Arcale (not verified) on 19 Sep 2016 #permalink

You can, but new posters always go into automatic moderation to make sure you’re actually a human being.

He's well aware of that already.

"You can, but new posters always go into automatic moderation to make sure you’re actually a human being."
It's not. It's an umbrella.

By Daniel Corcos (not verified) on 19 Sep 2016 #permalink

There is a chance he's not a sockpuppet, Narad, and even if he's not, I say it for the sake of silent readers so they know what the score really is.

By Calli Arcale (not verified) on 19 Sep 2016 #permalink

Also, just as an FYI, links always put posts into automatic moderation, even if your account has been whitelisted.

In my experience, one link per post is usually OK. I've never had any issues posting here as long as I have adhered to that rule. But anything with multiple links is normally flagged as spam.

I haven't done the experiment to see whether it matters if your link is "naked" (i.e., displaying the http part of the URL). I usually post links with descriptive text. Here's how you do that:
<a href="URL">Descriptive text</a>
where you replace "URL" with the actual URL (must be enclosed in double quotes) and "Descriptive text" with the text you actually want to associate with the link.

And in case you should ever need to post a literal "less than" symbol, do it by typing &lt; . Otherwise, the back end of the comment software assumes that everything between the "less than" sign and the following "greater than" sign is HTML code. If there is no matching "greater than" sign, the rest of your post gets eaten.

By Eric Lund (not verified) on 19 Sep 2016 #permalink

In my experience, one link per post is usually OK.

It's two here; Ethan Siegel has the maximum set to 1.

There is a chance he’s not a sockpuppet, Narad, and even if he’s not, I say it for the sake of silent readers so they know what the score really is.

Oh he is a sockpuppet and one of the most incompetent, if not persistent ones ever to leave skid marks here.

By Science Mom (not verified) on 19 Sep 2016 #permalink

I'm not sure this can work, mainly because we simply don't have the scientists anymore, and we can't import enough. NASA only got off the ground because we had to put religion aside in World War 2, and had a lot of tame ex-Nazis after the war. But now, most scientists from wealthy countries will stay in place, often with fatter budgets, more support, and a guarantee of students with enough education to be useful. Most students in the US will never hear about biology until they graduate high school.

By Politicalguineapig (not verified) on 19 Sep 2016 #permalink

As long as biology students continue to be taught the disproven membrane pump hypothesis there will be little progress.

Na⁺/K⁺ATPase is the Unicorn of biology. It doesn't do what they they say it does. Gilbert Ling has proven this in many different ways.

I’m not sure this can work, mainly because we simply don’t have the scientists anymore, and we can’t import enough.

I take it you don't spend a lot of time hanging around research universities.

The American system has a long-standing problem of overproducing Ph.D. scientists. Many of those scientists have to leave academia because there aren't enough jobs in academia for all of them. The problem is sometimes masked by expansions of funding, but when that expansion stops, you end up with even more Ph.D. scientists who can't get academic jobs. One of the potential downsides of this "cancer moon shot" is that it could perpetuate this cycle.

And again, if you think we're having trouble importing scientists, you haven't been hanging around research universities lately. It's true that we don't import a lot of people who obtained the Ph.D. or equivalent outside the US. Instead, we import them as graduate students, and they come from all over the world. True, we don't see that many from countries like Germany or Japan that have their own well-developed research sectors, but we do see lots of foreign grad students. Partial listing of the nationalities I have encountered over the years: Chinese, Indian, Korean, Turkish, Greek, Russian, Kazakh, Bulgarian, Brazilian, Peruvian, Eritrean, and even Iranian. Some of them eventually return to the old country, but many--IINM a majority--end up staying in the US, even if they don't stay in academia.

It's true that there are problems with K-12 science education in this country, but we had those problems at the time of the Sputnik launch, too. And the US is a big country, so even if there is only a fractionally small tail of people with the skill and inclination to become scientists, that's still a large number in absolute terms.

By Eric Lund (not verified) on 19 Sep 2016 #permalink

I was more curious about the claim that we laid religion aside during WWII - I've never heard that one before. In Russia, the exact opposite happened - under Stalin. People usually turn towards religion in times of war, not away from it

rhwombat @7: As someone who's worked in both HIV immune research and cancer immunotherapy ( monocyte-based) I say use everything and the kitchen sink.
Monocolonal antibodies! Vaccines like the one for HPV! Autollogus cell therapy! PD-1 inhibitors! CAR-T! (Even if it's so expensive to make it will never really fly.)

For (some) people looking from the outside in, there is only one 'immunotherapy' just like there is only 'cancer'. For people on the inside, we know most therapies will not work for most cancers. So you've got to try everything on everything until you find the pairings that work. (Hopefully narrowing down your search with basic science.)

By JustaTech (not verified) on 19 Sep 2016 #permalink

PGP @19: I'm going to agree with Eric; there are plenty of scientists. They just need to be convinced that leaving academia is not a failure. Regardless of what the trolls try to say, working in industry doesn't turn you into a monster or a shill. *Industry* is what actually brings treatments to market so patients can use them.

By JustaTech (not verified) on 19 Sep 2016 #permalink

Umbrella @4: Just in case anyone missed this when the news came out: In the past 10 years HVP vaccine has halved the number of new cervical cancers in Australia, and reduced HPV infections by 90%.
A decade on, vaccine has halved cervical cancer rate

So, no, you are wrong.

By JustaTech (not verified) on 19 Sep 2016 #permalink

I like the idea of a cancer moonshot. How many lunar residents have cancer?

By Mephistopheles… (not verified) on 19 Sep 2016 #permalink

#23 Agreed entirely.

One of the most common things I see on patient message boards is discussions about new "immunotherapies" and how they want to be on one, as if they are all essentially the same. Another worrying effect I see is doctors using this blanket term to gain patient enrollment in not particularly interesting clinical trials. The patient doesnt know that the treatment has very little chance of meaningfully helping them, but they are told its an Immunotherapy trial, and they know that is the hot ticket right now, so they acquiesce.

There doesnt even appear to be a consensus on the distinction between immunotherapies and other modalities . I see corporate websites discussing their new antibody drug conjugate and labeling it an immunotherapy when its not even designed for effective ADCC, making it essentially a "better" deliver method for chemotherapy. yet they still call it an immunotherapy....because...antibodies?

If they did actually make a national immunotherapy trial database I honestly believe it would be unethical.
Is there actually a medical or scientific reason to create this registry? I imagine the only reason this would be created would be to cash in on the concept patients have of immunotherapy being "better" and having "less side effects" which of course is a gross generalization. Taking advantage of patients misinformation to increase enrollment is dodgy.

Importantly, it also means they would be increasing enrollment in immunotherapy clinical trials, which may have an effect on non immunotherapy trial enrollment, meaning they would be shifting patient resources towards immunotherapy without any actual evidence that the future generations of immunotherapies will be any better than putting those reosources in to exploring trials of other modalities.

It just seems like every few years there is another bandwagon that pops up that will "change everything." One day its the PI3K pathway, the next its HDAC, and now its the giant umbrella of immunotherapy. Patients go get a generic TAA vaccine and have the success of PD-1 inhibitors in their mind while not being told of the miserable failure of vaccine only treatments in general.

Not all trials are equal and the sooner doctors start informing patients of the differences, the sooner that patients can benefit from the treatments that actually work.

Gilbert Ling has proven [sic] this in many different ways.

That seems superfluous, but at least I have another candidate for the 2017 deadpool.

And right on cue Fendlesworth aka the umbrella icon tried to leave another juvenile comment on my blog with the IP: 46.23.67.133
And here's his literary contribution:
Pppththt....?

Science Mom = ?

By Science Mom (not verified) on 19 Sep 2016 #permalink

Is there anything wrong with what oncologists are doing now? I mean, it seems that a 2% survival rate is a fine achievement.

I suppose maybe a 3% survival rate is something to strive for. You go people!

You get that cancer!!!

By Rebecca Eckles (not verified) on 19 Sep 2016 #permalink

That's depressing. No major breakthroughs - just painstaking small gains that maybe add up to a decent amount of extra years of life for most with better outcomes for some.

@ Eric
You are perfectly right concerning the number of PhDs.
But one may consider things otherwise: if a bright and creative student asks me whether he should consider to do a scientific career in medicine, I would rather advise him to find a way to earn his living and to make science as a hobby. I had the chance to do science as I wanted, but I have to admit that for young scientists it is not possible anymore. This failure of attracting bright people into science is the direct consequence of a bureaucratic, productivist view of science, where competition for grants and papers has replaced the quest for truth.

By Daniel Corcos (not verified) on 19 Sep 2016 #permalink

There aren't any lunar residents yet, Mephistopheles. But I would worry about the real possibility that future colonists on the Moon could get cancers from radiation and lunar dust inhalation.

There is a strong possibility that chronic exposure to radiation and lunar dust on the Moon could be carcinogenic. This is a dangerous risk that future colonists on the Moon would inevitably deal with.

@ Melissa
The cancer moonshot is a step before moon colonization.

By Daniel Corcos (not verified) on 20 Sep 2016 #permalink

Re: the '2% survival rate' idiocy above (anybody have better numbers on that?):

Life has a 0% survival rate. Everybody dies of something eventually.

You know why so many people die of cancer nowadays? It's because modern medicine has reduced or eliminated so many of the other things that used to kill people first.

By Jenora Feuer (not verified) on 20 Sep 2016 #permalink

M O'B @26 I can't help but think of it as "to the moon, cancer! To the MOON!"

By Emma Crew (not verified) on 20 Sep 2016 #permalink

A quick look at seer,cancer,gov shows overall 10 year cancer survival increased from 41.8 % in 75-79 to 61.8 in 2003.

5 year survival similarly increased from 48.9 to 68.9 in 2008.

Still a lot of deaths, but that's a big improvement.

By squirrelelite (not verified) on 20 Sep 2016 #permalink

Microsoft will solve cancer, within 10 years

Bwahahaha. Microsoft couldn't even roll out it's free Windows 10 offer without it blue screening three of my four Windows 7 computers even though Microsoft claimed the update was fully compatible. And you expect them to cure cancer?

By Chris Hickie (not verified) on 20 Sep 2016 #permalink

Microsoft couldn’t even roll out it’s free Windows 10 offer without it blue screening three of my four Windows 7 computers

Bwahahaha. So you just kept clicking 'ok' after the first, then second? No, wait; You didn't know that automatic updates were going to push it out on you?

So Chris. Are you still injecting children with Autism-in-a-syringe?

How many Autistic patients do you have now?

By Rebecca Eckles (not verified) on 20 Sep 2016 #permalink

Adrian @27: I strong;y disagree that a registry specifically of cancer immunotherapy clinical trials would be unethical. I think it is essential to 1) know who is doing what for what disease, 2) make it easier to figure out what *doesn't* work, 3) help the community come to a single meaning for "immunotherapy" (although that last one might be impossible: immunologists seem to want to have at least two names for everything and it is incredibly confusing).

The best way for doctors to inform their patients about which trials are more appropriate is to have a registry!

I won't argue that cancer research is just as susceptible to trends as anything else. But after the shine is off a lot of those "trendy" treatments, many of them are still good treatments, just for a more limited indication.

By JustaTech (not verified) on 20 Sep 2016 #permalink

Hmmmm.....Rebecca seems to be doing a pretty good impression of our morphing troll.

Anybody want to take bets?

#42 JustaTech

Everything you just said applies to a clinical trial registry in general. You would need to argue why they need to take immunotherapies out of a general cancer trial registry and make its own separate registry.

I would argue that the companies running trials, and top research doctors are already well aware of who is doing what in what cancers. The creation of a separate registry is for the uninformed, not the already informed. So why would they need a separate registry for the uninformed? Because they want to take advantage of the hype of immunotherapies to increase enrollment.

A separate registry would make it easier for uninformed doctors / patients to look up immunotherapy clinical trials in general. The only reason they would want to look up immunotherapy clinical trials in general would be because they "prefer" an immunotherapy trial over other trials which is based on general and unproven expectations like better results and safer treatment (neither of which appears to be true as a whole.) Again if the doctor is informed then he would look up a specific immunotherapy treatment like PD-1 inhibitors. This is easily done within a general trial registry. So the only benefit to a separate registry is for uninformed people, and it would exist solely to take advantage of that lack of information.

JP: I meant that religious prohibitions against science were laid aside during WW2 and throughout the Cold War period; progress in physics and biology were more important than keeping church people and school boards happy.

By Politicalguineapig (not verified) on 20 Sep 2016 #permalink