Professional Judgment Budget 2013

This year marks the 75th anniversary of the founding of the National Cancer Institute, the first so-called “categorical institute” of what has become the National Institutes of Health, with its 27 Institutes and Centers. Over the years, the Congress and the public have generously supported the NCI—and the NIH generally—with sustained budgetary increases. This was especially true for the NCI during the rapid expansion of its budget following the National Cancer Act of 1971 and for the NIH, including the NCI, during the five-year doubling of its budget, launched in 1998. Both of these eras of rapid growth were remarkably fruitful. The first launched the pursuit of cancer genes and the molecular basis of oncogenesis, laying the foundation for the transformation of clinical oncology that is now occurring. The latter accelerated the completion of the human genome project that now guides the study and control of all diseases, including cancers. Since 2003, however, the budgets of the NCI and the NIH have grown minimally, with their buying power shrinking by about 20 percent as a consequence of inflation.

This decade-long hiatus in financial growth has come, ironically, at a time of unmatched promise in the oncological sciences and at a time when the world of cancer research has expanded in talent, facilities, and ideas. Progress in molecular biology, especially in the deciphering of cancer genomes and the probing of the signaling pathways that govern normal and malignant cell growth, has transformed our ability to understand the broken parts of a cancer cell; to develop new and more precise therapeutic strategies; to begin to reformulate diagnostic categories; and to imagine screening for and prevention of some cancers in more powerful ways. In just the past few years, NCI-supported science has delivered a remarkable collection of genetic information about several types of cancers, a number of new targeted therapies for various cancers, compelling examples of successful immunologically based- therapies, persuasive evidence that radiographic screening can reduce lung cancer mortality, and many new observations about the genesis of cancer cells, their development, their behavior, and their micro-environment.

One of the goals of this annual report is to summarize some of these findings and their practical consequences, so that the NCI’s many supporters and beneficiaries can better appreciate the significance of the NCI and the argument for the enhanced support that we request in the “by-pass budget.” We provide this summary in two ways: by describing some of the NCI’s broad research programs that address a wide range of cancers and their underlying biological properties and by discussing several specific types of cancers (five this year) that exemplify the various strategies and the variable rates of progress on the different diseases that we are working to control. The latter disease-specific presentations also help to acquaint the report’s readers with some important fundamental principles: first, that different types of cancers are often united by common themes, but also characterized by inherent differences in epidemiological factors, molecular mechanisms, and clinical features; and second, that studies of each cancer type are strongly influenced by work on other types of cancer. These notions have implications with respect to the way we use the public funds we receive from Congress. We must, and we do, balance our knowledge about the public health burden of each cancer type against a consistent historical message: The sources of our greatest advances are difficult to predict and often emerge from unexpected places. So scientific opportunity, the richness of experimental ideas, and the talent of investigators must be taken into account, along with the toll taken by individual cancer types, if we are to spend our funds wisely and earn public trust, especially at a time of fiscal restraint.

When the National Cancer Act was signed in 1971, the NCI Director was deemed to be the leader of the National Cancer Program, the totality of the nation’s efforts to combat cancer. We now recognize that efforts to control cancer and its effects—through science, medicine, and social programs—are now so vast, conducted by so many people, and funded by so many organizations that leadership in any strict sense is not possible. Still, the NCI and its Director have enormous potential to lead the nation’s efforts through the NCI’s “convening power”—the ability to bring people together from all sectors working on cancer and to think cooperatively about how to solve our most difficult problems. In that spirit, the NCI makes frequent use of its many well- established external committees—the National Cancer Advisory Board, the Board of Scientific Advisors, the Clinical and Translational Advisory Committee, the Director’s Consumer Liaison Group, and others—to discuss new programs and obstacles to progress. In addition, especially over the past two years, the NCI has been convening a large number of workshops and creating new advisory groups to seek broad counsel on a variety of important topics. Most numerous among these have been the Provocative Questions workshops, designed to solicit ideas from a diversity of scientists and clinicians about important research opportunities that have been comparatively neglected (see p. 4). Other gatherings have been convened to explore ways to accelerate the improvements in medical practice, best called “precision medicine”, in the era of genetically-informed cancer care that we are now entering (see p. 13). The NCI also has new means for obtaining specialized advice about critical components of its scientific program: the National Frederick Advisory Committee for oversight of the Frederick National Laboratory for Cancer Research (see p. 50) and outside advisors for the National Cancer Informatics Program, (see p. 78) and for two new centers at the NCI: the Center for Cancer Genomics (see p. 8) and the Center for Global Health (see p. 66). Still other discussion groups have been assembled to consider the pending reorganization of the NCI’s Cooperative Clinical Trials Groups and the increasing recognition of the centrality of “team science” in cancer research.

Such group events inevitably illustrate the strength, size, and diversity of the organizations that share the NCI’s goals and work with us in various ways to reach those goals. Those organizations include private pharmaceutical and biotechnology firms; scientific and medical societies; disease advocacy organizations and other voluntary groups; state-based research programs; and a variety of research institutions, universities, and medical schools, especially the NCI-designated cancer centers.

Connected by financial ties that may be loose or tight, these organizations are joined solidly to the NCI by a fierce determination to make progress against the complex set of diseases that we group together as cancer. In many ways, the interactions among these groups—convened, organized and led by the NCI—constitute the backbone of the National Cancer Program. This report inevitably focuses on the specific contributions that the NCI makes to this complex national effort; our achievements constitute a reliable barometer of the National Cancer Program’s progress and promise. For that reason, the NCI offers this report as an account of how the entire nation is faring in its efforts to control a world-wide scourge.

Harold Varmus, M.D. Director, NCI