COMMENTARY

Biden's Real Moonshot to Prevent Cancer

Hello and welcome. I'm Dr George Lundberg and this is At Large at Medscape.

President Joe Biden, deeply wounded by his son Beau's unsuccessful struggle against glioblastoma multiforme, recently pledged to "end cancer, as we know it."

As a long-term oncologic pathologist and a member of the American Society of Clinical Oncology and the Association for Molecular Pathology, I agree with these sentiments. But that is what we have all been trying to accomplish for our entire professional lives, with narrow, sometimes spectacular successes and also widespread failures.

I was thus interested to read what Dr Ned Sharpless, director of the National Cancer Institute, had to say about the president's vision in a recent interview. Sharpless elaborated that the president did not mean end cancer as we know it in "...the old and frail...the idea is reduction of mortality and incidence in otherwise healthy individuals."

Exclude the Elderly?

Oh my. Cancer is a disease of aging; 70% of the approximately 600,000 Americans who died of cancer in 2019 were age 65 or older. There is a whole field called oncogeriatrics. Leaving most of us old folks out may make it easier, but it does not make it right.

I was further intrigued to learn that Director Sharpless has been quoted recently (personal communication by JM Tenenbaum from the Salutatory Address to the 2021 CCR Fellows and Young Investigators Colloquium, April 20, 2021) as saying the United States should be able to cut the mortality rate of cancer by 50% in 10 years.

When confronted by a reporter with the notion that preventing cancer may be the best way to accomplish such a dramatic cut in mortality rate, albeit not as quickly as 10 years, Sharpless said, "The bad news about prevention is once you get past tobacco, obesity, and the viruses we can vaccinate for, it starts getting harder fast."

Okay. Let's "blue sky" a little on that statement. I would instead say that the good news is that we do, indeed, know how to prevent a huge amount of cancer: Stop using tobacco, lose weight, and vaccinate, and we can prevent as much as 40% of the 600,000 annual cancer deaths of Americans. Prevention is "simply" execution using known information.

In the United States, about 30% of all adult cancer deaths are attributable to tobacco use. Thirteen different kinds of potentially lethal cancers are associated with obesity. Exact numbers of deaths attributable to these factors are elusive but large in aggregate numbers.

Aim for Harm Reduction

To greatly prevent cancers caused by tobacco, we need to sharply diminish the use of combustible tobacco. A certain amount of drug abuse and addiction is inevitable in any free country, but harm reduction, defined as "a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use," is quite achievable.

For tobacco, that would mean tolerating nicotine addiction but eliminating combustible tobacco as the nicotine delivery system. Legally permit, even encourage, many alternative nicotine delivery systems for nicotine addicts. It would take many years for the washout to occur, but cancer rates for lung and many other organs would plummet. This could be accomplished legally through US Food and Drug Administration regulation. But expect political and legal pushback to be extreme.

While the raging global obesity epidemic is a multicausal issue, there is uniform agreement among experts that mass consumption of ultra-processed food is a major driver. Government could define and ban such products, encouraging a return by Americans to eating "real foods," hopefully in reasonable portion sizes. As with tobacco, a long washout period would ensue, but we could turn a corner on the so-far unrelenting health toll of ubiquitous obesity, including many types of cancer.

Money Spent Is Money Saved

A focus on prevention need not diminish the scientific progress to which Sharpless alludes. Ongoing science will increase our understanding of the molecular and immunologic features of cancer in general and some cancers specifically. Narrow successes in precision oncology diagnosis and therapy can continue and expand, with the hope that our successes, achieved at great cost, can be expanded to benefit more people with cancer. For example, screening by liquid biopsy could become a "silver bullet" leading to early diagnosis.

But is it realistic to expect Biden's "prevention moonshot" to succeed simply by executing existing knowledge? Probably not. Not sexy enough; not enough money to be made. But think about how much money could be saved by preventing cancer.

Tobacco is sufficiently demonized that few will defend it, especially if it remains a legal product but simply without nicotine. The cause of obesity is so multifaceted that attacking the industry of ultra-processed food may not be enough. One well-done study showed that people ate more calories in a diet of ultra-processed food because it tastes so good, goes down so easily, and quickly makes portion size impossible to control.

Might demonization of the food industry work? Yes, but that movement is not yet mature enough to power radical change. But cancer prevention is worth a shot.

That's my opinion. I'm Dr George Lundberg, at large at Medscape.

George Lundberg, MD, is contributing editor at Cancer Commons, president of the Lundberg Institute, executive advisor at Cureus, and a clinical professor of pathology at Northwestern University. Previously, he served as editor-in-chief of JAMA (including 10 specialty journals), American Medical News, and Medscape.

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