February, 2016

Shoot the Moon

By Michael J. Katin, MD

Longer than the Peloponnesian Wars (431-404 BC), longer than the Thirty Years' War (actually 29.96 years, 1618-1648), longer than the War of the Roses (1455-1487), and even longer than the Hundred Years' War (actually 116 years, 1337-1453), and even longer than the Three Hundred and Thirty Five Years' War (truly 335 years, 1651-1986) has been a conflict waged between humankind and disease. Almost as long has been the war of words related to this.

Over five years ago this column dealt with the outcome of the "War on Cancer" declared by President Richard M. Nixon on January 22, 1971. At that time attention was called to the similar outcomes of the War on Poverty and the War on Drugs.
It was with a sense of déjà vu that we heard President Obama announce on during the State of the Union Address on January 12, 2016 about a new "moonshot " to cure cancer. He did not use the word "declare war," but described a "new national effort to get it done." Actually, he had previous declared war on cancer in June, 2009

It was very insightful for President Obama to rebrand the efforts against cancer. Wars have rarely come to a satisfying conclusion and, with rare exceptions, are at very high cost of resources and suffering. This particularly seems to have been the case with Wars on Cancer, Poverty, and Drugs. Making a connection between efforts against cancer and the space program may therefore seem to be an inspired idea....until one looks into it somewhat further.

Ironically, the space program benefitted from potential applications for warfare more than it did from the romantic goal of allowing humankind to explore the universe (rather than solving mundane problems of famine and pestilence on earth). The United States and the Soviet Union competed to locate the Nazi scientists and engineers who created the V-1 and V-2 rockets. The Vostok rocket used to launch Sputnik, the first satellite, on October 4, 1957, and Yuri Gargarin, the first modern-era person into space. on April 12, 1961, was a derivative of the R-7 ICBM ready to drop thermonuclear warheads onto the US, and the Atlas rocket was an ICBM used to launch the last four Mercury missions. Eventually the space program became (arguably) the mechanism for the end of the Cold War, when Ronald Reagan promoted Project High Frontier, otherwise known as the Strategic Defense Initiative. Oh, yes, in between, there were six manned moon landings!

It seems somewhat appropriate to link the moon program to the effort to conquest cancer. John F. Kennedy expressed: "its (space's) conquest deserves the best of all mankind....but why, some say, the Moon? Why choose this as our goal? And they may well ask, why climb the highest mountain? Why, 35 years ago, fly the Atlantic? Why does Rice play Texas?.....we choose to go to the Moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one that we are unwilling to postpone, and one we intend to win."

All of this can easily be applied to the effort against cancer, but if the moon program is to be the model, it should be remembered that setbacks and detours are to be expected. A major one for the space program occurred when three astronauts, Virgil Grisson, Edward White II, and Roger Chaffee, died in a fire in a ground simulation for Apollo 1. Amazingly, of two of the main causes, one should have been already corrected and the second was to have been implemented. Velcro used in the interior of the spacecraft was flammable, and had actually been removed at the astronauts' recommendation but then replaced anyway. The hatch door was to have been replaced by a different design on subsequent flights, but the way it was constructed (opening inward) it could not be opened when pressure inside the capsule was too high. The lunar mission schedule was set back by nearly a year. NASA Flight Control adopted the motto of "Tough and Competent," which probably would be good to be followed by the NCI and NCCN. Would that have prevented premature use of bevacizumab for breast cancer or epoetin to have been used on a widespread basis, even getting to the point of having represented the single greatest drug expenditure by Medicare for several years.

Even when things were going well in the space program, there were unexpected interruptions such as the near-tragedy of Apollo 13, launched at 13:13 Houston time on 4/11/70 (4+1+1+7=13). Fortunately, it turned out well for astronauts Lovell, Swigert, Haise, Hanks. Bacon, and Paxton.

The most important analogy to the moon mission, however, is probably overlooked. After accomplishing the unbelievable goal of putting a man (human) on the moon before the end of the decade of the 1960's, and then having seven attempts and six landings, the United States has not had another moon mission since Apollo 17, which departed the moon on December 14, 1972, over 43 years ago! In fact, the last three Apollo missions were nearly cancelled! There are multiple reasons given for why this is the case. The bottom line, interestingly, is probably cost.

Although there are major economic gains from colonizing the moon, the cost of doing this as subsidized by our government was thought to be prohibitive. In other words, expenditures now that would pay off with tremendous gains in the future are thought to be politically incorrect. Where else has this been the case?

Although nothing is supposed to be more important than preserving human life and quality of life, there seems to be a great deal of hesitancy in actually paying for medical care and medical breakthroughs. One could be cynical and say that developing cures for cancer that are expensive and lead to persons living longer and requiring more expenditures may not be desirable when there are more important things to fund. The National Health Service in England has already cut back on more than 20 cancer treatment drugs, with more expected to be restricted in the future.

The logical extension of the "Moon Shot" is that even if phenomenal new treatments and even cures are discovered, they will not be available for financial reasons. Maybe "Moon Shot" was a good choice of terminology after all.

Although we probably don't have to anticipate any breakthroughs. How's that brain mapping initiative working out for you?

Emanuel Countdown: The Emanuel Countdown will be suspended for several months, to be replaced by a tribute to each of the 8 persons currently seeking the position of President of the United States. The Emanuel Countdown will resume after the nominees of both parties have been selected. The clock, however, will still be running.
To the tune of Bad Case of Loving You

He made the move one day in May
He would come in to save the day
He had the skill, he had the med-
Icine to turn blue states to red

Doctor Carson, tell us your views
The people can't wait to vote for you
Only you can cure our blues
The people can't wait to vote for you

He was a star on Fox TV
Knew all about neurosurgery
He had the spine and had the brain
To make it big in the campaign

Doctor Carson, tell us your views
The people can't wait to vote for you
Only you can cure our blues
The people can't wait to vote for you.

He was a hit right from the start
Then things began to fall apart
He wasn't winning delegates
He fell asleep in the debates.

Dr. Carson, check your reviews
You shouldn't go home to get new suits
Your public cries for you to energize
Or time will start to run out for you.

Now Trump and Cruz, they like it on top
If you don't get with it, they can't be stopped.

When you said gays have made that choice
You made the Democrats rejoice
You touched a nerve with the RNC
They can't deal with being non-PC.

Doctor Carson, here is the news
You've got a fat chance of beating Cruz
Or Trump or Rubio
The polls all say you're gonna lose.