Part 2: Money—Is cancer beating cardiovascular disease?

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New York, NY - There are three reasons why the best and brightest minds in biomedical science might choose to devote their careers to one disease over another, according to Dr James Eberwine, codirector of the prestigious Penn Genome Frontiers Institute. The first is what he calls the "Pied Piper" effect: a faculty mentor whose enthusiasm is infectious and inspiring. The second reason, he says, is having an emotional history with a particular disease, prompting "the motivation to try to help."

And there's a third driving force, Eberwine continues, "which I don't like as much, but which is there, and that's the available funding. There are certain diseases that have captured the attention of the public and the [US] National Institutes of Health [NIH] beyond the attention of other things, and those tend to have money associated with them," he explains. "So the opportunity to do the research in a particular field might be a driving force as well."

Dr Donna Arnett

Whether the amount of available research funding can explain the surge in new cancer therapies approved or awaiting approval is uncertain. What's clear, however, is that the NIH, the "largest source of funding for medical research in the world," allots significantly more funds to its National Cancer Institute (NCI) than it does the National Heart , Lung , and Blood Institute (NHLBI). From its 2010 budget of $30.9 billion, plus the NIH injection of $1.56 billion in funds from the American Recovery & Reinvestment Act (ARRA), just 7.8% of overall funding was earmarked for cardiovascular disease research; 20.3% was granted to cancer.

It's a disparity that rankles with the American Heart Association (AHA), which points out that heart disease remains the number-one killer of Americans, while cancer occupies the number-two position. And incoming president Dr Donna Arnett (University of Alabama at Birmingham) sees that discrepancy as a key reason that new research into cancer therapeutics may be pulling ahead of cardiovascular disease.

Passionate mentors and emotional motivators play a role, she says, "But I honestly think that when you get to the level of a PhD student or an MD/PhD student, that [the choice is] really driven by where you get money to train. And because the NCI budget is higher than the NHLBI's, there is much more opportunity for training."

The numbers game

Leaving aside the ARRA numbers, the actual NIH dollar amounts shake out as follows. In the 2010 fiscal year, the NHLBI was granted an operating budget of $3.093 billion, of which $1.320 billion went toward research project grants in the cardiovascular sciences and an additional $450 million toward specialized cardiac centers, other research, contracts, and training programs (the remainder was spent in similar ways for blood and lung disorders) ^[1]]. By contrast, the NCI received $5.098 billion from the NIH pot, of which 42.5%, or $2.168 billion, was spent funding research grants, and the remainder toward specialized centers, research, contracts, intramural research, and other support ^[2].

Research funding, in billions, for the NHLBI and NCI: 2010

As NHLBI acting director Dr Susan Shurin points out, it is the US Senate's Appropriations Committee that determines how the NIH budget is divvied up between institutes, based largely on prior year's budgets and emerging needs. And she balks at the idea that funding for the diseases should be decided by medical need—the fact that heart disease is the nation's number-one killer does not mean the NHBLI deserves the lion's share of NIH funding.

Dr Susan Shurin [Source: NHLBI]

For one thing, she notes, stroke research is largely funded out of the National Institute of Neurological Disorders and Stroke, while projects within both cancer and cardiovascular disease might actually be funded out of the National Human Genome Research Institute or the institutes covering aging, diabetes, or environmental health.

"We don't consider ourselves in competition with cancer," says Shurin. "Many of the things that cause people to get cancer also cause people to get heart disease."

Besides, she says, some of the most important scientific advances come from the study of rare diseases. If government spending were determined solely based on the size of the population in need, funding might be better spent on public health over research or research targeting lower-income Americans and minority groups.

"I'm not saying we wouldn't like more money [for the NHLBI]," Shurin told heartwire . "I'm just saying that I worry when people talk about the idea that allocation ought to be on the number of people who are affected. It's the scientific opportunities that you want to pursue, and you're not always going to know where those are going to be."

Who is asking for what?

But if researchers, perhaps even subconsciously, were drawn toward a bigger pot of research dollars, that might show up in the number of new grant applications reviewed by the respective institutes each year. And indeed, in 2010, 7338 research project grants were submitted and reviewed by the NCI—62% more than were submitted and reviewed by the NHLBI, at 4528. In total, 903 of those sent to the NHLBI were ultimately funded, yielding a success rate of almost 20%, as compared with 1253 funded by the NCI, a success rate of 17%.

Dr Clyde Yancy

Dr Clyde Yancy (Northwestern University, Chicago, IL), who spoke out about what he saw as inadequate NHLBI funding when he was AHA president, told heart wire he worries that young scientists may be dissuaded, in part, from pursuing a career in cardiovascular sciences precisely because the heart-disease arena has already seen some blockbuster therapies in recent decades, coupled with a corresponding improvement in disease survival.

"There is a sense that the CV space is overpopulated," he admits, but stresses that funding also plays a powerful role: "I think that expression of 'going where the money is' matters in this circumstance," he says.

"Depending on what kind of thought process, what kind of philosophy, what kind of political persuasion underpins the statements that are generated to the public with regard to requests for funding proposals (RFPs), this will generate the kinds of responses," he explains. "So part of the reason there may be so many more grants submitted to the cancer institute is because people see opportunities and gravitate toward oncology, but there also could be a certain sense that the NCI has the flexibility to introduce more RFPs."

All research areas feel the pinch

Shurin points out that while the overall NIH budget has increased over time, the actual "buying power" of the NIH funding granted this year is at the same level as it was back in 2000 and 2001.

"The NHLBI is funding 8% fewer grants than we did last year, and the NCI is funding 15% fewer than it did last year," she said. "Believe me, I'm not telling you we don't need more money [for the NHLBI]: we really need more money. But the question is: what are the therapeutic opportunities that are not being pursued in heart disease? And I think there are fewer than there used to be, because some of this reflects that we have had some level of success."

But both Yancy and Shurin are adamant that the solution doesn't lie in sharing NIH funds more equitably between cancer and heart disease.

"Underfunding affects every area, and I would hate to be in a position in which we were cannibalizing one area of research in order to support another. I would not advocate reallocating funds that go toward cancer; I would strongly advocate funding research better," says Shurin. "And you can't throw money at a problem and expect to solve it, and you can see that in cancer. We've thrown a lot of money at cancer; we haven't solved a lot of the problems."

Yancy, likewise, insisted that the coffers for cardiovascular disease research can't be expanded "by shifting funds away from other very compelling diseases that have even larger unmet needs than we do." Instead, a greater commitment to biomedical research is needed, he says.

"Too many people get into this space and it becomes a tug of war, and it shouldn't be a tug of war; it should be a complementary discussion."

Nonprofit groups also raise money for research

Of course, the NIH is only one source of funding for heart and cancer research: dedicated societies for both diseases also fundraise aggressively for their organizations and allocate a portion of that money for research via grant submission and peer-review processes.

Here again, the numbers are at odds, although the gap is much smaller. In the 2010 fiscal year, the AHA spent $114.8 million on research (19.4% of its total budget) while the American Cancer Society spent $148.6 million (16% of its budget). Of note, research funding by both groups was actually more similar in 2009: $142.7 million for the AHA and $149.8 million for the ACS. The American College of Cardiology spent half a million dollars on CVD research grants in 2010.

Research funding, in millions, from the AHA and ACS: 2010

Arnett thinks heart-disease research needs a breakthrough discovery, in a new area, a stint on the marquee, to reinvigorate the field and points to some of the excitement bubbling in the areas of tissue engineering, embryonic or pluripotent stem cells, pharmacogenetics, nanotechnology, and bioengineering.

"There are so many cool things going on in cardiovascular disease right now," she says. "It's hard to believe that people think everything's been done."

Both the NIH numbers, determined by politicians, and the funds raised by nonprofit groups suggest that there are some even more fundamental, less tangible forces at play that push cancer ahead of cardiovascular disease.

Heartwire from Medscape © 2011 

Cite this: Part 2: Money—Is cancer beating cardiovascular disease? - Medscape - Aug 16, 2011.