In his 1971 State of the Union Address, President Richard Nixon announced that he would ask Congress for $100 million to find a cure for cancer. “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,” he said. “Let us make a total national commitment to achieve this goal.”
Nixon’s initiative resulted later that year in the National Cancer Act, which is now considered the starting point for the so-called war on cancer. It established the National Cancer Institute as part of the federal government and got the ball rolling on a number of important fronts, from establishing funding and spearheading research to building patient registries and even destigmatizing cancer in the public mind.
We’ve come a long way. Since then, we’ve learned much more about the disease, made significant strides in terms of detection and treatment, and successfully reduced certain cancer-causing behaviors, such as smoking. And with Joe Biden as President, the Cancer Moonshot program, which Biden established during the Obama administration, could once again make cancer a White House priority.
Still, nearly a half-century later, cancer remains the second-leading cause of death worldwide and is projected to become the first. About one in three women and one in two men can expect a diagnosis in their lifetimes, and the current death toll includes 600,000 Americans annually. While two vaccines for the novel coronavirus were developed and approved by the FDA in a little less than a year, a cure for cancer has remained so elusive for so long that it’s become something of a self-deprecating punchline in response to a compliment (“Thanks, but I’m not exactly curing cancer here”). As we approach the war on cancer’s 50-year mark, why has this disease been such a tough nut to crack?
THE PARADOX OF MEDICAL PROGRESS
“One of the reasons is that cancer is not one disease—it’s actually hundreds of different diseases,” says Dr. Deborah Schrag of the Dana-Farber Cancer Institute and Harvard Medical School. “Some cancers are caused by viruses, like the HPV virus, which causes cervical cancer. Others are related to tobacco, like lung cancer; or obesity, like pancreas cancer; and so on. There are so many different risk factors and pathways that lead to many different diseases. So even though we often refer to cancer as one condition, it’s really an umbrella term.”
An additional complicating factor, ironically, is that medical progress in other areas, especially involving heart attacks and other forms of coronary disease, has extended human lifespans to the point where people now develop higher risks for cancer simply by virtue of living longer. “The cardiologists save their patients, and then they become the oncologists’ patients,” Schrag says. “Ultimately, our goal is to pass all that business along to the geriatricians.”
A GAME-CHANGING DEVELOPMENT
The biggest hurdle, medical professionals agree, has been that early-screening procedures are currently available in the U.S. for only five types of cancer that comprise just 29% of all cancer deaths: PSA tests for prostate cancer; colonoscopy for colorectal cancer; mammography for breast cancer; pap smears for cervical cancer; and low-dose CT scanning for people at high risk for lung cancer.
“For those five cancers we can screen for, we generally detect them at much earlier stages, when they’re easier to treat,” says Dr. Eric Klein of the Cleveland Clinic. “The dozens of other cancers, which have no screening tests, tend to present at more advanced stages, when they have spread past the organ of origin, so the burden of treatment is higher.” That results in treatment regimens that are costlier, more cumbersome for the patient, and—most important—less successful.
But a new screening test called Galleri, developed by the healthcare company GRAIL, could be a game-changer. Instead of looking for cancers one at time, organ by organ, Galleri uses a single blood test to detect more than 50 different types of cancer and help identify their locations, potentially allowing doctors to address the disease while it’s still in its early, more treatable stages. Galleri is intended to be ordered by the patient’s primary care physician, and the blood sample can be drawn during a routine office visit, making it much more convenient than other types of cancer screening.
Galleri works by detecting DNA fragments that cancer cells shed into the bloodstream. Scientists have long known about these fragments, but until recently, were unable to screen for them. “The technology has now advanced to the point where it’s possible to detect really minute amounts of that DNA and get rid of all the background noise of all non-cancer-related molecules in the blood,” Klein says.
Schrag views blood-based testing as the next major stride in cancer detection. “I think the best analogy is the development of CT scans,” she says. “When scans and imaging came on the scene, we were able to move away from just relying on physical exams and detect smaller cancers sooner, before people were symptomatic. Blood-based assays such as Galleri can allow the same thing, but for multiple types of cancers. It’s like one-stop shopping.”
GRAIL envisions that absent other risk factors, people would undergo annual Galleri screening when they reach 50 (the same age when most people are now advised to have a colonoscopy). The potential benefits are eye-opening: The company’s models estimate that by adding Galleri to diagnosis by usual care, there is the potential to reduce late-stage (stages III and IV) cancer diagnoses by more than half in the U.S. among people aged 50-79. This decrease in late-stage diagnoses could translate to a reduction in five-year deaths by 39% due to earlier detection.
The really good news? Galleri is scheduled to become commercially available in Q2 of 2021. “I would hope that Medicare and private insurers would embrace it and cover it,” Klein says. “The downstream benefits, in terms of earlier diagnosis, higher cure rates, getting people back to work quicker, and so forth, will be significant.” There would also be major financial savings in terms of costlier late-stage treatments that would no longer be needed.
It remains to be seen whether Galleri will help us finally win the war on cancer, but the early signs are promising. “I really think that this approach is going to revolutionize how we screen for cancer,” Klein says. “And the bottom line is, when it’s caught early, it’s easier to cure.”