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Targeting the Cancer Moonshot.

Recently, the Obama administration announced the launch of a “moonshot” approach, led by vice president Biden, to finding a cure for cancer and reducing cancer mortality in the United States. Although preliminary communications about the plan mention the development of new vaccines to prevent cancer, the moonshot approach has generally been framed as a search for a cure for cancer, with increased investment in promising therapeutic approaches such as immunotherapy and the creation and sharing of data to simplify the search for personalized medicine and genomic markers that would permit customized therapies.1 While we believe these goals to have merit, we believe that they show a limited view of the overall problem of reducing cancer mortality and are shortsighted with respect to the lessons of history. Cancer mortality has fallen by about 15% since the War on Cancer began,2 and, indeed, there have been some important and notable cures for certain types of cancer over the past 45 years, such as many pediatric cancers, Hodgkin disease, and testicular cancer, and the development of adjuvant therapy as an adjunct to surgery for some of the common epithelial cancers. However, these are responsible for only a small fraction of this improvement in mortality. To appreciate the overall successes in cancer, a longer and broader view of medical progress from fields outside of cancer is necessary. Infectious diseases, for example, have always been the major threat to our health. Even as late as 1900, the life expectancy of an American was only 42 years, due in large part to infectious diseases. Beyond antibiotics—perhaps the most important set of curative drugs ever discovered—the real advances against infectious diseases resulted from improvements in sanitation—removing sewage from the fresh water supply and washing our hands before eating—and immunizations. This is fundamental public health, and history shows that it is effective. Chronic diseases such as cardiovascular heart disease, renal failure, chronic obstructive pulmonary disease, diabetes, and cancer arose as major medical problems after World War I as the life span improved, and to this day, we really have little in the way of cures for any of them—hence the label “chronic.” Most of our treatments are intended to control the potential damage and symptoms caused by these ailments, such as insulin for diabetes or dialysis for renal failure. Nonetheless, cardiovascular disease mortality, the leading cause of mortality in the latter half of the 20th century, has fallen by 60%—thanks in large part to the tools of prevention, such as blood pressure and lipid control, tobacco cessation, exercise, and aspirin.2 The true successes of cancer research, similarly, have been made in prevention. Lung cancer remains the leading cause of cancer mortality worldwide, but lung cancer mortality among men is plummeting in the United States.3 This is not because of new cancer treatments, some of which cost over $150 000 in return for tiny improvements in survival. It is because the smoking rate is less than one-third of what it was 2 generations ago. The rates of other tobacco-related cancers, such as squamous cell carcinomas of the esophagus, head and neck cancer, and bladder cancer, are decreasing as well. In fact, while the overall cancer death rate has decreased from approximately 200 to 165 deaths per 100 000 population, the variation across states today is greater than the overall improvement in mortality over the past 40 years: the cancer mortality rate varies as much as 30% across states and is strongly associated with state-level tobacco use (Figure).4,5 Improvements in cancer mortality are much more likely to be brought about by lowering a state’s smoking rate than by focusing exclusively on a search for cures. Other cancer success stories further underscore the power and efficacy of a focus on prevention. Gastric cancer used to be the leading cause of cancer mortality in the United States prior to World War II. Now, thanks to the widespread use of refrigeration, which permitted the safe and regular eating of fresh meats, fruits and vegetables and a reduction in the consumption of smoked and cured foods that contain carcinogenic nitrites and nitrates, it is not even in the top 10 for either men or women.6 Since its introduction after World War II, the widespread use of Papanicolaou screening has led to an 85% reduction in the incidence of cervical cancer, once the most common cause of cancer death in women.3 Even better, the new human papillomavirus vaccine has the potential now to wipe out the disease completely. Yet another cancer prevention success story is colorectal cancer; screening, especially with colonoscopy, has led to a 35% fall in the incidence of colorectal cancer since its peak in 1985, with the decrease continuing to accelerate as screening increases.3 History tells us that prevention has been the most successful approach to the control and eradication of most of the important diseases of mankind. To be sure, the strategy of the new moonshot approach is still being developed. Yet preliminary announcements suggest that the primary focus will likely be on developing new treatments and cures rather than on prevention. Given the focus of cancer research efforts in the past, this would not be a surprise. But it would clearly be a mistake. Careful attention should be paid to the balance of treatment vs prevention-related efforts. While research into treatment is essential, we should increase our efforts to define how obesity prevention, physical activity interventions, medical therapies, and control of VIEWPOINT