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Shooting for the moon: Reasons for optimism in oncology practice
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In his State of the Union Address in January, President Barack Obama unveiled plans for a “moonshot” to cure cancer and empowered Vice President Joe Biden to lead this effort.
Biden’s personal experience with cancer, losing his son Beau to a brain tumor, is well known and underscores his personal investment in the initiative.
The moonshot to cure cancer seemed an appropriate course correction from the old days of a “war on cancer.” This declaration of a national research agenda was optimistic, and a reflection of the creative ingenuity and resourcefulness of America’s scientists and health professionals.
The moment was well scripted. Biden soon began his visits with some of the brightest stars of cancer science and medicine, and topics that had generated tremendous recent buzz — immunotherapy, big data and precision medicine — were featured prominently.
A surprising consequence
To me, perhaps the most surprising consequence of this announcement was the cynicism and negativity that emerged from many quarters.
Some argued that cancer represents many different diseases, so the idea of a single “moonshot” was fundamentally flawed. Others questioned the true potential of any of the putative paths to a cure, instead pointing to the expected limitations of precision medicine and big data, for example.
Skeptics even viewed the proposed expenditures through a jaded lens: $1 billion for cancer sounds nice, but then again, so does $1 billion for Zika virus or $1 billion to end the epidemic of opiate misuse. What can’t a billion dollars theoretically fix these days?
Indeed, the current era of oncologic research and care is marked by significant pushback. Costs of care are too high and ever-increasing; the value of many cancer treatments requires clearer definition; and although new drugs are approved each year, many are associated with modest PFS or OS benefits.
Some observers bemoan the lack of good evidence behind many of the treatments we offer at the bedside. As a bone marrow transplant physician, I understand this concern, but I worry that appropriate caution can give way to a sort of cynical nihilism when it comes to expectations for the future of cancer care.
Some are beginning to view the current state of the field as inflated with hype, with little substance behind it. Has the pendulum swung too far?
Although I understand the concerns of the realists, I agree with the sentiments of the vice president. As oncologists, we know hope is a powerful resource in difficult times. Aiming for a moonshot reflects the best kind of hope — that despite the odds, we will persevere as a community in our united pursuit of better and safer treatments for those facing cancer, regardless of type, stage, curative potential or prognosis.
We know the path for each patient and the path for us as a community will not be easy, and there will be many setbacks and failures. But we will go on, as not going on admits to a failure of hope.
Co-voyagers
Compared with the start of my fellowship — more than 8 years ago now, but still not too long — I am so heartened and encouraged by the path we have already traveled as a community of oncologists, researchers, patients, caregivers and advocates.
I am an optimist — not because of a particular technology or scientific breakthrough, but because I see the way in which we have infused our practice with a new kind of humanism that sees our patients as partners, as co-voyagers on this journey to the moon.
What do I mean by this?
I recently attended on the inpatient bone marrow transplant service for 2 weeks. The mix of patients and clinical management challenges was typical: Some patients were newly admitted for transplant, some were confronting treatment toxicities in the early posttransplant period, and others had complicated and sometimes chronic concerns occurring months to years after transplantation.
Each day on rounds featured a host of decisions large and small, as is the way of clinical medicine at the bedside. Although we aimed to provide evidence-based care, relatively few of the decisions we made as a team were based upon randomized studies. Our patients or the issues they encountered were complex beyond the boundaries of clinical trial inclusion criteria, or the topics had simply not been studied.
We struggled in the way that all of us as oncologists struggle and persevere each day in clinic or on the wards. It is hard to complain about a lack of progress in oncologic care when practice often occurs in areas where there are no clear guideposts or benchmarks. We do the best we can for the patients with the tools we have and the training we’ve received, whether the particular management challenge is “textbook” or not. This is the essence of clinical medicine.
In this way, then, when I think of big data and registry projects, I think of bringing clarity to the murkiness of daily practice — empowering those of us at the bedside to learn how other patients with similar dilemmas have fared under different treatment scenarios.
I have hope that big data will make all of us better doctors. Although I don’t think that answers and cures will reveal themselves magically through machine learning and algorithm application, I do have hope that these approaches will allow me to do what I do with a little more creativity and confidence.
Opportunity for transcendence
When I think back to the discussions I had with patients these past few weeks, I am reminded about the language that we have started to use more frequently as we consider objectives and goals of treatment.
In bone marrow transplantation, there is a major national initiative to integrate palliative care into regular clinical practice. Whether our goals are curative or not, we recognize our palliative care colleagues are invaluable resources who offer our patients relief from pain or other symptoms, provide emotional support and ensure appropriate coordination of care.
Increasingly, we are realizing that physical function is prognostic, just like more traditional indices of disease severity.
We know preservation of function is a patient-centered outcome, because the ability to live one’s life — and to actualize one’s hopes and dreams — is a central goal for our patients and should be a cornerstone of our treatment plans.
We are learning there are many ways to think about physical, cognitive and emotional function, and the best way to find this out is to ask. Patient-reported outcomes often are just as important as more traditional measures of treatment success. A true understanding of “precision medicine” requires tailoring treatment plans and measuring the success of therapy by this rubric.
In my recent 2 weeks on the bone marrow transplant service, and in my 8 years in clinical oncology, I remain an optimist. I know we are living in a time of mounting frustration and cynicism about progress in clinical oncology. But when I think about what the oncology moonshot means to me, to my colleagues and to my patients, I think of hope — hope that the effort the president is funding will allow us to be better doctors for our patients and better witnesses to their journeys.
A moonshot is an opportunity for transcendence beyond the confines of our limits on Earth, and a reminder of the sacred space within which we exist with our patients.
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William Wood, MD, is assistant professor of medicine in the division of hematology/oncology at University of North Carolina in Chapel Hill. He also is a HemOnc Today Editorial Board member. He can be reached at UNC Health Care System, Division of Hematology and Oncology, 101 Manning Drive, Chapel Hill, NC 27514; email: wawood@med.unc.edu. You also may follow him on Twitter (@WoodBD).
Disclosure: Wood reports no relevant financial disclosures.