This is an unprecedented time in our history. In the cancer field, transformative research and technological innovation are driving astounding progress against the collection of diseases we call cancer. Unfortunately, our ability to continue the rapid pace of this progress is in jeopardy because of the enormous global public health challenge posed by the Coronavirus Disease 2019 (COVID-19) pandemic.
As the first and largest professional organization in the world dedicated to advancing every area of cancer research, the American Association for Cancer Research (AACR) is dedicated to increasing public understanding of cancer and the importance of medical research for saving lives. It is also committed to advocating for increased annual federal funding to government entities that fuel progress against cancer and improve public health, in particular the National Institutes of Health (NIH), National Cancer Institute (NCI), U.S. Food and Drug Administration (FDA), and Centers for Disease Control and Prevention (CDC).
The annual AACR Cancer Progress Report to Congress and the American public is a cornerstone of the AACR’s educational and advocacy efforts. This tenth edition of the report highlights how research continues to extend and improve lives, like the lives of the courageous individuals featured in the report who have shared their experiences with cancer. It also underscores how the COVID-19 pandemic has negatively affected cancer science and medicine, as well as how unwavering, bipartisan support from Congress, in the form of robust and sustained annual increases in funding for the NIH, NCI, and FDA, is vital if we are to accelerate the pace of progress against cancer for the benefit of families everywhere.
Cancer in 2020
Research is the backbone of progress against cancer because it spurs the development of new and better approaches to preventing, detecting, diagnosing, treating, and curing some of the many diseases we call cancer. These advances are driving down overall U.S. cancer incidence and death rates and increasing the number of children and adults who are surviving longer after a cancer diagnosis. For example, the age-adjusted overall U.S. cancer death rate declined by 29 percent from 1991 to 2017, which is the last year for which these data are available. In addition, the U.S. 5-year relative survival rate for all cancers combined rose from 49 percent for people diagnosed in the mid-1970s to 70 percent for those diagnosed from 2010 to 2016.
Even though we are making significant progress, cancer continues to be an enormous public health challenge around the world. One challenge is that the number of new cancer cases is projected to increase dramatically in the coming decades, with the rise in the United States alone projected to be from just over 1.8 million in 2020 to more than 2.3 million in 2040. This sharp increase is anticipated largely because of overall population growth and because the segment of the U.S. population that accounts for most cancer diagnoses—those age 65 and older—is expanding.
Another pressing public health challenge is that the burden of cancer is shouldered disproportionately by racial and ethnic minorities and other underserved populations. Racial and ethnic minorities, including African Americans and Hispanics, also are shouldering a disproportionate burden of the ongoing COVID-19 pandemic, laying bare stark inequities in health care. Disparities in health care are among the most significant forms of racial inequality and injustice, and it is imperative that all stakeholders play a role in eradicating the social injustices that are barriers to health equity, which is one of our most basic human rights.
The immense toll of cancer is felt through both the number of lives it affects each year and its economic impact. In the United States, cancer health care spending is estimated to have been $161.2 billion in 2017, the last year for which these data are available. This does not include the indirect costs of lost productivity due to cancer-related morbidity and death, which were $30.3 billion and $150.7 billion, respectively. With the personal and economic burden of cancer predicted to rise in the next few decades, it is vital that the nation invest in the groundbreaking research that drives progress against cancer.
Understanding How Cancer Develops
Discoveries across the spectrum of cancer research from basic science to translational, clinical, and population research have led to our current understanding of how cancer arises and develops.
We now understand that cancer is a collection of diseases that arise when the processes that control normal cell growth, division, and life span go awry. This happens primarily because of changes, or mutations, in the genetic material of normal cells. The identity of genetic mutations and the order and speed at which a cell acquires them determine the length of time it takes a given cancer to develop. Inherited mutations play a role in about 10 percent of cancer cases, but most cancers are caused by mutations acquired over an individual’s lifetime. Some mutations are acquired during normal cell multiplication, others are acquired because of persistent exposure to substances that damage genetic material such as toxicants in tobacco smoke and ultraviolet radiation (UV) from the sun, and yet others are acquired as a result of chronic inflammation fueled by medical conditions such as Crohn’s disease.
Although genetic mutations underpin cancer initiation and development in most cases, epigenetic abnormalities, as well as interactions between cancer cells and their environment—known as the tumor microenvironment—also play an important role.
Special Feature on COVID-19 and Cancer
The year 2020 will be inextricably linked to COVID-19, a disease that has drastically altered every facet of life, including cancer research and care. Therefore, this edition of the AACR Cancer Progress Report includes a special feature that provides an overview of the disease, the contribution of cancer research to its detection and treatment, and the opportunities and challenges ahead for the cancer community.
The global health crisis caused by the rapid spread of COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. As of July 31, 2020, more than 4.5 million people in the United States had been diagnosed with COVID-19 and more than 150,000 people in the country had died from the disease. These figures were about 25 percent of the global numbers on that same day.
COVID-19 is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Not everyone who becomes infected with SARS-CoV-2 goes on to develop symptoms of COVID-19. Even among people who develop symptoms, there is a wide diversity in the severity of the disease. Older adults, males, and individuals of any age with certain underlying medical conditions are at an
increased risk for severe COVID-19 illness.
The COVID-19 pandemic has created many challenges across the continuum of cancer care, with concern about the effects that delays in cancer screening, diagnosis, and treatment will have on outcomes for patients with cancer, in particular racial and ethnic minorities because these population groups have shouldered a disproportionate burden of COVID-19. Cancer researchers are playing a pivotal role in addressing the COVID-19 pandemic and are continuing to innovate to respond to the challenges posed by the pandemic, including
adapting the conduct of clinical trials.
Preventing Cancer: Identifying Risk Factors
Decades of research have led to the identification of numerous factors that increase a person’s risk of developing cancer. Given that exposure to many of these factors can be eliminated or reduced, many cases of cancer could be prevented. In fact, it is estimated that about 40 percent of cancer cases in the United States are attributable to preventable causes.
The main preventable causes of cancer are tobacco use, obesity, lack of physical activity, alcohol consumption, exposure to UV light from the sun or tanning devices, and failure to use interventions that treat or prevent infection with cancer-associated pathogens, such as cancer-causing strains of human papillomavirus (HPV).
The development and implementation of public education and policy initiatives designed to eliminate or reduce exposure to preventable causes of cancer have reduced cancer morbidity and mortality in the United States. Thanks to such initiatives, cigarette smoking among U.S. adults has been declining steadily since 1965, when it was 42 percent, and reached an all-time low of 13.7 percent in 2018. However, the use of electronic cigarettes (e-cigarettes) is rapidly increasing among U.S. adolescents, youth, and young adults. New legislation that raises the federal minimum age of sale of all tobacco products, including e-cigarettes, to 21 years should accelerate progress against cigarette smoking and e-cigarette use among these populations, but more must be done to curb their access to tobacco products.
The prevalence of obesity, another major risk factor for cancer, which is linked to 15 types of cancer, continues to rise among U.S. children and adults. In the past two decades, obesity rates among children, adolescents, and young adults ages 2 to 19 have risen from 13.9 percent to 19.3 percent. During the same period, obesity rates among adults age 20 and older increased from 30.5 percent to 42.4 percent. Therefore, it is essential that all stakeholders work together to enhance the dissemination of our current knowledge of cancer prevention and implement evidence-based policies to minimize the morbidity and mortality of cancers attributable to preventable causes.
Screening for Early Detection
Research discoveries that have deepened our understanding of cancer initiation and progression are the foundation of screening strategies to detect precancerous lesions or cancer at an early stage of development. Finding precancerous lesions or cancer at an early stage of development makes it more likely that a cancer can be intercepted, and a patient treated successfully.
Cancer screening refers to checking for precancerous lesions or cancer in people who have no signs or symptoms of the cancer for which they are being checked. Determining whether broad implementation of a cancer screening test across a defined population can decrease deaths from the screened cancer and provide benefits that outweigh the potential risks of undergoing the test requires extensive research and careful analysis of the data generated. Currently, there are five types of cancer—breast, cervical, colorectal, lung, and prostate cancer—for which screening tests have been used to screen large segments of the U.S. population.
Every person has a unique risk for each type of cancer based on genetic, molecular, and cellular makeup, lifetime exposures to cancer risk factors, and general health, as well as the person’s own personal tolerance of the potential risks of a screening test. Therefore, individuals should consult with their health care practitioners to develop a personalized cancer prevention and early detection plan.
Turning Science into Lifesaving Care
The dedicated efforts of individuals working throughout the cycle of medical research are constantly powering the translation of new research discoveries, made as a result of innovative cancer science, into lifesaving advances for people in the United States and around the world.
Among the advances made from August 1, 2019, to July 31, 2020, are the 20 new therapeutics that were approved by the FDA for treating patients with various types of cancer. During the same period, the uses of 15 previously approved anticancer therapeutics were expanded by the FDA to include the treatment of additional types of cancer.
Sixteen of the new anticancer therapeutics target specific molecules involved in cancer and are referred to as molecularly targeted therapeutics. They are part of the precision medicine revolution in cancer care that is improving the lives of patients such as six-year old Camden Green, whose brain tumor was found to be fueled by a genetic alteration that matched her to the molecularly targeted therapeutic entrectinib (Rozlytrek), and Sandra Griego, who has a rare type of cancer called epithelioid sarcoma, which is susceptible to the molecularly targeted therapeutic tazemetostat (Tazverik).
Five of the previously approved anticancer therapeutics that were approved for treating additional types of cancer are immunotherapeutics called checkpoint inhibitors. With these new approvals, as of July 31, 2020, one or more checkpoint inhibitors have been approved for treating 16 types of cancer and for treating any type of solid tumor characterized by the presence of certain molecular characteristics, microsatellite instability–high, DNA mismatch–repair deficiency, and tumor mutational burden–high. These transformative treatments yield remarkable and durable responses for many patients, as highlighted in the report by the experiences of Dr. Al Stroberg and Leonard Ganz.
Supporting Cancer Patients and Survivors
Research-fueled advances in cancer detection, diagnosis, and treatment are helping more and more people to survive longer and lead fuller lives after a cancer diagnosis. According to the latest estimates, more than 16.9 million U.S. adults and children with a history of cancer were alive on Jan. 1, 2019, compared with just 3 million in 1971.
Despite the progress, survivors of cancer often face serious and persistent adverse outcomes, including physical, emotional, and psychosocial challenges because of their disease and treatment. Each person diagnosed with cancer faces his or her own unique set of challenges, but one in four survivors reports a poor physical quality of life and one in 10 reports a poor mental health–related quality of life. Adopting a healthy lifestyle, using palliative care, and psycho-oncology programs can improve quality of life.
The transition from initial cancer treatment to follow-up, long-term survivorship care can be complicated. Emerging evidence suggests that survivors of cancer receive the highest level of care if their care is well coordinated, either by an oncologist and primary care physician, by multiple specialists, or by an oncogeneralist—a primary care physician with specific expertise in caring for patients and survivors with cancer. However, we need to identify the optimal way to provide comprehensive, coordinated care to
all survivors of cancer.
Looking to the Future
Research drives progress against cancer because it provides us with a deep understanding of cancer biology.
As we look to the future, many researchers, including AACR President, 2020–2021, Antoni Ribas, MD, PhD, are confident that we will be able to overcome the global public health crisis caused by COVID-19 and continue working diligently to accelerate progress against cancer by increasing collaboration and harnessing the new wave of technological innovation. For example, innovation in the application of artificial intelligence approaches such as machine learning to the analysis of vast amounts of health care information will accelerate the pace of progress across the breadth of cancer science and medicine. Cutting-edge techniques such as gene editing using CRISPR/Cas are poised to transform the development of cell therapies. The incorporation of novel technologies such as liquid biopsies into the clinic has the potential to have a major positive impact on early detection, diagnosis, and treatment of cancer in the near future.
Combatting Cancer through Science-Based Patient-Centered Policies
Federal investment in the NIH, NCI, FDA, and CDC has fueled tremendous advances against cancer by catalyzing scientific discoveries and facilitating the translation of these discoveries into new and better anticancer medical products and community-based programs to improve public health. If we are to continue to accelerate the pace of progress against cancer, we need robust, sustained, and predictable annual budget increases for the NIH and NCI. We also need continued congressional commitment to supporting the FDA and the cancer prevention and control programs at the CDC. These vital investments will help support a diverse research workforce, advance regulatory science initiatives, and allow us to pursue policies that improve cancer prevention, early detection, and control for individuals, families, and communities.
The AACR Call to Action
Medical research is driving scientific and technological innovation that is spurring progress against the many diseases we call cancer. Thanks to remarkable bipartisan efforts in Congress the NIH budget has grown significantly in the past five years, allowing our nation’s researchers to capitalize on many of the unprecedented scientific opportunities that exist today to improve health and save lives.
In addition to making medical research a national priority, Congress has acknowledged the need for increased innovation at the FDA to ensure the rapid translation of research discoveries into safe and effective treatments, and swift dissemination of these treatments to patients who need them urgently. Furthermore, Congress recognizes the vital role of an active CDC to protect our citizens from serious health threats.
During this unprecedented time in our nation’s history, there is also a need for our nation’s leaders to take on a much bigger role in confronting and combatting the structural and systemic racism that contributes to health disparities. Renewed attention has been drawn to the issue of pervasive racism and social injustices in light of the COVID-19 pandemic as well as the recent atrocities against people of color. Likewise, it is time for the scientific community to step up, and partner with Congress to assess and address this issue within the research community.
Therefore, the AACR urges Congress to:
- Continue to support robust, sustained, and predictable growth for the NIH and NCI by providing increases in their FY2021 base budgets of at least $3 billion and $522 million, respectively, for a total funding level of $44.7 billion for the NIH and $6.9 billion for the NCI.
- Ensure that the $195 million in funding designated through the 21st Century Cures Act for targeted initiatives, including the National Cancer Moonshot, is fully appropriated in FY2021 and is supplemental to the overall increase in the NIH base budget.
- Support the FDA’s critical regulatory science initiatives by providing an increase of at least $120 million in discretionary
budget authority in FY 2021.
- Support the CDC Cancer Prevention and Control Programs with total funding of at least $559 million. This includes funding for comprehensive cancer control, cancer registries, and screening and awareness programs for specific cancers.
- Continue to support appropriation bills that include increased funding for CDC’s Office of Smoking and Health, to continue to strengthen comprehensive tobacco prevention and control programs.
- Provide $50 million for the second year of the Childhood Cancer Data Initiative and “no less than” $25 million for the continued implementation of the Childhood Cancer STAR Act.
- Exempt NIH and other key public health agencies from the highly restrictive FY 2021 budget caps to allow them to forcefully respond to the COVID-19 health crisis, as well as to support the science that is necessary to improve and save lives from the myriad of diseases faced by Americans and by people all over the world.
- Eliminate the pervasive racial biases in the conduct of cancer research that have led to significant inequities in cancer care, low participation for minorities in clinical trials, and an underrepresentation of racial and ethnic minority scientists in the cancer research workforce by supporting a congressional effort that calls on the National Academies of Science, Engineering, and Medicine to undertake a study to assess systemic racism in academia.
The COVID-19 pandemic is one of the greatest health crises that this country has ever faced, leading to thousands of lives lost, an economy thrown into chaos, and significant alterations in everyday life for millions of Americans. The pandemic has also highlighted the vital importance of medical research. Across the country, funding for ongoing medical research was diverted to stop the spread of COVID-19 and to expeditiously develop vaccines and treatments for this unprecedented disease.
In the face of the current health crisis due to the COVID-19 pandemic, cancer and other diseases continue to be major ongoing challenges. If we hope to reach the day when cancer is no longer a major health threat to our nation’s citizens, Congress must provide the critical funding that is essential for research supported by the NIH and NCI. By providing robust, sustained, and predictable annual funding increases for the NIH and NCI in FY 2021 and beyond, Congress will accelerate the pace at which we make future scientific advances, capitalize on prior investments in cancer research, spur innovation and economic prosperity for our country, and bring lifesaving cures to many patients in the United States and around the world.