A Brief History of US Cancer Policy

              The story of cancer policy in the US is a fascinating tale of hopeful optimism clashing with stark reality. But in the decades-long history of cancer legislation, the community pushing to accelerate cures for cancer remains more hopeful than ever that a solution is just over the horizon. Let's take a look inside the minds of the individuals who have shaped the landscape of cancer in America and how exactly we ended up where we are today. 

Founding of the National Cancer Institute

              The story begins in 1937 with the signing of the National Cancer Institute Act by President Franklin Delano Roosevelt. Well, in reality the story began decades before 1937, but this is a great starting point for our purposes: the founding of the National Cancer Institute (NCI). This was to be the federal government's primary agency investigating the realm of cancer and its treatment. In effect, the NCI was created in the hopes that it would one find a cure for cancer. Though the bill did not designate any money toward the formation of the NCI, it established a committee which would eventually become the President's National Cancer Advisory Board.

              Three short years later, President Roosevelt designated six new buildings to the National Institute of Health (a parent agency to the NCI), one of which would become the NCI headquarters. This marked the start of a national effort to confront a disease that would eventually parade its way to the forefront of American life. At this time however, cancer had nowhere near the amount of public attention that it garners today. It competed against smallpox, typhoid fever, and tuberculosis among other diseases for the public's awareness. But that would quickly change as cancer related mortality jumped 30% between 1900 and 1916, climbing to the nation's second leading cause of death by 1926 - a position it still holds today just behind heart disease. Though the formation of the National Cancer Institute was a strong response to the spreading concern over this disease, America would need something much stronger to handle the relentless growth that cancer is capable of demonstrating.

The War on Cancer Begins

              Despite a promising start, the excitement and enthusiasm over the National Cancer Institute abruptly fell. The start of World War II reorganized American priorities, and thus cancer research took a backseat in the minds of many citizens. In fact by the 1950s, it was reported by an editor at the New York Times that they weren't even allowed to print the word "cancer" in their pages in fear of losing readership. But during this low point in the public's awareness of cancer, a new war was brewing in the shadows. Cancer wasn't waiting for geopolitical tensions to resolve. It marched on, quietly taking the lives of millions of Americans over the next two decades, and it became very clear that a new response was in order. The response this time would be all out war. Officially launched two days before Christmas in 1971, the National Cancer Act was signed into law by President Richard Nixon in front of a beaming media audience and the rest of the nation over TV.

              The National Cancer Act of 1971 promised "to strengthen the National Cancer Institute in order to more effectively carry out the national effort against cancer." So how exactly would it do that? Let's break it down.

  1. The director of the NCI would be granted greater authority to plan and develop a National Cancer Program. The program resulted in the creation of a "bypass budget" which was a procedure that allowed the NCI director to submit his annual budget directly to the President and Congress effectively bypassing its parent agencies - The Department of Health and Human Services and the NIH. 
  2. The existing National Advisory Cancer Council would become the National Cancer Advisory Board - an 18 member committee hand-picked by the president to aid in the development of NCI programs. 
  3. The President's Cancer Panel would be formed - a three member panel, once again hand-picked by the president, to submit annual reports on the national status of cancer research and treatment. 

              In total, over $400,000,000 would be pledged to fund the construction of 15 new cancer research centers across the nation. This amount of authority and attention given to cancer was unprecedented in US history. And there were two individuals at the heart of reconstructing America's relationship with cancer: Mary Lasker and Sidney Farber. 

              Mary Lasker was a Manhattan socialite and businesswoman described of possessing "legendary social and political energy". With deep connections in Washington D.C. and an unrelenting desire to end human suffering fueled by the loss of her loved ones to disease, Lasker personally spearheaded the overhaul of cancer awareness in the US. She leveraged her professional experiences and personal connections to fundraise millions of dollars throughout the 1940s. The shear amount of money and hype she was able to generate around cancer had never before been seen. She would team up with a scientist named Sidney Farber, and together they would become a formidable duo in the arena of cancer politics. 

              Sidney Farber was a pathologist at the Children's Hospital of Boston who began researching the idea of treating leukemia using chemicals in the late 1940s - an idea almost unheard of at the time. Up to this point, treating cancer meant either undergoing major surgery to remove the tumor or receiving huge doses of radiation to incinerate it. Leukemia was an enigmatic cancer of the blood that could not be treated by either of those methods. Farber's great insight was to use a class of chemicals known as anti-folates to demonstrate that the progression of cancer could be slowed down using medication. His contributions to this field eventually led to the development of chemotherapy as we know it today.

              Together, Mary Lasker and Sidney Farber provided the one-two punch that was needed in Washington to flip the script on cancer. With Farber's technical expertise and Lasker's political clout, the two launched an effort that eventually resulted in the signing of the National Cancer Act of 1971 along with a national embrace of the War on Cancer.

              So where did that get us? What kind of progress did we make as a result of the law passed in 1971? The number of NCI-designated cancer research centers grew from the 15 proposed in the bill to a whopping 69 in operation today. The $400,000,000 pledged in 1971 is absolutely dwarfed by the $5,210,000,000 appropriated to the NCI in fiscal year 2016.  An incredible total of $122,025,327,220 has been appropriated to the NCI since its inception in 1937.       

NCI Designated Cancer Research Centers.jpg

              This begs the question though: have any of these numbers resulted in any improvement for cancer health outcomes? Actually, yes! Though it may have taken a while to feel the impact, the American Cancer Society reported that cancer death rates have dropped 25% since they peaked in 1991. Our scientific understanding of cancer has taken leaps and bounds as technological innovations continue to shape today's research. Developments in cancer detection, diagnosis, therapy, and most importantly prevention have saved an estimated 2.1 million lives over the last twenty years. Progress has been remarkable and we are well positioned to continue on this path of success for years to come.

              But we have to be cautious in how we approach cancer in the 21st century. This community has often looked to NASA's successful Apollo program and Neil Armstrong's first steps on the moon as a bastion of American determination, leadership, and pioneering. President John F. Kennedy set the seemingly impossible goal for us to reach the moon in under a decade, and we absolutely crushed it. It's tempting to apply that same attitude toward cancer, and why not? If we just try hard enough and throw enough money at it, we can cure cancer too. Right?

              The problem, astonishingly, is more complex than rocket science. Believe it or not, our deepest understanding of the fundamental biological mechanisms that lie at the center of human health, let alone cancer, is incomplete! Yes, we are making tremendous headway in this field on a daily basis, but even this poses its own problem. The sheer amount of data and knowledge that we produce year after year does not easily translate into one, straightforward cure for cancer. For example, a basic scientific discovery that translates into a new type of cancer treatment may take years, even up to a decade to fully materialize from concept to tangible therapy. Progress in the medical sciences is a slow and lumbering process, and this is one area ripe for improvement in our next iteration for cancer policy. 

A Moonshot to Cure Cancer 

              While the War on Cancer was an effective stimulus for funding cancer research in the 1900s, we must move on to a new framework in how we think about this disease. Why? Because the analogy of fighting a war can only be upheld for so long before it begins to crumble precariously under its own weight. While one could make the argument that we are "winning the war on cancer," it's actually much easier to be critical of the progress that we would have hoped to make by now. Every president since Nixon has promised to be the one who ends cancer, and not one has lived up to that promise. Many cancer awareness campaigns have urged patients and their families to "fight on" and "never give up," and many have grossly overlooked the emotional toll of this mentality. Our relationship with cancer needs to transform from adversarial to educational so that we can truly understand what's going on in our cancer research and treatment centers across the nation. The 21st Century Cures Act, endearingly known as the Cancer Moonshot,  attempts in part to aid in this transition.

              In October 2015, Vice President Joe Biden made the announcement that he would not be joining the race for the presidency that would eventually be won by Donald Trump. In his announcement, Biden included a heartfelt message saying, "I believe we need a moonshot in this country to cure cancer. It's personal, but I know we can do this". He made the statement in honor of his late son, Beau Biden, who had recently died at the age of 46 after a two year period with brain cancer. Three months later, President Barack Obama would echo Biden's call for a national cancer moonshot during his final State of the Union address to the nation. In it he proclaimed, "For the loved ones we've all lost, for the families that we can still save, let's make America the country that cures cancer once and for all." Shortly thereafter, a Cancer Moonshot Taskforce was established under the leadership of Vice President Biden and the highest ranking administrators from the FDA, NASA, Department of Defense, National Science Foundation, Department of Health and Human Services, NIH, CDC, NCI, and a handful of other agencies.

              In collaboration with congress, the Cancer Moonshot Taskforce worked on a bill that would be called the 21st Century Cures Act. This federal legislation is comprised of three sections meant to impact various areas of healthcare: research and drug development, behavioral health, and healthcare access and quality improvement. The bill provides $4.8 billion in new funding to the NIH, $1.8 billion of which is specifically set aside for Biden's Cancer Moonshot over the next seven years.  The bill passed with huge support in both the House (392 to 26) and the Senate (94 to 5), and the bill was signed into law by President Obama on December 16, 2016. Just prior to the House vote, Senate Majority Leader Mitch McConnel (R-Ky.) asked to rename the section granting funds for cancer research after the Vice President's son, Beau Biden. The Vice President was moved to tears as the House was in full support of this amendment.

              On its surface the 21st Century Cures Act looks like a progressive bill with bipartisan support to accelerate research for cancer, Alzheimer's, and drug addiction. But it doesn't come without its cast of vocal critics. Senators Elizabeth Warren (D-Mass.) and Bernie Sanders (I-Vt.) both voted against the bill with Senator Warren going so far as to say, "When American voters say Congress is owned by big companies, this bill is exactly what they are talking about".

              Her comments refer to sections of the bill that work strongly to the benefit of big pharma and medical device manufacturing companies by deregulating steps in the manufacturing process. A progressive activist group known as Public Citizen echoed Senator Warren stating that "Congress gave Big Pharma and the medical device industry an early Christmas present that comes at the expense of patient safety by undermining requirements for ensuring safe and effective medications and medical devices".

So where does this leave us today?

              The good news for the cancer community is that a huge sum of money has been allocated for cancer research, and public awareness of the issue has sharpened with the former Vice President's involvement in honor of his late son. Of course, there is cause for concern under the Trump administration which has called for a $6 billion cut to the NIH - an agency that leads the world in biomedical research funding at $32.5 billion annually.

              Cancer remains a complex issue in the world of politics, but it is not impossible for the layperson to understand. Many of the nation's leading cancer research centers and agencies have spoken out against Trump's proposed budget and are poised to challenge it with the same ferocity that they approach their own work. Check out the links below if you want to learn more, and thank you so much for reading this month's post!

Links and References

https://goo.gl/Xw3dAC - The Emperor of All Maladies, Siddhartha Mukherjee

https://goo.gl/QWyFSj - Summary of the NCI

https://goo.gl/NYy0Bw - NCI budget fact book

https://goo.gl/LP0Xri - NCI summary of the National Cancer Institute Act of 1937

https://goo.gl/HnH8Ku - NCI summary of the National Cancer Act of 1971

https://goo.gl/Fac48r - Media coverage of the National Cancer Act of 1971

https://goo.gl/4r1bRO - NCI summary of the Cancer Moonshot

https://goo.gl/9rM7r9 - White House press release on the Cancer Moonshot

https://goo.gl/M51ceC - Media coverage of the Cancer Moonshot

https://goo.gl/AsvrTK - Media coverage of the Cancer Moonshot

https://goo.gl/e6XBwc - Media coverage of the Cancer Moonshot