publication date: May. 15, 2020

NCI Director’s Report

Sharpless: COVID-19 threatens to reverse long-running trend of decreasing cancer mortality

By Matthew Bin Han Ong

This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.

Delayed cancer diagnoses, deferred care, and postponed surgeries amid the COVID-19 pandemic will adversely impact cancer outcomes, which may show up as an increase in cancer mortality in the next few years, said NCI Director Ned Sharpless.

“I’ve been looking at the statistics about decreases in screening and deferred care, and I am getting very worried about this issue,” Sharpless said May 12 in a virtual meeting of NCI’s Board of Scientific Advisors. “The data regarding delayed diagnosis and delayed therapy are very clear from cancer research over the decades.”

An uptick in overall cancer mortality trends will likely be visible in the institute’s Annual Report to the Nation—jointly issued with the Centers for Disease Control and Prevention, the North American Association of Central Cancer Registries, and the American Cancer Society—in the coming years.

“I’m becoming worried that, because of the pandemic, that in 2021 or 2022 or 2023, we will have the first Annual Report to the Nation since 1993 that shows an increase in cancer mortality,” Sharpless said. “And I know exactly what the statistics will mean for patients. I know that that represents more cancer suffering and more bad outcomes, and more deaths.”

In related developments:

  • Health systems and academic cancer centers are cutting expenses to make up for operational shortfalls resulting from the pandemic—laying off employees, furloughing staff, and cutting salaries and benefits (The Cancer Letter, May 8, 2020).

  • Community oncology practices are experiencing a significant decrease in patient volume, as weekly visits dropped by nearly 40%, while cancellations and no-shows have nearly doubled (The Cancer Letter, May 1, 2020).

“I wanted to stress that we know all too well that the extramural community, as is the case in nearly every sector of the nation, things are really hurting out there,” Sharpless said at the BSA meeting. “And regardless of how the back-to-business plan does roll out at various institutions, it will really take some time to bounce back.

“Delayed diagnosis and deferred care leads to worse outcomes for patients with cancer. The things we do to prevent cancer and to diagnose cancer and to treat cancer well, they work, and they can’t be put off indefinitely.

“And if we do, we will lose ground, and we will give up hard-won progress.”

 

An excerpt of Sharpless’s remarks May 12 follows:

Today I would really like to keep most of the focus on regular NCI business. I’m really eager, in fact, to be talking about cancer research and concepts the NCI would like to release. And these will spur interest in cancer research and priority areas. But there is a pandemic going on and we do have some coronavirus items to address as well.

We just had a board meeting on this topic almost entirely devoted to COVID-19. We don’t have to do a whole lot on that topic today. But I will just use a few slides to summarize that presentation from the joint board meeting, and remind you of how the NCI has been taking a critical role in an unprecedented response to this pandemic. Also, since things are moving so fast around here right now, there actually have been a few significant developments in the coronavirus space—since even the joint board meeting just a few weeks ago. I’ll briefly summarize that news as well.

In particular, related to those developments, including a new and correct congressional appropriation. There are some COVID items that we do need, and Dinah Singer will direct that discussion at the end of today’s meeting.

But let me start out our short COVID discussion by repeating a statement I made last month at the joint board meeting, which is that the primary focus of the National Cancer Institute is, and always will be cancer research and cancer care. That’s a message I’ve been delivering in just about every presentation I’ve given, in every email and blog post and other materials I’ve written during this pandemic response.

And it’s one that Dinah Singer spoke to at her virtual presentation at AACR two weeks ago on April 28. If you haven’t seen this, I encourage you to check it out. Dinah also wrote a great post for our Bottom Line blog on the topic, which includes a link to the presentation.

So, this slide summarizes why the NCI is important to the pandemic response. It shows the disproportionate impact of COVID-19 on cancer patients, and patients with cancer who’ve survived cancer. Additionally, as I illustrated at the joint board meeting, the NCI has unique research expertise and capacity related to Frederick National Lab and our great extramural networks.

Therefore, we have to be involved in the pandemic response. And then, lastly, I think given the nature of this crisis, it has had a tremendous effect on public health. The NCI has a moral obligation to work in this area.

 

Impact of COVID-19 on patient outcomes

I want to call your attention though to the decrease in care delivery to cancer patients related to the coronavirus pandemic. And this is something, frankly, I’ve been worrying about a lot lately, and I’ve been hearing from a lot of you and other extramural leaders.

I’ve been looking at the statistics about decreases in screening and deferred care, and I am getting very worried about this issue. The data regarding delayed diagnosis and delayed therapy are very clear from cancer research over the decades.

Delayed diagnosis and deferred care leads to worse outcomes for patients with cancer. The things we do to prevent cancer and to diagnose cancer and to treat cancer well, they work, and they can’t be put off indefinitely.

And if we do, we will lose ground, and we will give up hard-won progress. And here’s a very specific fear I have, in this regard. Every spring, the National Cancer Institute, with the CDC and the ACS and NAACCR, puts out our Annual Report to the Nation on our progress against cancer.

Thanks to advances in screening and prevention and treatment and survivorship, that document has become an annual feel-good story for the NCI. Every year I’ve been here, the report has been good news.

It’s been a couple of percent drops in cancer mortality each year, and that’s been going on, in fact, for decades. But with all this deferred and delayed care and postponed surgeries and later, reduced chemotherapy, and canceled appointments for mammography or a Pap smear or colonoscopy, this is going to have an impact on cancer outcomes—an impact that I think we’ll see play out over years to come.

So, I’m becoming worried that, because of the pandemic, that in 2021 or 2022 or 2023, we will have the first Annual Report to the Nation since 1993 that shows an increase in cancer mortality. And I know exactly what the statistics will mean for patients. I know that that represents more cancer suffering and more bad outcomes, and more deaths. And let’s all agree, we don’t want that to happen, and we won’t let that happen. I know COVID has caused many changes to how we care for patients.

And we have a legitimate need to be careful during the pandemic in order to protect the public health. But we need to get back to work of caring for our patients. We need our hospitals and our clinics and our infusion centers to start doing what they do best, which is care for our patients who need this. Of course, we have to do this in a manner that is smart, that is careful, that protects patients and staff alike from the coronavirus.

But we need to get back to work. The cost of deferred cancer care will be significant. Neglecting cancer will produce a negative impact on the public health, and one that may trouble our patients for years to come. I plan on talking a lot more about this in the coming weeks. And I haven’t even spoken about the debilitating impact on cancer science, by having these labs closed and postponed—tremendous impact as well.

Just to remind you something that Dinah spoke about, and that is on the blog post as well, is the number of NCI COVID-19 funding opportunities that are somewhat new and recently posted, and still open. This is summarized here. I won’t spend a lot of time on them, other than to say we’re taking both administrative supplements and competitive revisions.

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We also had a good discussion at the joint board meeting about allowing a change of scope of certain grants, and we have received a small number of requests to do that, and are working through that. But I think that we are still considering administrative supplements and competitive revisions, and we will be making funding decisions related to these very soon.

 

Regular NCI business

Now with the COVID part of the discussion behind us, at least for the next few hours, let’s return to regular NCI business. Frankly, I am really excited, as I said, to be able to spend most of our time today on advancing cancer research and cancer science. Getting these concepts that the BSA will see today is really a lot of work getting these things together.

I think you will be impressed or you’ll be really shocked by how much the NCI has been able to get done during a period of complete telework. I think this is a testament to the really extreme efforts of the trained professionals in the NCI to get this work done, no matter what the situation.

As always, it’s good to mention where we are in the appropriations’ outlook. There’s really not a lot to report. At this stage right now, much of Congress’s focus has been on supplemental funding related to the coronavirus pandemic, and the work on the 2021 budget has been a little a bit behind that.

But Congress has been busy and has already passed these supplemental fundings, and as is widely reported, is working on a fifth emergency appropriations bill. At the same time, appropriators are starting to take up their work on the regular FY21 appropriations bill, and I suspect we’ll be hearing more about that soon. So, stay tuned.

Some really wonderful news during the joint board meeting last month, I was able to share some news about Dan Gallahan assuming the permanent role as director of NCI’s Division of Cancer Biology. And today I’m very pleased to share that Phil Castle will soon take the helm at NCI’s Division of Cancer Prevention.

Those of you who know, Phil is replacing Barry Kramer in this role, but DCP has been led for over a year now by Debbie Winn, serving in an acting capacity. Debbie has done a spectacular job in this role—very hard to be an acting in this role—and I want to thank her for taking this on for the benefit of the NCI. I would like a virtual round of applause for Debbie. Yay Debbie!

Phil is joining us from Albert Einstein College of Medicine in New York, where he served as professor in the Department of Epidemiology and Population Health. He was also the executive director and co-founder of the Global Coalition Against Cervical Cancer.

Phil is no stranger to the NCI. He was a senior tenured investigator and tenure-track investigator in the Division of Cancer Epidemiology and Genetics from 2003 to 2011. While at NCI, he was the lead investigator on several epidemiologic studies, including the Mississippi Delta project, the HPV Persistence and Progression Cohort, and the guidelines cohort and cancer at Kaiser Permanente, Northern California, and the Anal Cancer Screening Study.

I’m thrilled Phil is joining the NCI in this key role, and I’m really excited to have him join and provide vision for the DCP mission regarding cancer prevention, screening and early detection. So, welcome, Phil.

 

CCDI; CAR T

I’d like to give a brief update on the Childhood Cancer Data Initiative. We are anxiously anticipating an upcoming working group report for the joint board meeting in June. As some of you know, Jaime Guidry Auvil kicked off the BSA working group on March 27 and provided an overview of its activities, as well as its relationship with ongoing NCI pediatric initiatives.

While we await the report, it’s important to note that we are using the FY20 CCDI funding to support foundational aspects of childhood cancer research and data related to those efforts, from which to build CCDI in years FY21 to FY30. So, we are working on this at a good speed with the already appropriated funds and are eagerly awaiting more advice from the working group on the shape of this initiative.

I’ll just mention that the cell-based therapy and vector production efforts at Frederick National Lab are proceeding apace. As I mentioned though at the joint board meeting, we have actually had our first trial, using a CAR T-cells prepared at Frederick, open. The virus production facility will soon come online. And we’ll evaluate potential viral production projects proposed by the extramural community.

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So, we envision Frederick will have capacity to make viral vectors as needed for extramural searchers. This will include both developmental and clinical trial proposals.

Needless to say, I’m thrilled with the progress and ramping up of this facility. In fact, this summer we will begin accepting applications. We’ve dedicated space to produce viral projects, so those of you who will need help producing virus for, say, a CAR T trial or some other related efforts, stay tuned for the announcement about the acceptance of applications.

I think many on this board are aware of the interesting pattern of prostate cancer statistics over the last few years, regarding incidence and mortality, with changing recommendations related to PSA screening. The NCI has been following this area carefully. We had a very large internal NCI meeting, spanning the gamut from basic researchers to clinical trialists, to population health science researchers, to discuss where our prostate cancer research portfolio ought to be, in light of these changing statistics, and we decided a good way to go forward would be to have a lot of advice from the extramural community.

And for that reason, we’re working towards a workshop next spring to bring in extramural perspective to convene the best folks to try and understand where the NCI should be focusing its research mission related to prostate cancer now. Bill Dahut and others are leading this effort at the NCI.

 

Research updates

I thought I’d mentioned a few quick research updates that we found exciting. I always like to try and at least note some of the great science that NCI has done, either intramurally, or funded extramurally, and always try and bring up a few recent items.

This is work from the DeNardo lab at Washington University, published recently in Cancer Cell, related to dendritic cells in tumor immunotherapy. It proposes that the number of dendritic cells in a tumor may explain why immunotherapy works for some cancers, but not others, and work in mice—boosting dendritic cell number triggered an immune response in pancreatic cancer, which has been traditionally difficult in terms of immunotherapy. So exciting research proposals to follow.

Work from the Richard Kitsis lab at Albert Einstein tries to better understand the relationship between daunorubicin and doxorubicin and cardiomyopathy, and developed an experimental drug to prevent this chemotherapy-induced heart toxicity. It does so without interfering with the chemotherapy’s therapeutic ability to kill cancer cells in mice. So, interesting work for a long-standing problem related to the use of these agents at extended doses for patients.

In some microbiome research from Marcel van den Brink at Memorial Sloan Kettering in people with blood, hematologic malignancies, the health of their gut microbiome appears to affect the risk of dying after receiving allogeneic stem cell transplant, according to this NCI-funded study, published in the New England Journal of Medicine that got tremendous attention in the press. An exciting development to help improve outcomes for patients who need allogeneic transplantation.

Finally, in addition to our grantee blog, Bottom Line, which is now widely read, and our research enterprise blog, which is Cancer Currents, I also also want to remind everyone about an important resource on our cancer.gov site. This site is specifically designed for researchers with questions. And it is updated frequently with new information as it becomes available.

To date, we’ve tracked over 20,000 visits to these blogs and other researcher-focused web content. I wanted to stress that we know all too well that the extramural community, as is the case in nearly every sector of the nation, things are really hurting out there.

And regardless of how the back-to-business plan does roll out at various institutions, it will really take some time to bounce back. We know, for instance, that universities and institutions have begun furloughing staff and laying off researchers. We know clinical trials accrual is down, especially for non-treatment trials.

All of this will slow the pace of research, but beyond that and equally important, the public health crisis represents a real hardship for our families, our communities, and patients with cancer. NCI has not lost sight of this. We’ll do all we can help to recover from these significant setbacks.

 

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