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First Published Online February 11, 2009
The Oncologist, Vol. 14, No. 2, 117-118, February 2009; doi:10.1634/theoncologist.2009-0008
© 2009 AlphaMed Press
Commentaries |
Stone Soup: Commentary on "Five Strategies for Accelerating the War on Cancer in an Era of Budget Deficits"
Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
Correspondence: Robert C. Young, M.D., Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, Pennsylvania 19111, USA. Telephone: 215-728-2781; Fax: 215-728-3100; e-mail: Robert.Young{at}fccc.edu
Received January 16, 2009; accepted for publication January 20, 2009; first published online in THE ONCOLOGIST Express on February 11, 2009.
Disclosure: Robert C. Young: Employment/leadership position: Board of Directors, Human Genome Sciences and West Pharmaceutical Services; Consultant/advisory role: Chairman, Board of Scientific Advisors, NCI; Ownership interest (with spouse): Merck, Wyeth, Glaxo, Schering Plough, Johnson & Johnson.
The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by independent peer reviewers.
In Stone Soup, a fable by the Brothers Grimm about cooperation amid scarcity, travelers carrying only an empty pot, large stones, and water entice the townsfolk to make soup by adding small amounts of ingredients, one by one, finally producing a delicious and nourishing soup for the benefit of the entire community.
Reading the article crafted by the National Cancer Institute (NCI) leadership felt a little like reading the story of Stone Soup. To be sure, one should applaud their effort to accelerate the war on cancer in an era of budget deficits and to present five specific examples of how this might be achieved. Some of their proposals hold considerable promise, while others less so. The first—accelerating the pace of clinical trials by increasing Medicare enrollment—is sound because of both the need and the importance of proper representation of seniors in trials. As the authors point out, Medicare-aged patients represent >60% of new cancer cases but make up <30% of participants in clinical trials. Their solution is to increase physician reimbursement from CMS for the professional component of the patient visit to provide an incentive for physicians to enter Medicare patients into clinical trials. Although the strategy is sound, the $100 million increase in the Centers for Medicare and Medicaid Services (CMS) budget will likely be viewed differently by a sister agency also strapped for dollars.
The authors also seek to increase the collaboration between the NCI and CMS in determining the effectiveness of new cancer drugs. This is an important strategy and one sorely needed. The CMS has a clear financial interest in the cost of cancer therapies but has heretofore generally played a passive role in determining relative benefit. The authors provide persuasive examples of how such collaboration could accelerate discovery and identify what works and discard what does not.
Some of the other strategies seem more problematic. Although increasing colorectal cancer screening would, as the authors suggest, make a huge potential impact on cancer mortality in this country, it will be expensive. Furthermore, the confusing array of differing guidelines coupled with the varying screening procedures, all actively defended by physicians with a vested interest in a particular procedure, befuddle the public and lessen the acceptance of screening. One inexpensive effort that would yield positive results would be to clarify and simplify the screening message to the public and have the screening community advocate for any of the approved screening technologies. Any colorectal screening procedure is better than no screening at all.
Tobacco cessation efforts are one of the cornerstones of successful public health initiatives and have had a transforming impact on both cancer death rates and general public health. Having collected the "low hanging fruit" with existing methods, the field cries out for new initiatives directed toward the hard core addicted and the young people entering the "window of addiction." In both of these two important areas, existing strategies have been largely unsuccessful. Unfortunately, doing the same thing and hoping for a different result is unlikely to yield further transforming results. That's why the proposal to provide the U.S. Food and Drug Administration (FDA) with authority over tobacco presents an intriguing opportunity. Although there is much to be praised in this initiative, we need to be careful about what we wish for. Such legislation would finally legitimatize tobacco use for the foreseeable future and would set up prolonged legal jousting between the financially strapped, manpower-depleted, mandate-burdened FDA and the rich, well-focused tobacco industry with its huge cadre of well-paid lawyers. One must worry about the outcome of those legal jousts.
Finally, the authors propose a national outcomes research demonstration project enhancing and linking various existing programs. Although an attractive concept, many of these programs, including the clinical trials network, National Cooperative Groups, and other existing NCI programs, have been cut back or have failed to keep pace with biomedical research inflation. Linking programs already struggling to sustain their original mandate seems unlikely to achieve synergy.
Although one can certainly congratulate the NCI leadership for their efforts to develop strategies to make more from less, one must be realistic about the probability of success. The reality is that the National Institutes of Health (NIH) and the NCI have sustained funding reductions since 2004 that have reduced the NCI's purchasing power by 12%, or about $500 million. Efforts of the sort outlined in the authors' essay are unlikely to make up for these deficits.
What is actually needed for the authors' goals to be realized is for the country to endorse NIH and NCI funding as an economic stimulus strategy. Thousands of laboratories, scientists, and clinical investigators have "shovel-ready" ideas that will create high-paying nonoutsourceable jobs that will enhance this country's health. The Association of American Medical Colleges has pointed out that including $1.2 billion in the economic stimulus and recovery package would create 3,300 new grants and approximately 23,000 new well-paying jobs. The NIH is sitting with 10,000 scientifically meritorious peer-review approved but unfunded grants at 3,000 institutions across the country and is ready and able to implement these grants within 4–6 weeks. For these reasons, Senators Specter and Harkins have wisely proposed that the investment be increased to $10 billion.
What the Stone Soup fable tells us is that despite the pot, the stones and the water, a nourishing soup can only be made when the proper ingredients are added. Hopefully, our new administration will aid the NIH and NCI leadership in their commitment to reduce the burden of illness in this country and produce thousands of new jobs and economic stimulus at the same time.
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