Richard J. Boxer, MD, FACS
Fifty-two years ago, President Richard Nixon signed the National Cancer Act of 1971 into law, which established the National Cancer Institute (NCI) in its current form. At the time, the budget was $1.6 billion. Today, it is $7.8 billion, $4.5 billion less than the amount needed to keep up with inflation. Even if President Joe Biden’s 2024 budget allocation of $7.8 billion for the NCI, plus $2.5 billion for the Advanced Research Projects Agency for Health (ARPA-H) to help deliver on the Cancer Moonshot goals,1 is enacted, it will fall short of inflation by at least $2 billion.
Funding increases in 2023 for the NCI allow the agency to raise R01 paylines to the 12th percentile, compared with the 11th percentile in fiscal year 2022 (FY2022),2 but that still means that 88 of 100 research projects will go unfunded. This is crippling for the future of patients with cancer, cancer cures, and young investigators. I am a three-time survivor of different cancers and owe my life to brilliant scientists’ basic research and courageous patients who participate in clinical studies.
America can and must do better.
Funding Basic Research
The NCI has received about $160 billion since 1971, funding the discoveries of investigator-initiated basic science and advances through clinical trials. The result is that mortality rates have dropped for 12 of 15 cancer sites, including lung, oral cavity, and bladder cancers, largely because of reductions in smoking through education and public health measures, screening, and advances in research.3 Increased access to care through the Affordable Care Act, screening, and early detection may also have contributed to more recent declines. Lack of progress in parts of the South largely reflects unequal dissemination of the above. Yet, mortality rates have increased for pancreatic cancer, and progress has been limited in esophageal and brain cancers.3
Research shows that people living in low- and middle-income counties in the United States are more likely to die of cancer compared with those living in high-income counties. The disparities can be explained by examining eight factors, principally income, food insecurity, and risky health behaviors.4
Although the annual economic burden of cancer is approximately $210 billion,5 just 1% of the federal budget goes toward science and medical research.6 Considering the impact cancer has on our lives, that seems relatively paltry.
Now let’s get serious. Increasing funding, improving access to health care, and applying technology will certainly reduce the cancer burden. The generous American taxpayer who funds the NCI deserves both thanks and the best that science and medicine have to offer.
President Biden quotes an expression his Dad often used: “Don’t tell me what you value. Show me your budget, and I’ll tell you what you value.”7 In 2021, the NCI spent 42.3% of its $7.3 billion budget on more than 5,000 research project grants.8 In President Biden’s 2024 budget, billions of dollars more are designated for cancer prevention, treatment, and education programs in other federal departments, including the Environmental Protection Agency, the Department of Defense, the Department of Veterans Affairs, and the Centers for Disease Control and Prevention.1 However, looking at funding for pure basic and clinical research, the NCI Intramural Research Program (IRP) receives just 16% of the total budget, a reduction of 9% since 1995, when it was 25%.
The benefit of IRP is that remarkable discoveries in basic science and patient care occur. The challenge is to apply those clinical discoveries or treatments to the broad population of patients with cancer within the United States. A demonstration of the remarkable benefit of the IRP is Dr. Douglas Lowy’s team’s creation of the vaccine against the virus that causes cervical cancer.
Among the most important contributors to developing a knowledge base that will reduce the cancer burden in the United States is the NCI’s Extramural Research Program, which comprises 72 centers of excellence and receives 84% of the research grants of the NCI. In 2022, 50 states, 2 territories, and 17 countries received extramural research grants.9 This is the engine and “mother’s milk” of discovery.
Discovering the Next Generation of Cancer Treatments
The NCI is a jewel in the crown of the National Institutes of Health. Its sole purpose is to discover preventions, treatments, and cures for cancer. The scientists and clinicians who are funded through the NCI dedicate their careers to improving patient outcomes. Future scientists and clinicians must be encouraged to pursue their work through NCI grants. And cancer centers must have increased NCI funding to discover the next generation of medicines, train our future scientists and clinicians, and afford to launch clinical trials.
It is in the national interest to maximize participation in cancer clinical trials. The knowledge obtained today brings cures tomorrow. Hospitals are much more likely to participate in cancer clinical trials if they do not lose money recruiting patients for enrollment.
Despite this need, funding for clinical trials has been drastically reduced from nearly $900 million in 2018 to $200 million in 2020. Hopefully, the FY2024 budget will include more money targeted for cancer clinical trials. To incentivize cancer centers to recruit more patients, additional funds must be provided.
Getting Creative to Increase Research Funding
Although budgetary concerns are real and important, there may be a method for increasing research in cancer prevention, treatments, and cures and not materially raising the budget. For example, in 2007, Texas voters overwhelmingly approved the creation of the Cancer Prevention and Research Institute of Texas (CPRIT), modeled after California’s stem cell research bonds, aimed at funding the best cancer research and prevention opportunities in the state. Today, CPRIT is a $6 billion initiative that awards grants for a wide variety of innovative cancer-related research and product development as well as for the delivery of evidence-based cancer prevention programs and services by public and private entities in Texas.10
Why not establish a type of U.S. Treasury Bonds for cancer research? Billions of dollars could be raised, and the obligation would likely be only the interest amount paid.
Reducing Inequities in Cancer Care
I have been a medical director of a federally qualified health center, which serves medically underserved areas and patient populations, and have witnessed the inequities of cancer care. The lack of access to cancer care for underserved patients has caused unnecessary cancer deaths. It adds terrible insult to catastrophic injury for a patient or loved one to know that treatments or cures are available, but not to them because of access or cost. Neither the lack of health insurance nor economic status should dictate the outcome of a diagnosis of cancer.
In 2001, the NCI established the Center to Reduce Cancer Health Disparities to help reduce the unequal burden of cancer in our society. But the problems persist, and more must be done.
Since 1946, Veterans Administration (VA) hospitals have partnered with medical schools to bring the brightest physicians to care for our veteran heroes. There are currently 1,298 health facilities, including 171 VA medical centers, and 1,113 outpatient sites to cover more than 9 million veterans enrolled in the VA health-care program.11 Why not have our medical schools partner with the 1,400 federally qualified health centers around the country to improve care for marginalized patients with cancer? The University of California at Irvine and the University of North Carolina have successful programs partnering with federally qualified health centers and should be models for the nation.
Expanding Knowledge Through Technology
Technology has and will continue to expand our knowledge and care of cancer. I helped create the clinical standards for telemedicine 17 years ago, changing the way health care is delivered and bringing affordable access to quality care. We are just scratching the surface of the possible ways in which technology may expand our knowledge of cancer. Artificial intelligence will increase our research capabilities and ability to target therapy, which will usher in an entirely new era of treatments. Computer-aided cancer screening, sensor-based detection, biomarker detection, cancer prediction and cancer treatments through drug discovery and repurposing, clinical decision support systems, assisted surgery, radiation therapy, and cell programming are just a few areas of research that are already being engaged.
Patient Care Not Paperwork
Grant applications have become extraordinary in time and expense. A Cancer Center Director recently told me that to maintain their NCI designation, a 2,500 page NCI reviewed document requires minimally several thousand person-hours including 35 writing groups, consultants and graphic designers on retainer going full steam devoted to preparing and writing the grant for a year, instead of doing cancer research or caring for people with cancer. And that is only the application; the review process by our brilliant scientists consumes hundreds of hours. Multiply this by the 72 centers, time and millions of dollars consumed take away from the principal goal of preventing, treating, and curing cancer.We must do better.
Preparing for the Future
The NCI has had spectacular success in promoting and funding prevention strategies, treatments, and cures of cancers. The FY2024 NCI budget and future budgets should specifically include increasing funding for clinical trials, research in technology, and the underserved through federally qualified health centers. Funding for NCI research project grants should be increased to more than 42%, and R01 paylines should be increased at least 25%.
The past and present have prepared the NCI for the future. By increasing funding to catch up with inflation, creatively increasing research funding through bonds, partnering medical schools with federally qualified health centers, and exploiting technology (especially artificial intelligence), the NCI will fulfill the promise of President Biden’s Cancer Moonshot goals to reduce the cancer burden in the United States by 50% in the next 25 years.1
DISCLOSURE: Dr. Boxer has served as a consultant at Pager, Intercept Telehealth, and UpScript.
REFERENCES
1. The White House: Fact Sheet: President Biden’s budget accelerates progress toward the goal of ending cancer as we know it. March 9, 2023. Available at https://www.whitehouse.gov/ostp/news-updates/2023/03/09/fact-sheet-cancer-fy24. Accessed July 31, 2023.
2. National Cancer Institute: NCI funds more research grants thanks to action by Congress. February 6, 2023, by NCI Director Dr. Monica Bertagnolli. Available at https://www.cancer.gov/grants-training/nci-bottom-line-blog/2023/nci-funds-more-research-grants-thanks-to-congress. Accessed July 31, 2023.
3. American Cancer Society: New analysis from the American Cancer Society shows large declines in cancer mortality since 1971 passage of National Cancer Act. November 11, 2021. Available at https://pressroom.cancer.org/waroncancer. Accessed July 31, 2023.
4. National Cancer Institute: Eight factors may link disparities in cancer death rates and income. November 8, 2018, by NCI Staff. Available at https://www.cancer.gov/news-events/cancer-currents-blog/2018/factors-linking-cancer-death-income-disparities. Accessed July 31, 2023.
5. National Cancer Institute: Cancer Trends Progress Report: Financial Burden of Cancer Care. Available at https://progressreport.cancer.gov/after/economic_burden. Accessed July 31, 2023.
6. Center on Budget and Policy Priorities: Most of the budget goes toward defense, Social Security, and major health programs. Available at www.cbpp.org/most-of-the-budget-goes-toward-defense-social-security-and-major-health-programs. Accessed July 31, 2023.
7. The White House: Remarks by President Biden announcing the Fiscal Year 2023 budget. March 28, 2022. Available at www.whitehouse.gov/briefing-room/speeches-remarks/2022/03/28/remarks-by-president-biden-announcing-the-fiscal-year-2023-budget. Accessed July 31, 2023.
8. National Cancer Institute: NCI Budget Fact Book. Available at www.cancer.gov/about-nci/budget/fact-book. Accessed July 31, 2023.
9. National Cancer Institute: Grant and Contract Awards. Available at https://www.cancer.gov/about-nci/budget/fact-book/extramural-programs/grant-contract-awards#grant-contract-by-state-institution. Accessed August 8, 2023.
10. The State of Texas: Cancer Prevention & Research Institute of Texas. Available at www.cprit.state.tx.us/about-us. Accessed July 31, 2023.
11. U.S. Department of Veterans Affairs: Veterans Health Administration. Available at www.va.gov/health/aboutvha.asp#:~:text=The%20Veterans%20Health%20Administration%20(VHA,Veterans%20enrolled%20in%20the%20VA. Accessed July 31, 2023.
Dr. Boxer is Clinical Professor, David Geffen School of Medicine at the University of California, Los Angeles, and Member, National Cancer Advisory Board.
