Success against cancer need not deliver the Moon.
When John F. Kennedy pledged in a 1961 presidential speech to land a man on the Moon and return him safely to Earth, he launched more than a space programme. He introduced the ultimate metaphor. Today, moonshots no longer need to shoot for the Moon. They can signify merely the launch of a grand effort fuelled by bold ambition that will elevate society to some new heights.
The latest is the US Cancer Moonshot, a US$1-billion plan, to be spearheaded by vice-president Joe Biden, that aims “to eliminate cancer as we know it”.
The project and the promised investment are welcome indeed. The name and the rhetoric less so, and not just because they are so unoriginal — moonshots and Apollo programmes have been launched in recent years on everything from renewable energy and neuroscience to an assortment of Google X pet projects and at least three efforts to fight cancer.
Perhaps the United States was due for another national promise to cure cancer: the last — a 2005 pledge by Andrew von Eschenbach, then head of the US National Cancer Institute — was scheduled to have vanquished the disease by 2015. This followed then President Richard Nixon’s 1971 pledge to use $100 million to cure cancer. To be sure, pledges to cure cancer have a long history of succeeding in one respect: fundraising. But the idea that $1 billion could eliminate cancer is misleading, and only becomes more so as each passing year reveals more about the full challenge of fighting the disease. With apologies to Biden, the more we ‘know it’ the harder it becomes to think we can ‘eliminate cancer’.
Today, we have a clearer view of cancer’s complexity. The sequencing of tumour genomes has revealed heterogeneity not only among cancers and patients, but in a single tumour. Within those complex mixtures of cells can lurk mutations that give rise to drug resistance. Therapies against cancer-causing mutations have been transformative for some patients in the short term, but nearly always fail in the long term as resistant cells reseed the tumour.
Real progress is being made, little by little. Chemotherapy cures more than 85% of children with acute lymphocytic leukaemia, for example. And for a small number of patients with various cancers, new immunotherapies have produced remissions so prolonged that doctors have begun to whisper the word ‘cure’. But although combinations of these therapies could hold the key to expanding their success, testing combinations in clinical trials is complex — and quite likely to cost more than $1 billion. As with everything, the more successful we get, the harder it is to improve. For many cancers, a more reasonable aim might be to turn them into chronic, manageable diseases.
Setting an unreachable goal plays down the tremendous progress that cancer researchers have made.
In statements and conversations, Biden has acknowledged this complexity, and has even reportedly expressed regret for choosing the moonshot theme. It is unfortunate that sound bites from Biden and the White House continue to back its simplistic framework. Repeated invocations of these bold but doomed quests to cure cancer in a decade, or with a given sum of money, feed public cynicism about the value and potential of science. And setting an unreachable goal plays down the tremendous progress that cancer researchers have made.
Details of the latest cancer moonshot are sketchy; Biden is still gathering input from the country’s scientific glitterati. From what we know, he hopes to double the pace of cancer research by breaking down the barriers — logistical and cultural — that keep researchers from sharing data. This can include having electronic medical records that talk to one another, encouraging collaboration, and developing central repositories that can handle big data. Some of these issues are already being tackled: the National Cancer Institute, for example, is putting together a large database that aims to unite disparate data sets, along with clinical information and the privacy concerns entailed, in one place.
There is also no guarantee that Obama’s $1-billion request will come to pass. Congressional leaders have pledged to ignore the president’s budget request. And Obama sought to establish the funding for the cancer moonshot using an unusual approach that would circumvent the usual congressional funding process. Congress is unlikely to sign up to that. But there is hope that the programme will survive in some form: this Congress has a soft spot for medical research, and Biden is an authority on the art of congressional compromise.
Let us hope it will. Biden’s early vision of the programme, if executed well, has the potential to be high-impact. Cancer research is in the middle of a revolution, and may be on the brink of even greater success. The US Cancer Moonshot has the potential to build on this momentum. The project does not need to mislead the public, and damage its trust in science, in the process.
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Back to Earth. Nature 530, 253–254 (2016). https://doi.org/10.1038/530253b
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BMC Medicine (2016)