Pathologist and cancer researcher Michael Becich has two criteria for setting goals: they should be measurable, and they should lofty, even if that means they border on unattainable. “By trying to hit a lofty goal, we start to measure ourselves against that,” he says. “And what gets measured gets done.”
US President Joe Biden announced on 2 February that he would renew the US Beau Biden Cancer Moonshot Initiative — a $1.8-billion cancer research programme that began 5 years ago and was slated to run for another 2 — with a fresh target of decreasing cancer deaths by at least 50% in the next 25 years. Becich saw a goal, albeit a lofty one, that he could get behind. “Here’s a politician trying to understand the science,” he says. “And I applaud him for what he wants to do with it.”
For Becich, who works at the University of Pittsburgh in Pennsylvania, and other cancer researchers, that’s a welcome change. For decades, they have been tethered to unrealistic political promises. In 1971, former president Richard Nixon aimed for cancer to be cured in five years. In 2016, then-vice-president Biden declared that the moonshot would achieve ten years of cancer research in only five years — a target that Becich considers worthy, but too subjective and difficult to measure. Even now, as researchers hope the renewal of the programme will come with a fresh influx of funds — Biden has yet to say how much — it will take years to determine whether the first five years has met that original target.
Congress awarded the moonshot’s first $1.8 billion over seven years. Although this sounds like a dazzling sum, it constituted a relatively small annual investment, says epidemiologist Cary Gross at Yale School of Medicine in New Haven, Connecticut. The funds amounted to a yearly increase of only about 5% to the budget of the US National Cancer Institute (NCI), which funds moonshot programmes. “What was conveyed to the public with great excitement was that we’re going to reshape the way we do cancer research,” says Gross. “They said, ‘We’re going to revolutionize everything: you were getting $100, now we’re going to give you $105.’”
Still, the NCI found room to launch more than 240 projects covering a wide spectrum of cancer research. Moonshot programmes are studying therapies that stimulate the immune system to fight paediatric cancers, and are compiling 3D atlases of tumour cells as they progress from precancerous lesions to advanced disease. There are programmes to address disparities in access to health care, and to improve the implementation of best clinical practices after they have been identified in clinical trials. And the NCI built data-sharing infrastructure, such as the Cancer Research Data Commons, to maximize the use of the generated data — a crucial way to amplify the impact of moonshot programmes, says Gross.
Despite the moonshot’s achievements, it will be difficult to determine whether the programme has delivered on Biden’s initial pledge to accomplish ten years’ worth of progress in five. At a December meeting of the National Cancer Advisory Board, NCI deputy director Dinah Singer said that moonshot programmes had already yielded 1,212 publications, 14 supported patents and 22 clinical trials. On average, moonshot publications tended to be more heavily cited than other NCI-funded research, but Singer noted that this could be a by-product of the moonshot’s focus on large collaborations, which tend to draw more citations. “We’re struggling to identify what the right metrics are,” Singer said.
That struggle will be compounded by an explosion in cancer research that began well before the moonshot’s start date, says biomedical informaticist Jeremy Warner at Vanderbilt University in Nashville, Tennessee. Fuelled by advances in genomics, genome editing, diagnostics and biomarker discoveries, researchers have been pouring into the field. “It’s even harder to ascertain if the moonshot itself accelerated progress,” Warner says. “Because progress was already on a steep, non-linear climb.”
Over the years, the NCI has worked hard to attract researchers from other fields to cancer research, says Anna Barker, chief strategy officer at the Ellison Institute for Transformative Medicine at the University of Southern California in Los Angeles and a former NCI deputy director. But the influx of applicants for funding combined with US budget uncertainty has led to low rates of awarded grants, she notes. Only about 9% of grant applications to the NCI are funded, and the NCI will struggle to keep that from dropping any lower, she says. “Recent advances are dragging all of these great people from other disciplines, which was the goal,” Barker says. “We’ve been successful in doing that, but now we’ve got lots of applications.”
Biden’s decision to renew the moonshot — if it is accompanied by significant funding — could allow the NCI to delay the difficult task of shutting down projects linked to the initiative. As of December, about two-thirds of the funded projects had expressed interest in continuing past the original end of the moonshot, Singer told NCI advisers. Not all of these programmes were likely to win continued funding, she said — but if they did, the NCI would need an additional $100 million each year to allow them to continue without taking funds from other NCI grant pools. “It’s really easy to start programmes,” says Barker. “And very difficult to stop them.”
Details of the next iteration of the moonshot and its priorities are unclear at present, but Biden’s statement included references to advancing technologies that can lead to earlier diagnosis of cancers, and harnessing mRNA vaccines to target tumours. It also reiterated a commitment to data sharing.
For oncologist Bishal Gyawali at Queen’s University in Ontario, Canada, Biden’s renewed emphasis on ensuring access to cancer screening and early detection could represent a key moment for the field. In 2017, Gyawali called for a cancer ‘groundshot’ initiative that would focus on ensuring access to available treatments rather than hunting for the next cure. “All the fuss was about how wonderful the new innovations will be,” he says. “But that did not acknowledge the fact that we already have so many interventions in oncology that we already have proven to work, and most of the patients of the world don’t have access to these treatments.”
Lack of access is also a problem in the United States itself, says Amelie Ramirez, who studies population health at the University of Texas Health Science Center at San Antonio, Texas. For example, cancer is the number-one killer in the US Latinx community, she says. Many in this group lack access to early cancer screening — so they are diagnosed later in the disease course, she notes. “I was heartened to hear the specific words ‘to address inequities’ as its own goal in the renewed moonshot,” she says. “The call to action for cancer screening is desperately needed.”
For any moonshot effort, data sharing will be pivotal to ensure that the programmes maximize their impact, says Becich. Researchers in the first generation of moonshot programmes have been slower than he expected to upload their data to the Cancer Research Data Commons and other platforms, and he worries that they might not do so before the original moonshot comes to an end in two years.
“Instead of making the moonshot more complex, what we need to do is make sure that the central goal of sharing data [happens] as quickly as possible,” Becich says. “Let’s not just talk about doing it, let’s measure the data-sharing. Let’s make that a central part of where the moonshot goes.”