Roxanne Nelson, BSN, RN


June 24, 2016

Editor’s note: What would you like to know about the Cancer Moonshot? Tweet your questions to @MedscapeOnc, using hashtag #CanServe, and we’ll forward them to the experts featured at the National Cancer Moonshot Summit, being held in Washington, DC, on Wednesday, June 29. Follow @MedscapeOnc for more details about the Summit.

Vice President Joe Biden made the difficult decision last fall not to seek the Democratic nomination for president in 2016 for a number of reasons—one being the lofty goal of finding a cure for cancer.

He believed that a cancer "moonshot"—a heroic effort coordinated across many specialties—was needed to put an end to this insidious disease, and he has now asked the oncology community to step up to the plate and play an active role in this mission.

Biden Urges Oncologists to Put the Brakes on Cancer

Speaking at the annual meeting of the American Society of Clinical Oncology (ASCO), the Vice President implored oncologists and the other medical professionals attending the meeting to join this effort to put the brakes on cancer once and for all. In order to succeed, the Vice President told attendees, "I desperately need help."

He explained that the Moonshot's goal is "to eliminate cancer as we know it by fostering research, early detection, and access to treatment."

"The whole world is looking to you," Vice President Biden said to a capacity audience. "Your success can literally change the world. We need you now more than we ever have."

"No one knows the problems or the potential solutions better than all of you assembled here today," he said.

While the Vice President highlighted all of the objectives of the initiative, he emphasized the need for sharing data and facilitating collaborations to advance cancer prevention, treatment, and care.

The Cancer Moonshot is 'the only bipartisan thing left in America,' quipped Biden.

"No single oncologist or cancer researcher can find the answer on his or her own," Vice President Biden said. "The good news is, today, oncologists and cancer researchers realize they can't do it alone, either."

Joking that the Cancer Moonshot is "the only bipartisan thing left in America," Vice President Biden said it was time to "seize the moment."

But in coming to the ASCO meeting, the Vice President was clearly laying the cards on the table. Without the active support and participation of physicians, nurses, scientists, patients, advocates, and everyone involved in cancer care, the Moonshot will have little chance for success.

"I think it's incredible that Vice President Biden is engaging with oncologists and researchers the way he is in launching the Moonshot effort," commented Candace Johnson, PhD, president and CEO of Roswell Park Cancer Institute in Buffalo, New York. "He has been listening to all of us talk about the excitement and the promise we see, but also the challenges we face in trying to get better therapies to patients faster."

She pointed out that in particular, Vice President Biden "highlighted something that's been a theme of this year's ASCO meeting: the need for greater collaboration among cancer researchers, and I think the open database he announced today is a great way to jumpstart this effort."

Sowing Seeds for the Genomic Data Commons

Among the key points of Vice President Biden's ASCO speech was the announcement of a new project called Genomic Data Commons (GDC), which aims "to facilitate sharing of genomic and clinical data among cancer researchers to help promote advances in personalized treatment for the many forms of the disease."

The GDC is a public database for clinical genomic data that is overseen and funded by the National Cancer Institute (NCI). Designed to facilitate the sharing of information about sequencing of tumors and response to treatment, it will begin with genomic and clinical data for 12,000 patients.

A core component of both the Cancer Moonshot and the President's Precision Medicine Initiative, the GDC is being built and managed by the University of Chicago Center for Data Intensive Science, in collaboration with the Ontario Institute for Cancer Research, which are under an NCI contract with Leidos Biomedical Research.

The use of informatics platforms such as the GDC is essential for moving cancer research and care forward.

Data will be centralized, standardized, and drawn from such large-scale NCI programs as The Cancer Genome Atlas (TCGA) and its pediatric equivalent, Therapeutically Applicable Research to Generate Effective Treatments (TARGET).

The use of informatics platforms such as the GDC is essential for moving cancer research and care forward, by means of data sharing and collaboration, said Subha Madhavan, PhD, director of the Innovation Center for Biomedical Informatics at Georgetown University Medical Center.

"Systems such as the GDC and Georgetown Database of Cancer create a shared scientific exchange environment that permits new hypothesis generation without the need for scientists to download terabytes of data or install bioinformatics tools," said Dr Madhavan. "They can jump right into the data and start asking questions."

These systems help with genotype-phenotype integration in a single portal that eliminates the need for researchers to manually connect clinical data with genomic data, she noted.

Data science and bioinformatics are also critical to bringing the best analysis and evidence from clinical research to help cancer patients. "We need to connect omics to patient history to clinical outcomes to adverse events to growing scientific knowledge of genes and pathways involved in cancer," she explained. "We need to structure unstructured data from literature, conference proceedings, clinical notes, and social media to generate and validate clinical hypotheses."

Dr Madhavan agrees with Vice President Biden that individual oncologists have a major role to play in the Cancer Moonshot. Some of the steps they can take include educating themselves on precision medicine that can help their patients, enrolling patients in appropriate clinical trials to help generate the highest level of clinical evidence for therapies, and sharing de-identified data on their patients through public cancer research portals.

"Oncologists can also get involved with national and international efforts such as ClinGen,[1] the Global Alliance for Genomics and Health,[2] ASCO's TAPUR trial,[3] and professional societies to help standardize clinical actionability of genomic data," she added.

Vice President Biden emphasized the importance of pooling patient data, and commended ASCO's CancerLinQ initiative, which has expanded to 58 oncology practices in 39 states, involving 1000 clinicians. To date, 750,000 patient records have been collected.

A Short History of the Moonshot

Vice President Biden first mentioned a cancer initiative last October, noting that the issue was "personal" for him, because his 46-year-old son, Beau, had died only a few months earlier from brain cancer.

However, the Cancer Moonshot became a national initiative when President Barack Obama made it a line item in his final State of the Union address, and placed Vice President Biden in charge of "mission control" during the remaining months of the administration.

The President affirmed that there was going to be a "new national effort to get it done." 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."

Not surprisingly, President Obama's speech created a media stir. Many reactions were highly critical, others were more tempered but still doubtful. On the flip side, there was cautious optimism that the time had come for a major push to find more effective cancer treatments, as well as outright enthusiasm and support from many organizations and cancer experts.

But Barack Obama is not the first president to publically declare an end to cancer. Exactly 45 years ago, another president made a similar promise during his State of the Union address. Not only did Richard Nixon launch what would be called the "War on Cancer" in 1971, but he also invoked the image of a moonshot. Just 2 years earlier, American astronauts had walked on the moon, and the euphoria emanating from that event was still powerful. "The time has come in America when the same kind of concentrated effort that split the atom and took man to the moon should be turned toward conquering this dread disease. Let us make a total national commitment to achieve this goal," he said during his speech.[4]

President Nixon asked for an appropriation of an extra $100 million to launch an intensive campaign to find a cure for cancer. Of course, $100 million is pocket change these days, and even the $1 billion that President Obama has requested for the current initiative is merely to get the ball rolling.

President Nixon planned to have cancer cured by 1976, in time for the nation's bicentennial. The date came and went with no cure, and decades passed.

Cancer is now known to be hundreds of different diseases, making the definitive cure all the more elusive. Although cancer death rates have declined and high cure rates have been achieved for certain malignancy types, the mortality rates in others remain as dismal as they were during the Nixon Administration.

Survival has increased, but cancer is still a major killer and is on track to surpass heart disease as the leading cause of death in the United States.

Houston Builds a Prototype

Vice President Biden undoubtedly remembers astronaut Neil Armstrong's historic walk on the moon and the National Cancer Act of 1971, but his current proposal is directly related to a moonshot that launched only 4 years ago.

Inspired by the resolve to put a man on the moon, the University of Texas MD Anderson Cancer Center in 2012 launched their own ambitious initiative called the Moon Shots Program.[5]

"Our moon shot initiative served as an inspiration for the national Moonshot," said MD Anderson president Ronald DePinho, MD. "The Vice President came here, and we had many discussions before he made the announcement."

The primary goal was to significantly increase patient survival over the next decade.

The primary goal was to "significantly increase patient survival" over the next decade by creating large teams of researchers and clinicians who would work together and focus on specific cancers. Their program consists of 10 platforms or research engines as well as dozens of multidisciplinary flagship projects that involve more than 2000 MD Anderson faculty and staff.

Their program is focused on a wide range of cancer types including lung, prostate, breast/ovarian, colorectal and pancreatic cancers, melanoma, glioblastoma, human papillomavirus–related cancers, B-cell lymphomas, multiple myeloma, chronic lymphocytic leukemia, and myelodysplastic syndrome/acute myeloid leukemia. The platforms also include such areas of research as drug development and data generation, aggregation, and analysis.

Of note, the success of the program at MD Anderson has proved that it is possible to create a comprehensive and collaborative program if given sufficient time, motivation, and resources.

"We have, as a field, reached this amazing inflexion point of knowledge and technology that has put us in a position where we can accelerate progress in producing declines in cancer mortality," said Dr DePinho, noting that cancer mortality has only declined about 1% per year for the past few decades.

"We are now in a position, because of the knowledge we have, to accelerate that decline more dramatically," he said. "That was why we launched our moonshot initiative 4 years ago."

One of the key features of their program that is high on the list of Vice President Biden's objectives for the national initiative is the rapid translation of information, generated by their research engines, that can result in new approaches to treatment and prevention.

Another is the collaboration of their physicians and researchers, who are combining their knowledge and expertise to devise diagnostic tests, therapies, and novel care practices that can benefit cancer patients as quickly as possible.

The opportunity to aggregate data in a format that we can use is one of the great opportunities that exist in cancer science and medicine in general.

Dr DePinho explained that there was an enormous amount of knowledge within the medical records and research portfolios, but that data were not being captured systematically and scholars also could not access it on demand.

"Right now the data we have in the field, between research and clinical practice, is pretty compartmentalized, so the opportunity to aggregate data in a format that we can use is one of the great opportunities that exist in cancer science and medicine in general," said Dr DePinho. "We conveyed that to the Vice President, and that is one of the major areas of interest for him. We are going to find ways to capture data in a standardized and secure manner, which is very important to the Cancer Moonshot and to medicine overall."

MD Anderson was successful in bringing their data together under one roof, so to speak, but can this be replicated on a nationwide level?

Dr DePinho acknowledges that taking this approach nationally will not be easy. "It was challenging enough to do it in one institution, going between different departments," he said. "But imagine doing this between major institutions. You need a cloud that is secure, a format that allows you to analyze the data, and an infrastructure to bring it all together, while keeping in mind issues like security and patient privacy."

The HIPAA laws will also need to be examined. "They were developed before the advent of genomics and big data, so they need to be considered, as does regulatory compliance," he noted.

Basically, an "interstate highway" has to be built for transporting and aggregating data.

He emphasized that the GDC is a great step in the right direction, and MD Anderson will help and contribute to that data. "But we need to look down the road and build a digital system to aggregate data not just from institutions but from everywhere," Dr DePinho said. "All of it can be powerful and transformational in helping us manage disease."

Growing Momentum for the Cancer Moonshot

At an ASCO panel discussion held prior to Vice President Biden's address, James H. Doroshow, MD, director of the Division of Cancer Treatment and Diagnosis at NCI, emphasized the speed at which the initiative is coming together. He and members of the National Cancer Advisory Board's Blue Ribbon Panel outlined the initiative's progress to date.

The White House Cancer Moonshot Task Force, formed immediately after the State of the Union address and chaired by Vice President Biden, serves as the "administrative" arm of the Moonshot. It focuses on proper appropriation of federal investments, targeting incentives, and reviewing private-sector efforts from industry and philanthropy that support cancer research and improvement in care.

"We have been meeting every other week to find ways for the federal agencies to work together better and break down silos," said Dr Doroshow, who joked, "I want to say that many of these silos are the hardened type, the kind we used to put missiles in. This is not easy."

A Blue Ribbon Panel has also been established, comprising 28 experts who will advise the NCI on how to allocate resources. The panel's purpose is twofold: (1) to identify major scientific opportunities that could be accelerated by further emphasis and funding, and (2) to identify major hurdles that can be overcome with additional emphasis and funding.

"They will then develop a small number of recommendations that will go forward to the National Cancer Advisory Board and then back to the NCI and the Task Force, and then to the Vice President's office," he said.

Some of the ideas these groups have come up with are game changing—if we had the resources to carry them out.

The Blue Ribbon Panel has also established seven working groups made up of leading experts from the cancer community and industry, in such diverse areas as clinical trial expansion, immunology, and prevention. In turn, each of these groups will develop two to three recommendations for major opportunities that could lead to significant breakthroughs in cancer research.

Although Dr Doroshow was prohibited from divulging specifics, he was allowed to reveal that "some of the ideas these groups have come up with are game changing—if we had the resources to carry them out."

The timeline is perhaps the most "compressed" for anything that the NCI has ever done, he also pointed out. "Going from a committee that was established in April/May to having ideas that go forward in August, it really is a remarkable effort."

The next major forum will be a daylong conference of scientists, oncologists, and patients—dubbed the National Cancer Moonshot Summit—which will be held on June 29 at Howard University in Washington, DC. Hosted by Vice President Biden, the summit will focus on five strategic areas: advancing research discoveries, data sharing, access for patients and community oncologists, prevention and early diagnosis, and accelerating the delivery of therapies to patients.


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