Cancer moonshot 2.0: A missed opportunity for prevention

President Biden’s new initiative to “reignite the cancer moonshot” proposes the laudable goal of cutting the cancer death rate in the United States in half in the next 25 years, but misses the opportunity to advance the strategies that could achieve that target.

Noting that the Covid-19 pandemic has claimed nearly 900,000 lives in the last two years while cancer has killed more than 1.2 million Americans in the same period, Biden called for a new sense of urgency in making progress in reducing the burden of cancer.

For the more than 50% of American families who have had someone in their immediate family diagnosed with cancer and the 40% of individuals who can expect a diagnosis of an invasive cancer in their lifetimes, progress in creating new and earlier tests, more effective and affordable treatments, and better insurance coverage will be welcome. And for the president and Congress, finding bipartisan consensus on reducing a problem that brings suffering, death, and high costs to so many Americans and the U.S. economy could help restore declining faith in government’s ability to solve problems.

But like the many other declarations of war against cancer since President Richard Nixon signed the National Cancer Act in 1971, Biden’s moonshot proposal, motivated in part by his family’s own experiences with cancer, should be bolder, more comprehensive, and contribute more to improving the health of the American people. Understanding why the president proposed such a modest initiative illuminates the deeper limitations of public health policy in the U.S. today.

What are the shortcomings in Biden’s proposal? First, he proposed no additional funding for this moonshot. If the United States is to “end cancer as we know it,” as the president vowed, it will require strategic investments in prevention, screening, and treatment. In the absence of a plan to get congressional approval for such investments, this moonshot is an appealing vision, not a practical plan.

Even more, the very concept of a moonshot against cancer is problematic. Reducing the toll from cancer is not a narrow technical problem. More than 200 forms of cancer have been identified, with many subtypes, and different causes and treatments. Furthermore, cancer is deeply rooted in our social, economic, and political systems, shaped by what we eat, drink, and smoke; how pollutants are spread and regulated; carcinogenic exposures in the workplace; and how we deliver and pay for drugs and health care.

As cancer researcher Sol Spiegelman observed at the start of Nixon’s war on cancer, “An all-out effort [to find a cure for cancer] at this time would be like trying to land a man on the moon without knowing Newton’s laws of gravity.” Fifty years later, much more is known about cancer but many types of cancer still lack effective treatments or cures and research on prevention has yet to be a priority.

Framing the solution to controlling cancer as a moonshot reinforces the reductionist, corporate-influenced view of science and technology that has dominated American health policy since World War II. It is a view that neglects prevention, ignores complexity, and fails to acknowledge that powerful sectors of U.S. society benefit from a status quo that produces recurrent health crises such as the Covid-19 pandemic, the climate emergency, and persistently high rates of cancer. The moonshot metaphor also encourages scientists, policymakers, advocates, and businesses who appeal for public and private funds to support the effort to exaggerate its successes and prematurely claim seeing the proverbial light at the end of the tunnel.

What might a meaningful effort to reduce the burden of cancer include? First, it would make prevention a priority, a domain mostly ignored in the moonshot proposals. Researchers estimate that 20th century tobacco-control programs and policies were responsible for preventing nearly 800,000 lung cancer deaths in the U.S. between 1975 and 2000. Another striking accomplishment has been the drop in disparities in cancer death rates between Black and white Americans, falling from a peak of 33% higher in Black people that white people in 1993 to only 14% higher in 2016, an accomplishment largely due to declines in smoking rates among Black teens. This success shows the promise of public health strategies to reduce cancer inequities compared to the lack of progress in shrinking gaps in access to and quality of cancer treatment for Black people, goals emphasized in the recurring moonshot proposals.

It took decades of research and a concerted mobilization of citizens, elected officials, and health professionals to reduce the cancer toll from tobacco. Could targeting other industries whose marketing, production, labor, and environmental practices contribute to cancer lead to similar results?

Up to 40% of cancers could be prevented by reducing the consumption of highly processed foods, high-calorie diets, and certain fats, increasing consumption of fresh fruits and vegetables, and getting people to be more physically active. Alcohol consumption increases the risk of several types of cancer and accounts for 19,500 cancer deaths a year. Air pollution is a major cause of lung cancer and may also increase bladder and breast cancer. And one study found that pollution in U.S. drinking water could have caused 100,000 cancer cases between 2010 and 2017.

But neither Biden nor previous cancer warriors have suggested comprehensive policies to prevent cancer by strengthening regulation of the carcinogenic practices of multiple industries.

Making prevention the priority, or targeting industries that contribute to cancer, could jeopardize elite support for the war on cancer, a prerequisite for continued public and private funding for research, philanthropic contributions, and the favorable media coverage essential for the public’s support of any war.

In the United States, corporations and their allies increasingly reject policies that jeopardize their profitability or political power. By accepting the political status quo that allows businesses to veto public health measures they dislike, elected officials are forced to propose only those approaches that can win corporate support. As shown by the flawed response to the Covid-19 pandemic, the failure to enact forceful policies to reduce climate change, and the narrow approach of the “””cancer moonshot,””” this defect in our democracy leads to missed opportunities for saving lives and reducing health inequities.

What approaches to cancer control might lead to better results? In today’s economy, as scholar Anne Pollock has observed, “the pay structure at present does not provide financial incentives to find a cure for cancer.””” Drug companies profit by selling exorbitantly expensive drugs to the few who can pay for these treatments. They market niche cancer drugs to those who can afford them, even after the development of these drugs has been subsidized by federal funding. Despite the fact that 80% of cancers seem to be caused by extrinsic factors, relatively little research has focused on the biological, social, or political interventions that could reduce such exposures.

The human costs of allowing businesses rather than scientists and doctors to shape cancer research are high. By pursuing cancer treatment options that are the most profitable rather than the most effective for the largest number of people, the medical enterprise misses opportunities to make more substantial progress. Today, as in the past, Black Americans, low-income Americans, and women continue to experience poorer survival rates, less access to the most effective treatments, and more inappropriate cancer screening tests. In fact, many of the recent advances in treatment for breast cancer and liver cancer have widened rather than closed these gaps because of racial/ethnic differences in treatments and access to care.

By proposing additional measures to make prevention the priority, tackle commercial determinants of cancer, and avoid the technological quick fix suggested by war and moonshot metaphors, those seeking to reduce the burden of cancer can develop more effective and equitable approaches.

Nicholas Freudenberg is a professor of public health at the City University of New York and the author of “At What Cost: Modern Capitalism and the Future of Health” (Oxford University Press, March 2021).