Cancer Groundshot: From Blog Post to ASCO Session

Bishal Gyawali, MD, PhD


April 20, 2022

"Cancer Moonshot" is almost a household phrase in the US. When then-Vice President Joe Biden first announced the $1.8 billion initiative in 2016, he set the lofty goal to "end cancer as we know it." The major focus of the Cancer Moonshot was genomics, precision therapy, immunotherapy, and artificial intelligence.

At that time, I was a trainee in medical oncology and was not yet active on social media or publishing. I had started writing a blog in ecancer in 2016 April called Last Month in Oncology with Dr Bishal Gyawali, where I summarized the major oncology news from the past month and provided my own, unbiased commentary.

In November 2016, I came across a very strange news article. It said that a top US cancer center and a billionaire were in legal battle about who owned the term "moonshot." The lawsuit disturbed me. I couldn't understand why owning the term "moonshot" was such a big deal. The competition, I felt, should be centered on who helps more patients, removes disparities in cancer care, and eases pain and suffering, not who owns a term.

The news made me think about one of my patients in Nepal who had ovarian cancer. Her best-shot was treatment with carboplatin and paclitaxel. But to afford these drugs, she was forced to sell her house.

The side-by-side comparison was alarming. I saw a patient in a low-income country struggling to pay for necessary care vs a wealthy nation pumping money into moonshot initiatives with questionable value and people battling over who owns the term itself. As I reflected on this patient and this predicament, I wrote the following lines in a December 2016 blog:

[W]e should focus on ways to improve outcomes in cancer patients, rather than arguing who coined the term "cancer moonshot." When public health keeps getting ignored, when cancer remains a killer, when more than 90% of cancer patients globally can't afford cancer treatment, who owns the term "cancer moonshot" is immaterial. Forget the moon; let's get back to blood and flesh reality on the ground.

I'd rather support a "cancer groundshot" that focuses on smoking and obesity reduction campaigns, promotes exercise and healthy diet, and encourages research that can be immediately applied to every global community. "Cancer groundshot" is the term. Please feel free to use it.

In October 2017, I was invited to deliver a talk at the Royal Society of Medicine's global oncology meeting. I chose this venue to expand on the concept of a cancer groundshot. In my talk, I highlighted that we need to prioritize initiatives that help any patient get the care they need. When 90% of the patients in low-income countries do not have access to radiation and 50% don't have access to timely surgery, I was clear that we couldn't "immunotherapy our way out of global cancer burden." If we invested a fraction of moonshot money to groundshot activities — surgery, radiation therapy facilities, curative treatments, proven cheaper drug therapies, pain medicines — we would save more lives. I received an extremely positive reception from the audience.

At that time, I had completed my training and was working as a medical oncologist in a public hospital in Nepal. I was in final discussions to move to Harvard for a research fellowship in a few months. But by some twist of fate, I got introduced to Chris Booth, MD, of Queen's University, Kingston, Canada by Ian Tannock, MD, and Richard Sullivan, MD. While I was still in Nepal, we connected by telephone. Two things happened in that call. One, it marked the start of a long friendship. We are now colleagues working together in the same clinic at the same institution. And two, we discussed transforming my Royal Society talk into a paper. That led to my first formal publication on the cancer groundshot, published in The Lancet Oncology in 2018.

Subsequently, the idea started to take on a life of its own on social media. Unlike some of my other, slightly more controversial ideas — such as ramucirumab is not a good drug — everyone seemed to get behind this concept. Oncologists, policymakers, regulators, and laypeople could all see the merits of the cancer groundshot philosophy and believed that this initiative needed as much priority and funding as the cancer moonshot to truly "end cancer as we know it."

Since then, the idea has continued to gain traction. I have given dozens of talks on the cancer groundshot, both in high-income and low-income countries and at meetings including ecancer, the AORTIC International Conference on Cancer in Africa, ASTRO (American Society for Radiation Oncology), and the European Cancer Summit. I have coauthored a chapter on the concept for the ASCO Educational Book 2022. And on the 5-year anniversary of the cancer moonshot, Nature published my views on a cancer groundshot. When I got invited to the 2022 ASCO Annual Meeting to chair an educational session on the cancer groundshot on June 3, it made me reflect on this journey that I am sharing today.

Despite the momentum behind the cancer groundshot, I know that this is just the beginning. Talks and papers do not save lives. We need concrete action, and I hope these talks and papers create momentum and encourage effective policy that will save lives.

I am telling this story not to highlight how fantastic my idea is, but to stress that no matter where you are in today's world, you can make a difference. I hope to encourage the global community of young oncologists that regardless of their background, they can make a difference.

Bishal Gyawali, MD, PhD, is an associate professor in the Departments of Oncology and Public Health Sciences and a scientist in the Division of Cancer Care and Epidemiology at Queen's University in Kingston, Ontario, Canada, and is also affiliated faculty at the Program on Regulation, Therapeutics, and Law in the Department of Medicine at Brigham and Women's Hospital in Boston. His clinical and research interests revolve around cancer policy, global oncology, evidence-based oncology, financial toxicities of cancer treatment, clinical trial methods, and supportive care. He tweets at @oncology_bg.


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