Maurie Markman, MD
The Moonshot initiative to “make America the country that cures cancer once and for all” that President Obama announced during his State of the Union address in January has generated the responses one would anticipate from a variety of audiences.1,2
An expected increase in federal funding for the National Cancer Institute is welcomed by academic leaders, their institutions, research-oriented organizations, and cancer advocacy groups.
However, many others in the oncology arena find the metaphor of a “moonshot” troubling. It sends a message that cancer—that is “all cancer”— can be cured, just like a war can be won or “we can land a man on the moon,” if we simply provide sufficient funding and, as a society, we make the effort a true national commitment. Of course, the dollar figure to attain this goal will certainly be very high and the timeline perhaps a little fuzzy, but it can be accomplished.
For quite understandable reasons, such language has great appeal to the general public and politicians on both sides of the aisle. Cancer is surely an “enemy” and if it can be eliminated shouldn’t we make such an effort to accomplish this worthy goal?
Simplistic Statements Belie Facts
Unfortunately, it is increasingly certain that this rhetoric has preciously little, if any, biological foundation. Cancer is not one, not 100, or not even 1000 different diseases. Rather, it is a massive group of conditions, highly molecularly heterogeneous between individuals and even within the same individual.
Further, it is now well recognized that rather substantial and clinically relevant molecular changes that may drive a cancer to spread and become resistant to treatment frequently occur during the natural history of a malignancy in a single individual. In addition, such changes may be substantially magnified under the biological pressure of therapy.
Therefore, arguing that sufficient funding and a strong desire will result in the discovery of a “cure for all cancer” must surely suggest to most knowledgeable observers a striking lack of understanding of the basic biology of malignant disease, an essential disregard for communicating objective scientific truths, or perhaps a combination of these and other factors. A simple-minded goal “to cure all cancer” fails to acknowledge the reality of the challenge.
As a result, the legitimate goal of focusing public support for vital cancer research may lose its momentum as critics cite these objections, with some even claiming that federal officials are seriously uninformed, naïve, or outright disingenuous.
Rescuing the Concept
However, there is a context in which the concept of a “moonshot” and the use of the term is appropriate— and that is if one considers that a critical feature of the space exploration efforts was the eventual goal to land a man on the moon. This focus resulted in the development of an infrastructure involving multiple essential partners to achieve this end result. These partners included the companies that built and assembled the many complex components within the spacecraft, numerous academic physics and engineering departments, the experts who selected the astronauts and guided their intense training, and government funding agencies.
The enhanced collaboration and cooperation that led to the first lunar landing optimized efficiency and ensured quality while at the same time recognizing the non-negotiable requirement that the goal be accomplished.
In the current discussion of the Moonshot cancer research program, the desired outcome is not that a particular study arm is shown to be beneficial (although one always hopes for such a finding), but rather that a given therapeutic concept or a specific drug/combination regimen has been efficiently, cost effectively, and fairly evaluated.
If the findings are positive, the concept/drug would appropriately move forward for further evaluation and would perhaps subsequently be introduced into routine medical care. Conversely, if the outcome of a given clinical trial or a research strategy failed to produce a meaningful clinical benefit, that also would be very important to learn and then report to both the oncology community and the general public. The infrastructure being established to permit the development of a national Moonshot initiative will hopefully result in multiple clinical trials focused on real-world patients, and not on the highly selected 2% to 3% of individuals who currently participate in cancer studies and who simply are not representative of the larger community of patients with cancer seen in daily medical practice when such factors as age, the presence of comorbidities, and prior treatment history are considered.