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Balancing hope and realism: It may be time to adjust the sails
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“The pessimist complains about the wind; the optimist expects it to change; the realist adjusts the sails.”
— William Arthur Ward
Events of recent weeks have kept the focus of the oncology community in the United States on President Barack Obama’s national cancer moonshot initiative.
Like many other cancer centers nationwide, Huntsman Cancer Institute was selected to host a regional summit to coincide with the National Cancer Moonshot Summit held at Howard University in Washington, D.C. This was an opportunity for further expert input on a broad basis and another chance to widen the audience of stakeholders who could have meaningful input into the lofty goals of the initiative.
It was an enjoyable and very informative afternoon, and I left feeling that the “moonshot” metaphor was a perfect descriptor for the ambitious plans to address the cancer challenge. However, I since realized I may be wrong about that.
The day after the summit, I met with one of our younger staff members, who had no idea what “moonshot” meant! So, the metaphor may work for us as oncologists — the median age of our workforce is 51 years — but it does not necessarily resonate with other members of our community.
I remain positive and optimistic about the potential impact this additional attention to cancer could have. I also am increasingly aware of the gulf that can develop between the hopes and expectations we create and the reality of meeting and managing those expectations.
I have chosen three examples from literature that highlight this.
Data disparity
In March, the American Cancer Society published Cancer Facts & Figures 2016.
Within the wealth of data in the report was the observation that the rate of breast cancer in white women had remained stable. However, the 0.3% yearly increase of breast cancer in black women has resulted in converging rates of breast cancer for the first time. This is a disturbing trend given the disparities in outcome for black women.
The causes of these disparities are well documented and have been addressed by Derek Raghavan, MD, PhD, HemOnc Today’s Chief Medical Editor for Oncology, in previous editorials. In addition to the many social, economic, cultural and geographic factors that play into this disparity, biologic and genomic heterogeneity may be part of the explanation for this poorer outcome. This is certainly a credible hypothesis, and there are emerging examples of genomic diversity of cancers, such as prostate and lung cancers, in different racial groups.
One could reasonably expect that as tissue banks and datasets grow — provided all racial and ethnic groups are proportionately represented — we will accumulate meaningful data relevant to these minorities that should inform our prevention, detection and treatment strategies.
Although that seems like a reasonable expectation, the reality may be quite different.
A study conducted by Spratt and colleagues of the racial distribution of samples included in The Cancer Genome Atlas (TCGA), published in JAMA Oncology, produced some disturbing results.
This study showed that, for the tumor types studied, the relative proportion of racial and ethnic minorities represented in the TCGA is roughly representative of the U.S. population.
However, the key to the utility of these analyses — and where the results are concerning — is the absolute number of samples. In only one example — black women with breast cancer — are there sufficient samples to detect a mutation with a frequency rate of 10%. By contrast, there are adequate numbers to meet this criterion for all 10 major tumor types represented in the white population.
The message from this study appears clear: Proportional representation of minority populations in genomic studies may have no impact on our understanding of the biologic heterogeneity of these tumors. Delivering the promise of genomic medicine to these populations may require overrepresentation in these datasets.
Trends in survivorship
The second example is a report from NCI of projected cancer survivors in the United States 2040.
Here again, the news appears good. Between 2016 and 2040, it is anticipated that the number of cancer survivors in the United States will increase from 15.5 million to 26.1 million. In what they describe as a “silver tsunami,” the researchers point out that 73% of these survivors will be aged 65 years or older. The comorbidity burden of these survivors is likely to be high, especially among those aged 85 years and older.
The increasing numbers of cancer survivors is a mark of the success of cancer management strategies. But, this reality will also pose major challenges of illness and symptom burden for patients, as well as workforce and resource management for health care services. Adjusting to this increased demand and addressing the health needs of this population is another issue that must be considered in any big-picture projects to advance cancer care.
Closing the gap
The third example is a provocative report and thoughtful editorial on cancer center advertising — perhaps the situation in which the potential for a gap between expectations and reality is highest. The study by Vater and colleagues explored trends in cancer center advertising from 2005 to 2014. It showed a marked increase in spending on advertising over that time, particularly on the internet.
There have been ongoing concerns that cancer center advertising can generate unrealistic expectations for survival or cure in our patients. Although not specifically analyzed in this study, previous studies suggest that this could be true in some instances.
The editorial accompanying this publication calls for more research and possibly increased regulation of cancer advertising. It may be too early to tell whether this is necessary or would help, but closing the gap between expectations and reality is a potential priority for the future.
Optimism for the future is central to the moonshot metaphor and to the entire program. We should all support the efforts to keep that optimism alive.
Not surprisingly, those affected by cancer may interpret that optimism very differently, and our responsibility to move this agenda forward enthusiastically needs to be tempered with a real-world understanding of the obstacles we need to overcome.
Managing expectations will be a work in progress as new knowledge emerges, and our ability to respond and “adjust the sails” will be essential to maintain the confidence of all those touched by cancer.
References:
Bluethmann SM, et al. Cancer Epidemiol Biomarkers Prev. 2016;doi:10.1158/1055-9965.EPI-16-0133.
Cancer Facts & Figures 2016. American Cancer Society. Available at: www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2016/. Accessed on July 12, 2016.
Schwartz LM and Woloshin S. JAMA Intern Med. 2016;doi:10.1001/jamainternmed.2016.3278.
Spratt DE, et al. JAMA Oncol. 2016;doi:10.1001/jamaoncol.2016.1854.
Vater LB, et al. JAMA Intern Med. 2016;doi:10.1001/jamainternmed.2016.0780.
For more information:
John Sweetenham, MD, is HemOnc Today’s Chief Medical Editor for Hematology. He also is senior director of clinical affairs and executive medical director at Huntsman Cancer Institute at University of Utah. He can be reached at john.sweetenham@hci.utah.edu.
Disclosure: Sweetenham reports no relevant financial disclosures.