All-Star Panel Spells Out Onc Promises, Problems

HOLLYWOOD, Florida—The decline in total cancer mortality in the United States that began in 2003 looks set to continue and even accelerate as more research moves "from bench to bedside"—unless the basic and translational science feeding that change is strangled by budget cuts and red tape, according to experts at the 11th Annual Conference of the National Comprehensive Cancer Network (NCCN). The panel on "Cancer Care in the 21st Century" identified promising areas of research, pointed out major barriers to advancing that research, and suggested changes that might overcome some of those problems.

The panel had considerable star power. It was moderated by veteran ABC newsman (and melanoma survivor) Sam Donaldson, and included former Senator Connie Mack (R-Fla), as well as oncology leaders from Johns Hopkins, Dana-Farber, Roswell Park, Memorial Sloan-Kettering, M.D. Anderson, the National Cancer Institute (NCI), University of California, San Francisco (UCSF), and Fox Chase Cancer Center.

Robert C. Young, MD, president, Fox Chase Cancer Center, put the discussion in context by pointing out that the age-adjusted cancer mortality rate rose steadily from 1900 to 1990, but then began to fall. "Every year since 1990, the cancer mortality rate has gone down," Dr. Young said. "Naysayers said, due to the larger population of older patients, that mortality would just go up and never go down. But in 2003 it began to go down. The issue is, how do we accelerate the pace."

The panel attributed this change to cancer prevention (especially the decrease in smoking) and to improvements in many aspects of cancer treatment. They also predicted an accelerating pay-off from recent research. "In the next 10 to 20 years, I expect startling improvements in cancer survival," said Martin D. Abeloff, MD, director, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University. Three areas expected to contribute to this are targeted therapy, the fusion of imaging with treatment, and exploitation of the recent discovery of cancer "stem" cells.

John Mendelsohn, MD, president, University of Texas M.D. Anderson Cancer Center, said, "For cancer, the dream scenario is that we would biopsy a tumor, identify the abnormal genes, and either fix the defective gene or replace it or block the gene product. I expect that in another 20 or 30 years we will have a huge medicine chest with 500 possible therapies for cancer, from which we would put together a cocktail. None of this would be possible without the fabulous technologies that have come about because of the Human Genome Project and other basic science."

Margaret A. Tempero, MD, deputy director, UCSF Comprehensive Cancer Center, also predicted that targeted approaches will soon shape all phases of cancer diagnosis and treatment. She noted that recent discoveries on how the cancer cell collaborates with its microenvironment have opened up a whole new range of possible therapeutic targets.

David C. Hohn, MD, president, Roswell Park Cancer Institute, Buffalo, said, "I think we're going to see a fusion of imaging with treatment." He pointed to work with nanoparticles that home to the tumor, are visible with high-resolution scanning, and carry a therapeutic agent. Dr. Hohn said that the National Institutes of Health have made research on this approach a priority.

John E. Niederhuber, MD, chief operating officer, NCI, described the role of newly identified cancer "stem" cells and suggested that ignorance about such cells has contributed to the ineffectiveness of many cancer therapies. "When genetic changes occur in the primary tumor, they accumulate in 'stem' cells able to perpetuate them. These are a small percentage of the cells in a tumor, but they have unique properties. They can remain quiescent, stay resident in tissue for a long time, and move from one site to another in the body because of their embryologic properties, and they have unique genes that encode cell surface proteins able to kick our drugs out of the cell about as quickly as we can get them in," Dr. Niederhuber said.

NCI Budget Reductions

Dr. Niederhuber pointed out that better cancer treatment has dramatically increased the population of cancer survivors from 3 million in 1971 to more than 10 million in 2006, and that this has increased the costs for cancer care. Tighter research funding, such as the proposed reductions to NCI funding included in the Bush Administration's proposed budget, means harder choices between funding clinical trials and funding basic research [see ONI March 2006, page 14].

Former Senator Connie Mack, who is on the board of the H. Lee Moffitt Cancer Center, Tampa, Florida, said, "Research requires clinical trials, and clinical trials just consume budgets. I think we're going to have to find a different way to fund clinical trials, or there will be nothing left for basic research."

The panel spent considerable discussion time on the proposed changes to the NCI budget, including strategizing about ways to reverse them. Several initiatives were proposed with the thought of bringing pressure on the Bush Administration to restore the NCI budget.

Senator Mack promptly brought that line of argument to a halt. "We need to understand that there is not going to be a budget increase," he said. "We are wasting our energy and our resources if we get drawn into that being our number one priority. Why don't we accept reality and make some tough choices on what research to fund? Until we can ignite the imagination of both the public and Congress, we are not going to get them to refocus on what we are doing."

Dr. Niederhuber added that other, perhaps more malleable barriers to research lie in current regulatory policies. "We need to change the drug approval system so that we can test more than one drug at a time. We have to change intellectual property laws and restraint of trade issues to bring companies together in a noncompetitive way," he said.

The panel suggested several initiatives to help cancer patients involving information management, more attention to communicating with Congress and the public, and an even stronger emphasis on what individuals can do to protect themselves from cancer.

Uniform Electronic Medical Record

"The most important single thing we could do for cancer survivors would be to develop a uniform electronic medical record," Dr. Mendelsohn said. He predicted that this would reduce the medical errors that kill 100,000 people per year, improve patient care, and both improve and reduce the cost of medical research. "At M.D. Anderson, we now have nearly as many people working on billing as we have clinicians," he said, noting that the British have appropriated 7 billion to develop an electronic medical records system while the United States has appropriated only a fraction of that.

Edward J. Benz, Jr., MD, president, Dana-Farber Cancer Institute, noted that cancer research should not be limited to drug development. "We need research in how to get people to stop smoking, how to modify behavior, and how to use reimbursement mechanisms to promote early detection," he said.

Dr. Mendelsohn added, "The most important thing we can do in the short run is to emphasize the accountability of the individual. We know that if they quit smoking, exercise, stay thin, and have regular check-ups in the prescribed ways, we could probably cut the cancer death rate by 50%. It is a huge challenge to teach the American public to treat your body as well as you treat your car."