Cancer Moonshot 2.0: Three Big Questions to Track

February 21, 2022 Andrew Hertler, MD, FACP

Is the Biden administration’s new Cancer Moonshot initiative on target?

At first glance, the ambitious plan to reduce the cancer death rate by 50% over the next 25 years identifies most—though perhaps not all—of the levers that we need to pull. Developing new treatments is, predictably, key to the plan, but so too is better prevention, screening and elimination of disparities, among other goals. It outlines a comprehensive approach that recognizes the systemic nature of cancer and cancer treatment.

At this early stage, it’s still hard to fully assess the initiative. Funding for the $1.8-billion original Moonshot, approved in 2016 when Biden was vice president, does not run out until 2023. In the meantime, a new Cancer Cabinet composed of leaders across government departments and agencies will help drive the effort, including (presumably) new asks for federal funding. When we see these and other specifics, we’ll be able to gauge the relative importance being given to various components of the plan.

As the Moonshot prepares ready for liftoff, here are several issues that I’ll be tracking.

How Much Emphasis is Placed on Fighting Metastatic Disease vs. Preventing It?

It may sound odd, but the less the initiative feels like a moonshot approach, the more effective it will likely be. No doubt, the Moonshot offers a captivating metaphor, harkening back to a time when Americans’ engineering and scientific prowess put the first person on the Moon. Yet, the concept also conjures up the increasingly dominant approach to cancer treatment—the use of immunotherapies and new treatments to make a precision strike on cancer cells or the mechanisms driving their growth. Massive amounts of academic and industry research are flowing into the development of drugs for metastatic disease that too often bring marginal (if any) improvements in survival or quality of life at an exorbitant cost.

Due to the complexity of cancer, I don’t believe that we are around the corner from a cure to metastatic disease. We still have an incomplete understanding of the immune system, the genetic instability of cancer with its rapidly evolving mutations, and the role of the microenvironments where cancers grow. Given these limitations, let’s hope that the Moonshot puts substantial emphasis on prevention and early detection. Blood tests that use Next Generation Sequencing, though not ready for widespread use, have shown promise and should play a greater role. Improved imaging tests and technologies can also help, and cancer screening tests need to be deployed equitably to historically underserved groups.

As some critics have pointed out, there is scant mention in the Moonshot announcement of tackling some of the ultimate contributors to high cancer rates, such as environmental carcinogens, alcohol use and poor diets. Let’s not forget that dramatic decreases in tobacco use among young people is one of the main drivers of the progress we’ve seen in the cancer fight over the last several decades. Working further upstream to prevent cancer is hard, but worth it.

Is There a Plan to Get True Comparative Effectiveness Data for Cancer Therapies?

The Moonshot framework highlights the need to target the right therapies to the right patients—a laudable goal. Unfortunately, our current drug approval process makes that task exceedingly difficult. To determine the optimal therapy for an individual patient, providers should be able to find results from comparative effectiveness trials that compare viable treatment options against one another. Participants in those trials should reflect, as closely as possible, the real-world patent population. In fact, neither of those is typical. Too many clinical trials for cancer drugs are designed to obtain FDA approval—comparing a drug against an inferior, decades-old treatment rather than against the current standard of care. Socioeconomically disadvantaged groups as well as the elderly, are under-represented in trials, which typically results in a rosier picture of the drugs’ effectiveness in the real world.

Redesigning and bolstering clinical trials is one way the leaders of the Moonshot could demonstrate that they are serious about matching the best therapies to individual patients. A host of changes should be contemplated: Consider giving the National Cancer Institute/NIH national oversight of trials, rather than relying on the pharmaceutical companies. Require that more trial designs offer head-to-head comparisons of viable treatment options. Fund more clinical research infrastructure– research nurses, data analysts, support staff—in socioeconomically disadvantaged areas. Create a national database of trial sites that expands beyond the traditional base in academic medical centers.

While clinical trials data is critical, so is real-world evidence. Once therapies are approved, we need to track whether they achieve the same outcomes outside of trials. The Moonshot can facilitate efforts—public or private—to collect real-world evidence and then use it to inform better treatment decisions, through clinical decision support and artificial intelligence. It’s heartening that the Moonshot announcement touts the importance of collecting patient data (with their permission) and learning from their experiences.   

Will There Be Sufficient Focus on Improving Delivery of Care?

The Moonshot announcement includes a call to action to start making up for millions of cancer screenings that have been missed since the start of the pandemic. Tapping into the infrastructure that the government has built and strengthened to fight COVID-19, as well as existing NCI networks, the plan envisions many more access points for screenings, with an emphasis on reaching high-risk individuals.

Hopefully this effort will be successful and lead to many similar ones in the future fight against cancer. Finding new therapies tends to grab the headlines, but this kind of hard work to deploy screenings and high-quality treatments too often gets overlooked. Implementation science—the work of translating evidence into everyday practice—receives a tiny fraction of the government funding awarded to basic science and clinical research. However, its impact can be profound.

This new Cancer Moonshot will be more successful if it focuses on the hard, albeit less glorious, work to augment our delivery infrastructure and systems. The private sector also has an important role here. Tools such as high-value clinical pathways can help remove unwarranted variation while helping providers identify the best therapy for each patient.

I’m optimistic about the new Moonshot for many reasons, not the least of which is that it’s an issue that could find support in a divided Congress. We already have many of the tools we need to put a dent in the burden of cancer, and others are in reach. This is an opportunity to deploy more of them at scale.

About the Author

Andrew Hertler, MD, FACP

As the chief medical officer of Evolent, Dr. Andrew Hertler is responsible for the advancement of the company's clinical quality and value-based strategy, utilization management policies and clinical thought leadership initiatives. A practicing board-certified oncologist for 30 years, he is a nationally recognized leader in oncology clinical practice. Dr. Hertler has volunteered on a number of American Society of Clinical Oncology (ASCO) committees, including the Clinical Practice, Quality of Care and Payment Reform Committees, as well as the Quality Oncology Practice Initiative Certification Program Oversight Council.

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