#The fight against cancer faces daunting new challenge: debt politics

Even in times of federal budget tightening, cancer research has garnered bipartisan congressional backing, combining with private sector funding to fuel significant scientific progress in tackling the killer disease.

“Cancer’s escaped the political gravitational pull,” said Lawrence Gostin, a professor of global health law at Georgetown University Law School.

But this year could be different, as Democratic lawmakers and research advocates are raising the alarm that the new debt ceiling deal could dramatically curb future NIH spending growth. 

The legislation, which President Biden recently signed into law, keeps nondefense discretionary spending kept roughly flat for 2024 and gives only a 1 percent increase in 2025. Health agencies could see cuts to keep the government’s non-defense budget under $652 billion.

Sen. Tammy Baldwin (D-Wis.), chair of the Senate appropriations subcommittee in charge of funding the Department of Health and Human Services, said she has concerns the new budget constraints will have a negative impact on funding cancer research.

“The deal that was passed would lead to flat funding” for arguably the next two years, Baldwin told The Hill, adding that she anticipates putting together an appropriations bill will be “challenging” because of the caps. 

In the House, the top Democrat on the appropriations committee, Rep. Rosa DeLauro (Conn.), noted the level of non-defense spending in the cap is about $9 billion below current levels, so the money is going to have to come from somewhere.

“$9 billion is a cut. And so where does it come from? 12 appropriations bills,” DeLauro said.

But Republicans are playing down those concerns.

“I don’t see any reason why [the spending caps] would jeopardize that at all,” Rep. Mike Kelly (R-Pa.), co-chair of the House Cancer Caucus, said during an event on cancer care sponsored by The Hill. “You can’t outlaw cancer … But what you can do is, you can guarantee funding.”

Rep. Tom Cole (R-Okla.), a member of the Appropriations Committee who previously backed NIH as the leading Republican on the Labor-HHS-Education subcommittee, claimed that since Republicans have fewer spending priorities than Democrats, the NIH legislation won’t get bogged down with other issues. 

Still, he said he anticipates a tough appropriations process.

“I don’t think it’ll [NIH] be shortchanged, but I would expect the entire Labor-H [Labor, Health and Human Services] budget to be under a lot of pressure,” Cole said. 

President Biden has said he wants to build on the bipartisan progress in the fight against America’s No. 2 killer, and has made fighting cancer a priority of his administration by relaunching the “cancer moonshot.” 

The first iteration of the moonshot was created in 2016, at the tail end of the Obama administration when Biden was vice president. 

“We had a broad goal of speeding impact, speeding progress in anything that impacted patients. And a lot was done in that time. But it was the final year of an administration. And so we were in a sprint,” said Danielle Carnival, the White House moonshot coordinator.

Carnival said it helps to have a president who wants to prioritize cancer research, but changing administrations didn’t slow the work being done. The National Cancer Institute (NCI), which oversees the initiative, says it has already spent $1 billion on more than 240 research projects.

“It was important to have that carved out sustained funding, specifically for cancer moonshot initiatives,” Carnival said.

“We worked really hard with agencies and departments to make sure that even if there wasn’t a central White House office like there was in 2016, and there is now, focused on this effort, that the work continued and that collaboration continued” across the government, Carnival added.

Carnival said funding cancer research has always been a bipartisan effort, and she was not concerned Congress would shortchange it moving forward.

Last year, Biden announced his intent to “supercharge” the moonshot with a plan to reduce the death rate from cancer by at least 50 percent over the next 25 years.

Biden also asked Congress to reauthorize the National Cancer Act, which officials said would help build new clinical trial networks and modernize data collection in order to improve detection and treatment. 

The moonshot provides a significant injection of funding, but it also aims to go beyond research of treatments and drugs.

Carnival said the new plan emphasizes the role that the public can play by getting back to cancer screenings missed during the pandemic, quitting smoking, and participating in trials.

The administration in April released its National Cancer Plan to “end cancer as we know it,” a roadmap for the moonshot and call to action to improve all facets of cancer care.

The plan emphasized eight specific goals, including eliminating inequities in prevention, treatment and even research. 

Cancer is extremely well funded, especially compared to other diseases and public health threats. The federal government, drug companies and nonprofits have poured hundreds of billions of dollars into the effort. 

But there’s concern about how it is being spent. Some of the most well-funded cancers are the most survivable, while cancers that are the most lethal receive the least amount of research money.

“You will have certain cancers that have extraordinarily high profiles and there’s a lot of public support to amply fund them. And I think Congress and even the NIH is sensitive to that. So there’s a real correlation between advocacy, public clamoring for a particular disease and Congress’s and NIH’s support,” said Gostin, who is also a member of the National Cancer Institute’s National Cancer Advisory Board.

“All things being equal, funding should reflect the actual burden of disease. And that funding should go to things that cause the most harm to the most people, rather than any political calculation or things that tear [at] the heartstrings,” Gostin said.

Cervical, ovarian, and uterine cancers have consistently ranked near the bottom in funding from the National Cancer Institute. Experts have said the impact of that can be seen in fewer clinical trials available to patients, and decreased trial enrollment in the ones that are available, resulting in a lower number of high-level treatment options.

For example, NCI funded just under $121 million in ovarian cancer studies in FY 2018, the most recent data available. Breast cancer meanwhile received nearly $575 million. The disparities in money will make it difficult, if not impossible, for research into those underfunded cancers to catch up.

Suneel Kamath, a GI medical oncologist at the Cleveland Clinic who has researched funding disparities in cancer, said the federal government, and the cancer moonshot specifically, can step in to try to reverse the longstanding inequities. 

“Your research into difficult to treat diseases is not going to be a five year plan, you know, it’s going to be 20 and 30 year investment, and I think that’s something that a federal agency can do, whereas private entities, if they’re not getting enough return on investment in a certain period of time, that money might dry out for them,” Kamath said. 

The federal government supplies much of the money for basic, early-stage research, and then usually hands it off to the private sector to fund the development of treatments and taking them through late-stage clinical trials and eventually a submission to the Food and Drug Administration.

The pharmaceutical industry has an incentive to put money into lucrative therapies and treatments, which can skew the investments into specific cancers. 

A study from last year found that among 10 of the world’s largest pharmaceutical companies, revenues generated from the sale of cancer drugs increased by 70 percent from 2010 to 2019, to $95.1 billion.

Ezekiel Emanuel, an oncologist, professor at the University of Pennsylvania and former White House adviser, said industry has a bias but he doesn’t necessarily see an overreliance on industry money in research.

The government can shape research priorities with incentives like orphan drug designation and pediatric exclusivity. Agencies just have to make sure companies don’t exploit them.

“Drug companies do something really important. I don’t want to minimize what they do. That doesn’t mean you pay a king’s ransom for what they do,” Emanuel said.

Research funding is well aligned with incidence rates — how commonly a disease affects people — but it’s very poorly aligned with mortality rate, Kamath said. 

A more significant factor is the success of early research and trials. “If the win is going to be, you know, very delayed or may not occur at all, that does detract funding and then it becomes this kind of feed forward cycle unfortunately,” Kamath said. 

If initial outcomes are poor, that particular disease won’t get the money needed in order to better understand it and develop something that will make an impact and reverse the cycle. 

“From a federal and governmental perspective, that’s an opportunity to plug that hole. We don’t have to have the same ROI in a short period of time,” Kamath said. 

“We can choose to say, this matters to the people in our society and our community. We’re going to keep funding this even though you know, we’re not getting the dividends yet. Because it matters.”