Last year, the National Cancer Institute estimated that 1.6 million new cases of cancer would be diagnosed in the United States. Data from 2012 indicate that close to 40 percent of men and women will be diagnosed with cancer at some point in their lifetimes. As the number of cancer survivors increases, so do costs; national expenditures for cancer care could surpass $155 billion by 2020. Although the overall cancer death rate has declined since the 1990s, it is still among the leading causes of death worldwide.
Launched in 2016 by the Obama administration, the National Cancer Moonshot aims to bring about a decade’s worth of advances in eliminating cancer in five years. Last December, Congress passed the 21st Century Cures Act authorizing $1.8 billion in funding for the Cancer Moonshot over seven years. The initiative will work to accelerate research efforts and break down barriers to progress by enhancing data access and facilitating collaborations with researchers, physicians, philanthropies, patients, patient advocates, and biotechnology and pharmaceutical companies. The goal is to make more therapies available to more patients, while also improving prevention efforts and early detection.
Former Vice President Joe Biden led the Cancer Moonshot Task Force (now folded into the Biden Foundation), which focuses on making the most of federal investments, targeted incentives, private sector efforts from industry and philanthropy, patient engagement initiatives and other mechanisms to support cancer research and enable progress in treatment and care. President Obama charged several federal agencies with serving on the task force to provide recommendations. After meeting with oncology experts across the country, Vice President Biden identified areas of focus and received commitments from private sector companies and organizations with which to partner and/or invest to meet the initiative’s goals.
A Key Player in Early Detection and Prevention
At a Cancer Moonshot Summit last June, more than 350 researchers, oncologists, data and technology experts, patients, families and patient advocates convened to discuss the challenges and opportunities for advancing the field of cancer research and treatment. Dr. Sarah Peters, immediate past president of the Hematology/Oncology Pharmacy Association (HOPA) and associate professor at the Albany College of Pharmacy and Health Sciences, attended the summit as a representative of the academic pharmacy community in her role as HOPA president.
“I was fortunate to be able to participate in roundtable discussions,” Peters said. “We were assigned to different workgroups and contributed ideas to White House staff about how we make 10 years of progress in five years.”
The two small group discussions focused on the topics of incentivizing breakthrough research discoveries in cancer care and supporting preventative health behaviors. In the first group, talks addressed the limitations of funding for academic cancer research, and the contrast between the tenure system rewarding the PI and not recognizing the inherent necessity for team-based research.
Peters’ second session addressed the need for funding for public health, and the importance of community pharmacists as part of the public health workforce in promoting smoking cessation, sunscreen use and cancer screenings, etc. Her recommendation was added to an ideas whiteboard by White House staff.
To ensure that the Cancer Moonshot’s goals and approaches are grounded in the best science, Vice President Biden’s task force consulted with external experts, including the presidentially-appointed National Cancer Advisory Board. A Blue Ribbon panel of experts was established as a working group of the NCAB to assist the board in providing this advice. The panel’s charge was to provide expert advice on the vision, proposed scientific goals and implementation of the Cancer Moonshot.
The panel’s report describes 10 transformative research recommendations for achieving the Moonshot’s ambitious goal:
- Establish a network for direct patient involvement.
- Create a translational science network devoted exclusively to immunotherapy.
- Develop ways to overcome cancer’s resistance to therapy.
- Build a national cancer data ecosystem.
- Intensify research on the major drivers of childhood cancers.
- Minimize cancer treatment’s debilitating side effects.
- Expand use of proven cancer prevention and early
- detection strategies.
- Mine past patient data to predict future patient outcomes.
- Develop a 3-D cancer atlas.
- Develop new cancer technologies.
Peters said that she sees two areas within the panel’s recommendations where pharmacy can have influence. “One is minimizing cancer treatment side effects,” she noted. “Side effect management applies to those pharmacists who are meeting with patients as a provider as part of the interprofessional clinical care team. The other is expanding the use of early detection strategies. Our pharmacy colleagues who work in community settings have a role in cancer prevention. They can recommend age-appropriate screenings. For example, pharmacists should talk with women who are 50 and older about potential calcium deficiencies and osteoporosis screening. Why can’t they recommend that women 50 and older have a mammogram and colonoscopy? Being an advocate for staying on top of health screenings and following up with primary care physicians is really important.”
Communication between the pharmacist and patient is critical, she added. “Having conversations with patients and including cancer screenings as part of those overall health and wellness conversations,” she explained, puts pharmacists in a position to help achieve the panel’s recommendations regarding prevention strategies. She added that clinical pharmacists are also part of the equation.
“If you see patients in a clinic and you are involved in the management of their care along with their other healthcare providers, you play a central role in their care,” she continued. “There’s an important reason why we’re consulted. We help manage the side effects of treatment so that they can stay on treatment longer, which ultimately improves their survival.”
Turning Research Into Reality
Equally important is academic pharmacy’s contribution to research, including looking at how cancers respond to various treatments and studying optimal dosage and medication combinations. “Our colleagues in pharmaceutical science departments are doing basic research and gaining an understanding of the biology of the disease and doing cancer research in the laboratory,” Peters said. “Unless we really understand the biology, we can’t identify targets for treatment.” In practice, she hopes pharmacists are exploring how to optimize supportive care. “We have patients who suffer from all sorts of [other illnesses]. It’s an art to manage some of these. If we could identify risk factors and explore drug interactions, this would be an important area for practice faulty to engage in.”
Adherence to drug therapy also stands out to Peters as an area that deserves more attention. “So many cancer treatments are oral drugs. They are taken on varying schedules….sometimes they require breaks, or they are taken multiple times a day, or there are drug or food interactions. Identifying risk factors and evaluating outcomes of services is something faculty are already doing and we should be doing more of.”
As pharmacy schools continue to engage in research that can help the Moonshot initiative reach its goals, Peters thinks there will be a need to take a closer look at real-life outcomes. “Clinical trials are done in the ideal patient,” she pointed out. “I think the results we see are not what we’ll see in actual practice. We should be thinking about that from a drug therapy perspective as well as a population perspective. How well do these work in real patients who have all of these problems?” With many cancer patients today suffering from other diseases at the same time, Peters noted that pharmacists need to think about the best drugs for these patients.
“How do we optimize options for cancer patients now that there are choices to make?” she continued. “In the past, there was a clear direction because there was only one drug therapy or regimen available; but that’s not the case anymore. There is a real opportunity for pharmacists to have a role in deciding the best cancer treatment as well as the supportive care medications.”
Peters also noted that, as more people are being diagnosed with cancer, oncology pharmacy is a growing practice area. “It’s important that the Academy recognizes that more of our graduates will be interacting with cancer patients,” she said. “We have more people surviving cancer and we will have more graduates taking positions to take care of cancer patients because the need is so great. We can’t think of oncology as a specialty that our graduates won’t engage in, because they will.”
From Molecules to Medicine
Long before new medications even make it to patients, basic scientists like Dr. Kevin Dalby, Johnson & Johnson Centennial professor of chemical biology and medicinal chemistry in The University of Texas at Austin College of Pharmacy, play a critical part in discovering new molecules that may inspire the next cancer drug therapy. Dalby, co-director of the Texas Screening Alliance for Cancer Therapeutics, is helping to make some of those new therapies a reality, thanks to a grant of roughly $5 million from the Cancer Prevention and Research Institute of Texas to support his Targeted Therapeutic Drug Discovery & Development Program.
Involved in the initial stages of drug discovery, Dalby works with other cancer researchers, often physicians, who validate drug targets. He and his team develop tests to further explore the drug target his physician colleagues are interested in as a means to find small molecules that impact its function, the sign that they might be onto something. His ultimate goal is to generate more molecules to get them out into the hands of clinical researchers to pick up and advance the work. The more molecules with potential drug-like activity tested in trials, the more possibilities to cultivate new cancer drug therapies.
“It’s all about generating new ideas and new molecules to keep the pipeline going, because so many ideas don’t come to fruition when it comes to drug development,” Dalby said. That’s how he sees his role: finding a molecular needle in a haystack to help patients.
“Our goal is to help (researchers) get new molecules to test in preclinical studies. They will have a candidate molecule, and depending on how things look, we could try to make better versions so that they’re more potent, with more drug-like properties,” he said. “If something looks really good, then we could get it into a clinical trial.”
Presently, Dalby has several promising projects in the works. One involves an inhibitor of a protein kinase called maternal embryonic leucine zipper kinase. “We think that this is an important target in inflammatory breast cancer, and probably also in triple negative breast cancer. We are in the process of simultaneously developing new and more potent inhibitors of the kinase to test in preclinical studies, while also trying to understand the biology of the kinase in the cancer,” he said.
Other projects target metastasis in lung cancer and metabolism in pancreatic cancer. He also spoke about a project that looks to develop inhibitors against an important pathway in melanoma, for which there are clinical drugs but there’s also resistance.
“There’s a lot going on,” Dr. Dalby said.
To the Moon and Back—To Basics
There’s no doubt that Moonshot aspirations have energized the scientific and medical community. Aiming to do what could be done in 10 years and do it in five, and to combine resources and create a data ecosystem available for all that would accelerate understanding, prevention, treatment and a possible cure, is an impressive goal but Dalby cautions that the end game should not eclipse the crucial step of basic research.
“The thing that we should be constantly thinking about drug discovery is that we need to be funding the basic research where investigators are trying to understand biology behind the disease,” he said. “Only then will you develop the perspective of what might be a good pathway to direct a drug discovery program towards.”
The Blue Ribbon Panel recommendations could focus more on the genesis of discovery as well as on the goal, Dalby admits. “I’m always a little worried when I see these large, government directives such as this because they sometimes forget the basic work that is the foundation. It’s harder to sell that to politicians, but you can’t do it without understanding what’s going on.”
To make initiatives like the Moonshot successful, there is an important role for AACP and other like-minded organizations in supporting basic, mechanistic investigations, Dalby said. Without that groundwork, “We can’t do anything translational, and while the translational work gets the immediate accolades when it works, it’s built on the backs of many, many researchers over a long period of time. We must never forget that.”
He likens basic research to a roadmap, and says that trying to do translational work without it would be like trying to go from Austin to Dallas 100 years ago without a map. Someone may make it, but a map sure would be nice. “You cannot do translational work without knowing where you’re going,” he said. “Basic, mechanistic work is like creating a roadmap to actually get to your destination.”
The Next Mission
As a scientist in a position of responsibility, Dalby said he wanted to do something that would benefit the public. That’s when he started dedicating some of his time to thinking about the processes that go on in cancer, applying his expertise in chemistry and biochemistry.
“We must ask ourselves, ‘Are we doing the best we can to get young people interested in doing the basic, mechanistic research?’” he asked. “Because if we create an environment that doesn’t look like a good place in which to work, we’re going to lose a lot of talent.”
The medical community and legislative bodies must nurture the scientific process and attract the brightest minds to better the chances of solving problems down the road.
“I hope to encourage future researchers to meet the challenges. Science is difficult, sometimes it’s quite lonely, but mostly it’s incredibly rewarding if you do it right,” Dalby said. “If you find your passion and you follow your passion in science, there’s nothing better.”
The mission of the Cancer Moonshot Initiative— to accomplish a decade’s worth of progress in five years—is ambitious, but achievable. Still, this mission likely won’t completely eradicate a disease that is among the leading causes of death worldwide. That’s why we need a solid workforce of both clinicians and researchers to continue aiming for the stars.
Jane E. Rooney is a freelance writer
based in Oakton, Va.
Athena Ponushis is a freelance writer
based in Ft. Lauderdale, Fla.