Reflecting on the golden age of cancer research

q&a Reflecting on the golden age of cancer research 50 years after the National Cancer Act was signed into law, Nature Cancer spoke with the National Cancer Institute Director Dr Ned Sharpless about the progress in cancer research and care, the complications of the pandemic and what to expect in the future. ■■The National Cancer Act (NCA) was signed into law 50 years ago. What were the milestones in cancer research in the last 50 years? NS: The 50th anniversary of the NCA is a good time to be having this discussion. The NCA did not create the National Cancer Institute (NCI)— the NCI dates to the 1930s — but, in some ways it created the modern NCI, by providing funding that allowed us to support more science, and by providing for new authorities and capabilities, such as the Frederick National Laboratory and the Surveillance, Epidemiology, and End Results (SEER) program, which is the most widely used database of cancer statistics. The Cancer Center program also existed before the NCA, but the NCA really made it into the modern-era Cancer Center program. It also created the modern National Clinical Trials Network that we have in the United States for cancer research. Most importantly, the NCA made cancer a disease we could talk about as a nation. It removed a lot of the stigma surrounding cancer and changed it into something that politicians and advocates would speak about emphatically. You could also say that the NCA introduced modern cancer advocacy in the United States. In some ways the NCA was very visionary. It created a great foundation for future cancer research through its broad reach and scope, the funding capabilities it provided, and the path it paved for advocacy. In other ways, though, it was also quite naive — primarily in its understanding of the molecular biology of cancer. For example, some in the cancer community, including Sidney Farber, had told President Nixon that we could have a cure for cancer in five years. That would have been by 1976, and of course that didn’t happen, because back in 1971 we did not know what we did not know about cancer. Over the past 50 years we have filled in that knowledgebase through detailed basic and translational science that has given us a very good understanding of the biology of cancer. Now we know where the gaps are that we still need to fill, to make progress. We understand that cancer is not one disease, but that each cancer, in some ways, is almost unique to the patient, and that to really make progress, one has to approach each cancer as a unique entity. Credit: National Cancer Institute (NCI) Appreciating the heterogeneity of cancer and understanding the driver events that underlie each cancer has been a major development in the past 50 years that has allowed us to now talk about ending cancer as we know it, as President Biden has stated. ■■Would all this have been feasible in the absence of the NCA? NS: How would cancer research have fared without the NCA? We don’t know. But if you read the work of individuals involved at the time, and then talk with people who have followed the work of the NCI since, there is a strong feeling that the legislation transformed cancer research nationally. I’m talking about capabilities such as SEER and the Cancer Center network, both unique biomedical research tools that only exist in their purest form as tools for cancer research. That can largely be ascribed to the NCA and in that sense, I think it’s fair and accurate to say cancer research would not have been nearly as successful had the NCA not been passed into law. One piece of evidence that cancer research has proceeded at a steady pace is the excitement Nature Cancer | VOL 2 | December 2021 | 1271–1275 | www.nature.com/natcancer around cancer therapeutic agents and device development, the massive increase in cancer-relevant FDA approvals, the many new ideas for clinical trials and approaches to treating and diagnosing cancer. At the NCI we’re inundated with applications, with requests for funding having doubled since 2013. I think that is because scientists from disparate disciplines are converging on the NCI with great ideas from disciplines such as physics and mathematics, computer science and health services research, nursing and pharmacy, just to name a few, because there is a feeling that we can make considerable progress given our very sophisticated understanding of this disease. Cancer is leading the way in biomedicine and that success, which is evident today in so many ways, is attributable to the NCA. ■■Do you think that the NCA shaped the NCI in a different way than what might have been without it? NS: A way to consider that question is by looking at what is different at the NCI compared with other National Institutes of Health (NIH) institutes that didn’t have 1271 q&a anything equivalent to an NCA. One of the most obvious differences is that, unlike at other institutes, the Director of the NCI is a presidential appointee. That has pluses and minuses, as it assures that the NCI Director’s position changes a lot more. For example, Anthony Fauci has been running the National Institute of Allergy and Infectious Diseases (NIAID) for nearly 40 years, and I’m the seventh NCI Director that he’s worked with. In addition, the framework now known as the National Clinical Trials Network doesn’t exist to the same extent for non-cancer disease areas, and that was enabled by the NCA. The Cancer Center program is also very different, which was surprising to me when I started at NCI. As an academic, I thought that there must be similar centers for other diseases and that the cancer centers were the cancer-specific version of the NIH Center grants, but that is not the case. The center programs of other NIH institutes are much smaller in scope, not organized in the same way, and are more like program project grants. The NCI Cancer Center program has the attention of Congress and was essentially created by federal statutes. Centers wanting to demonstrate a certain standard in cancer research can pursue NCI designation and medical institutions advertise whether or not they have NCI designation. As an example, the state of Oklahoma passed a state law about 20 years ago that asked the University of Oklahoma to seek NCI designation. Because of this desire to have an NCI designated center in the state, they worked for 17 years, raising approximately US$400 million from philanthropy, state funding and other sources to build the Stevenson Cancer Center that now exists in Oklahoma. So, the Cancer Center grant is a program like no other across the United States, and it was created by the NCA. ■■You mentioned that the NCA was visionary, but perhaps a bit naive. President Nixon at the time had stated that “the time has come in America when the same kind of concentrated effort that split the atom and took man to the Moon should be turned toward conquering this dread disease”. 50 years from that, how close are we to conquering cancer? (...truncated)