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"A New Deal for Cancer"

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"A New Deal for Cancer"

February 15, 2022

Yale Cancer Center Grand Rounds | February 15, 2022

Hosted by: Eric P. Winer Presentations by: Dr. Charles Fuchs, Abbe Gluck, Dr. Melinda Irwin, Dr. Cary Gross, and Greg Simon

ID
7458

Transcript

  • 00:00I wanna welcome everyone
  • 00:02to to our Grand Rapids.
  • 00:05I think this is the second or third
  • 00:08that I've presided over in my very
  • 00:10brief tenure at at Yale so far.
  • 00:13And today we're doing
  • 00:14something a little different,
  • 00:16a little different from most of the
  • 00:18presentations that that I've seen.
  • 00:20And today's grand rounds grows out
  • 00:23of or comes out of a book that
  • 00:26that Abby Glock at the law school,
  • 00:29and Charlie Fuchs,
  • 00:30who you all know well as my predecessor.
  • 00:35And who was here until just
  • 00:36a matter of months ago?
  • 00:40A book that that that they put
  • 00:43together called a new deal for
  • 00:45cancer lessons from a 50 year war.
  • 00:48And this book. Thank you Melinda.
  • 00:52There's this this book as described to me
  • 00:55when I was first asked to write a chapter.
  • 00:59Is a book that isn't necessarily meant purely
  • 01:04for scientists or purely for clinicians,
  • 01:07but as a book that's meant
  • 01:09for students and for doctors,
  • 01:12and for other health care professionals,
  • 01:15and for the lay public,
  • 01:16and for really everyone to review where we've
  • 01:19come with cancer over the past 50 years?
  • 01:22Not so much where we've come scientifically,
  • 01:24describing scientific progress
  • 01:26and exquisite detail,
  • 01:28but more of a sociocultural.
  • 01:30Look at the evolution of of of
  • 01:33of cancer and our approach as a
  • 01:35society to cancer and in truth some
  • 01:38of the great progress we've made.
  • 01:40So there are many chapters
  • 01:43in this wonderful book,
  • 01:45and we've we've put together a
  • 01:48group of people today who have
  • 01:51been involved with the book,
  • 01:54mostly writing chapters and and,
  • 01:58and we've asked each of them to come
  • 02:01together and to speak for about 5 minutes
  • 02:04about their piece of this project.
  • 02:07And then we're going to have time
  • 02:10for some questions at the end.
  • 02:12So without further ado and I'm going
  • 02:14to act as moderator and I will
  • 02:16introduce each of the the speakers
  • 02:19and our first speaker is well known
  • 02:22to all of you Doctor Charles Fuchs,
  • 02:24who was the former director of the
  • 02:27Yale Cancer Center and Physician
  • 02:29in Chief of Smilow Cancer Hospital.
  • 02:32And is now the.
  • 02:36Genentech's,
  • 02:36head of oncology and hematology
  • 02:39global product development.
  • 02:40Charlie is an internationally
  • 02:43recognized GI oncologist.
  • 02:46Before coming to Yale,
  • 02:49this is now probably five to six years ago.
  • 02:54He was a professor at Harvard Medical
  • 02:57School and the chief of the GI
  • 02:59Oncology Division and the Robert E
  • 03:01and Judith B Hill Chair in pancreatic cancer.
  • 03:03At Dana Farber,
  • 03:05where he and I were colleagues
  • 03:08for approximately 19 years.
  • 03:11So Charlie,
  • 03:12without further ado,
  • 03:15maybe you could start us
  • 03:16off with some comments.
  • 03:18Eric, thank you. And and it's so
  • 03:20great to see you and everybody,
  • 03:22and I'm really so honored to be back at
  • 03:25this wonderful forum and and I guess
  • 03:28virtually at this amazing center.
  • 03:30You know, I I my years at Yale,
  • 03:33were just such a privilege interacting
  • 03:35and working with so many talented
  • 03:38people and the experiences were
  • 03:41really transformative. For me,
  • 03:43but you know related to today's forum,
  • 03:45I think 1 Red Letter day came in
  • 03:49the summer of 2017 when I first met
  • 03:52Abby Gluck in my office at Smilow,
  • 03:55who approached me with the idea of
  • 03:58let's do a conference between the law
  • 04:01school smilow and the Cancer Center.
  • 04:03And admittedly I it just didn't
  • 04:07seem to click.
  • 04:08It seemed inconceivable that we could
  • 04:10come up with such a venue, but.
  • 04:12You know, really all of this is
  • 04:15the product of Abby's vision,
  • 04:17her genius, and really,
  • 04:19it's she is the architect
  • 04:21of this and you know,
  • 04:23she sort of led me along this path
  • 04:26to launch this joint conference,
  • 04:28which, as many of you know,
  • 04:29was an extraordinary van bringing
  • 04:32together leading figures in cancer care
  • 04:36research regulation policymaking and was,
  • 04:39as Abby can attest,
  • 04:42one of the leading cancer conferences.
  • 04:45In Connecticut, and I think, uh,
  • 04:47an important event in terms of
  • 04:49what we know about cancer.
  • 04:51Following that,
  • 04:53Abby,
  • 04:53the innovator,
  • 04:54really the the engine of all this
  • 04:58suggested that we craft a book and
  • 05:02and what I think the end result was a
  • 05:06constellation of amazing thought leaders,
  • 05:08innovators many of whom from Yale and Smilow,
  • 05:12some of whom presenting today
  • 05:15and one thing I think we wanted
  • 05:17to do was to plan the book.
  • 05:20To launch around the 50th
  • 05:23anniversary of the National Cancer
  • 05:25Act or as many of you know,
  • 05:26the the war on Cancer Act that Richard
  • 05:30Nixon signed into law in December 1971,
  • 05:34which is really where the phrase moon
  • 05:37shot as it relates to cancer care and
  • 05:41research emanated from with the idea
  • 05:44that they would launch a NASA like
  • 05:47program and would conquer cancer.
  • 05:49By the 200th anniversary of
  • 05:52the United States,
  • 05:54that is five years later in 1976 and
  • 05:58ambitious perhaps unrealistic goal.
  • 06:00But bottom line is a lot of
  • 06:01great things happened, you know?
  • 06:03And at the time the bill was signed,
  • 06:05we spent $0.89 per person on
  • 06:08Cancer Research in this country.
  • 06:10Now we spend $20 per person,
  • 06:14you know we launched the NCI
  • 06:16Comprehensive Cancer Centers,
  • 06:17of which Yale is a leading part of that.
  • 06:21We saw a new opportunities for
  • 06:23funding new programs for research,
  • 06:26the revolution of therapies,
  • 06:28targeted therapies, immuno oncology,
  • 06:30new technologies and no less importantly
  • 06:33the launching of careers of countless
  • 06:36talented individuals across the
  • 06:37spectrum of what we do in cancer.
  • 06:40And you know,
  • 06:41among the advances were the fact that
  • 06:43cancer mortality rates declined 29%
  • 06:45really over the past 20 or 30 years.
  • 06:49But you know what?
  • 06:51We also learned where the gaps?
  • 06:53Right that that the war on
  • 06:55cancer wasn't against a
  • 06:56single enemy, and I don't mean just single
  • 06:59cancer 'cause we obviously know the cancer,
  • 07:02or hundreds potentially thousands of
  • 07:04subtypes, but many other things about
  • 07:07the complicated way we fund cancer care.
  • 07:10You know how we use the payment
  • 07:12on drugs and and procedures to
  • 07:14cover the costs of payout of care,
  • 07:16nutrition, social work,
  • 07:18clinical research that are
  • 07:20largely under reimbursed?
  • 07:22The pressures of everyday practice
  • 07:24in cancer medicine.
  • 07:25The paucity of resources provided
  • 07:27to public health and prevention.
  • 07:30The challenges of supporting the next
  • 07:32generation of researchers and providers.
  • 07:35The issues of HealthEquity.
  • 07:37The fact that R&D is extremely costly,
  • 07:41redundant, and inefficient.
  • 07:43The fact that the landscape of regulate
  • 07:46regulation is fragmented and costly,
  • 07:49that our approach in government
  • 07:51is highly fragmented.
  • 07:52And our approach to how we
  • 07:54leverage the vast data we collect
  • 07:57is fragmented and inefficient.
  • 07:58And you know, really,
  • 08:00with with Abby's vision what we did
  • 08:03with the authors is challenging not
  • 08:05only to reflect on the past 50 years,
  • 08:08but to really offer a vision for the future.
  • 08:10And that was really the idea of
  • 08:12a new deal for cancer that is
  • 08:15not only to address the science,
  • 08:17but a truly comprehensive effort to
  • 08:20tackle the full panoply of challenges.
  • 08:23To eradicate radical cancer and
  • 08:26you'll hear from the coauthors,
  • 08:28my colleagues and of course,
  • 08:30Abby.
  • 08:31But you know,
  • 08:32among the things that just I wanted to
  • 08:34highlight was a really an extraordinary
  • 08:37chapter from David Solid and colleagues
  • 08:40about the advances in treatment,
  • 08:42namely,
  • 08:42targeted immune based therapies,
  • 08:45but also the need going forward to come up
  • 08:48with innovative clinical trial designs,
  • 08:51regulatory flexibility,
  • 08:52the ability to.
  • 08:54Really understands sensing resistance and
  • 08:57also to address diversity and bringing
  • 09:00all these innovations to the underserved.
  • 09:03At the same time,
  • 09:04Charles Sawyers and colleagues talk
  • 09:06about the the vast data we now collect
  • 09:09in clinical care and tumor sequencing.
  • 09:11We're sitting on a goldmine,
  • 09:13but we're so fragmented in that
  • 09:15collection of data that we don't
  • 09:17have the ability to leverage that
  • 09:19for true innovation and they offer.
  • 09:21A lot of ideas and future reforms
  • 09:24of how to reinvent data and privacy
  • 09:27protections Tigard patients.
  • 09:29But to leverage these great datasets
  • 09:32collectively to generate insights you know,
  • 09:36rich shulsky and colleagues talk about,
  • 09:38you know we we created a lot of
  • 09:41government infrastructure to build
  • 09:43cancer care and research by virtue
  • 09:45of the Act 50 years ago,
  • 09:47but we now it's so fragmented we
  • 09:50don't really harness all its power.
  • 09:52So really is,
  • 09:53as we say in the introduction
  • 09:55what's needed now to to move to the
  • 09:58next level is in all hands on deck
  • 10:01approach a new deal that reinvests,
  • 10:03and last week we saw that you know
  • 10:05that is with the Biden moon shot,
  • 10:07and I think the book is so you know
  • 10:10is almost tailor made for what is
  • 10:12needed in the future and what obviously
  • 10:14Biden in the White House are trying to offer,
  • 10:17you know,
  • 10:18before I conclude I I want to,
  • 10:20you know, thank you Gene Russon who.
  • 10:22Worked with Abby and me and
  • 10:24in in creating the book,
  • 10:26and really was tireless in his efforts.
  • 10:29I want to thank Abby,
  • 10:30who's been an amazing partner and really
  • 10:32the visionary and architect of all this.
  • 10:35And then lastly,
  • 10:36I get the privilege of introducing.
  • 10:37I think the next speaker,
  • 10:39who is a great friend and colleague
  • 10:42and a great leader in cancer care and
  • 10:47research who always has made himself
  • 10:50available to me in times when I.
  • 10:53I needed support for family members
  • 10:56with cancer who was really an amazing
  • 10:59mentor during my years at Harvard and
  • 11:01who is now a great leader at Yale.
  • 11:04I want to introduce the physician in
  • 11:06chief of Smilow Cancer Hospital and the
  • 11:08director of the Yale Cancer Center,
  • 11:10Eric Weiner.
  • 11:12Thanks Charlie. Then thanks thanks.
  • 11:14Thanks for your your comments.
  • 11:16There may be a little overlap
  • 11:18between your comments and and mine.
  • 11:19I'm I'm actually not the
  • 11:21supposed to be the next speaker,
  • 11:23so I'm going to move on.
  • 11:24And introduce our next speaker who is Carrie
  • 11:27Gross and Kerry is a professor of medicine,
  • 11:31public health and director of the National
  • 11:34Clinical Scholars Program at Yale.
  • 11:36He's the founding director
  • 11:37of Yale's Cancer Outcome,
  • 11:39Public Policy and Effective Research
  • 11:41Center Effectiveness Research Center,
  • 11:43otherwise known as copper,
  • 11:46and he has coauthored not one but two
  • 11:50chapters in the book, a real hero from.
  • 11:54Like Charlie and Abby's standpoint?
  • 11:58And those chapters are are on pricing
  • 12:00and also on the role play by state
  • 12:03governments in shaping cancer policy.
  • 12:05I called up Kerry before I took this
  • 12:08job because I wanted to know what was
  • 12:11going on in terms of in in terms of
  • 12:15healthcare effectiveness research,
  • 12:16and he very generously on his
  • 12:19sabbatical spend time with me and
  • 12:21reviewed all all that was taking place.
  • 12:23And there were just really rich interactions
  • 12:26between copper and the Cancer Center.
  • 12:28So Kerry.
  • 12:30All yours.
  • 12:31Thank
  • 12:32you and yeah again, thank you Charlie
  • 12:34and Abby for the opportunity to.
  • 12:37Participate in the book and
  • 12:39by writing two chapters I I
  • 12:41get 2 free copies of the book,
  • 12:42so it's well worth it.
  • 12:45So I'll yeah try to keep my comments brief,
  • 12:48but I do want to touch on
  • 12:50both chapters briefly first,
  • 12:52the chapter looking at state
  • 12:54policy had the pleasure of
  • 12:56working with Doctor Deb Schrag,
  • 12:58also with Harvard roots on that end.
  • 13:03Well sorry, I'm having
  • 13:04a cat attacked me here.
  • 13:07Basically, if there was ever any doubt about
  • 13:11the importance of states in public health,
  • 13:13I think the last two years of the COVID
  • 13:16epidemic has been raised that there's
  • 13:18actually been a fourfold very variation.
  • 13:21I just looked it up this morning and
  • 13:23COVID mortality rates across states so
  • 13:25that really underscores the importance of
  • 13:28what states can do in the public health
  • 13:30arena and that pertains to cancer as well.
  • 13:32There's a 7070% variation across
  • 13:35States and cancer mortality rate.
  • 13:37So in Debs and my chapter we looked
  • 13:40at some of the levers that states can
  • 13:44employ to effect. Cancer incidence,
  • 13:46cancer mortality and the patient experience,
  • 13:49and we live in a federalist society
  • 13:53which really does allow states great.
  • 13:58Variation in how they use these
  • 14:00these levers to address cancer care,
  • 14:03cancer access, Cancer Research,
  • 14:04but it's critical of to to look
  • 14:07at how states are doing this,
  • 14:08so Deb and I call for greater transparency,
  • 14:12greater accountability on the behalf
  • 14:14of the federal government to maybe
  • 14:17have some more carrots and sticks with
  • 14:20to address and improve how states
  • 14:23are on our tackling cancer.
  • 14:26The other chapter deals with the cost of
  • 14:29cancer care and this I worked on with Zeke,
  • 14:33Emanuel and Stacey Juice had seen a.
  • 14:36It was a lot of fun bringing our diverse
  • 14:40viewpoints and here we talked about what
  • 14:43I think about is a cancer cost trifecta.
  • 14:47You know, it's common question,
  • 14:49how do we end up with a $200 billion
  • 14:52system of cancer care in our country?
  • 14:55And basically it's too many cancers,
  • 14:58too many treatments,
  • 15:00too many dollars per treatment.
  • 15:02Too many cancers.
  • 15:05First of all, we're an aging population.
  • 15:07Cancer is largely aging related disease,
  • 15:10so we're going to see more and
  • 15:12more cancer as time goes by,
  • 15:14but also to many cancers.
  • 15:16You know,
  • 15:17tobacco still accounts for about
  • 15:19a third of all new cancers.
  • 15:21We've made tremendous progress
  • 15:23in decreasing tobacco use,
  • 15:25but we have a lot of people still
  • 15:27developing preventable tumors
  • 15:29from the tobacco front.
  • 15:31We've also made tremendous progress
  • 15:33on developing new modalities.
  • 15:35To prevent cancer or detect or prevent
  • 15:38cancer death over the past 50 years,
  • 15:40I mean HPV vaccine.
  • 15:42A variety of screening tests called naskapi,
  • 15:44etc.
  • 15:45Those are underutilized,
  • 15:46so too many cancers also gets at
  • 15:50this issue of we're not optimally
  • 15:52using our screening,
  • 15:54but also too many cancers deals with this
  • 15:57issue of over screening and overdiagnosis,
  • 16:01particularly for the older population.
  • 16:03Getting screening tests when.
  • 16:05People have very short life expectancy,
  • 16:07for example,
  • 16:08or overuse of screening that doesn't
  • 16:12have a really solid evidence base
  • 16:14can lead to over to detection of
  • 16:17cancer that may not have caused
  • 16:18a problem in the 1st place,
  • 16:20so too many cancers, too many treatments.
  • 16:23We're in a very.
  • 16:24We're very aggressive society
  • 16:26when it comes to treatment,
  • 16:28so you know our.
  • 16:31System of reimbursement and
  • 16:34finance at every step of the way
  • 16:37is aligned in favor of maximizing
  • 16:40the amount and intensity of
  • 16:43treatment. So we if we reimburse very
  • 16:46heavily on a fee for service basis,
  • 16:49and that substantially contributes
  • 16:51to in some cases over use of
  • 16:55a variety of cancer screening
  • 16:57and treatment modalities.
  • 16:59And if that's over.
  • 17:03As far as over treatment are too many
  • 17:06treatments and as far as too many dollars
  • 17:09to how expensive are our treatments?
  • 17:12Again, it's not just our health
  • 17:16system reimbursement that.
  • 17:17Incentivizes the use of expensive treatments,
  • 17:20but also our system of research.
  • 17:23We are in our regulatory framework.
  • 17:26The FDA has been lowering its bar for
  • 17:30approval of new drugs over the past decade.
  • 17:33In particular,
  • 17:34where now the majority of drugs that are
  • 17:38approved for clinical use by the FDA are
  • 17:41approved by these alternate pathways
  • 17:44such as the accelerated approval process.
  • 17:47This doesn't have as rigorous of a
  • 17:50bar for approval usually does not
  • 17:53have things such as overall survival.
  • 17:56And the challenges that we in
  • 17:59the US increase.
  • 18:01For many years have linked
  • 18:04reimbursement with FDA approval,
  • 18:05so it is usually just a reflex decision.
  • 18:09By and by CMS to pay for.
  • 18:13I'll pay for drugs that are FDA
  • 18:15approved even when it's through
  • 18:17one of these alternative pathways,
  • 18:19so we have a lot of opportunity to
  • 18:23make changes to decrease costs by
  • 18:26hitting each angle of this trifecta
  • 18:29by improving the regulatory process,
  • 18:31improving our screening and cancer
  • 18:33prevention approach,
  • 18:34and redesigning our health care
  • 18:36system to decrease overuse in in, in,
  • 18:38improve, patient centeredness and equity.
  • 18:41I look forward to discussing further.
  • 18:44Thanks Gary. The the matter of
  • 18:47redesigning the whole healthcare
  • 18:49system is of course a simple one.
  • 18:51But you know, we all we all wish that we
  • 18:54could be the individual desire to do it,
  • 18:57but it is really.
  • 19:00It is really something that we have
  • 19:02to tackle it at some point soon.
  • 19:05So our next speaker is someone who I
  • 19:09have known for many years collaborating
  • 19:12between my former institution and and Yale.
  • 19:16And that is Melinda Irwin,
  • 19:18who is the Susan Dwight Bliss
  • 19:21professor of epidemiology and
  • 19:22associate Dean of research at the
  • 19:25Yale School of Public Health.
  • 19:27She is also, thankfully,
  • 19:29the associate director of Population
  • 19:32Sciences in the Yale Cancer Center
  • 19:34and in the core Grant and deputy
  • 19:37Director for Public Health and the Yale
  • 19:40Center for Clinical Investigation.
  • 19:42And together with her Co author,
  • 19:45she's written an important chapter
  • 19:47on the place of public health and
  • 19:49prevention in addressing cancer and
  • 19:51area that I think our health care
  • 19:54system has been somewhat lacking it.
  • 19:58Melinda, please,
  • 20:00thank you. Yes, I'd like to share
  • 20:03with you a bit about our chapter,
  • 20:05and I'd like to acknowledge my
  • 20:07Co authors from the Yale School
  • 20:08of Public Health, Abby Freedman,
  • 20:10Nicole Diesel and Linden Nicolai.
  • 20:13So our chapter focuses on four areas with
  • 20:16really a focus on policy implication,
  • 20:20so tobacco control, obesity,
  • 20:23environmental carcinogens,
  • 20:24and HPV vaccination.
  • 20:25So I'm just going to share
  • 20:26a couple points with you.
  • 20:28That we think are critical because
  • 20:30many of these issues have been
  • 20:33discussed and debated for decades
  • 20:35yet how can we we make further
  • 20:38progress so we know that a third of
  • 20:41all cancer cases are preventable
  • 20:42and public health approaches to
  • 20:44cancer prevention represent the most
  • 20:46cost effective long term strategies
  • 20:48for reducing the cancer burden.
  • 20:50Yet, interestingly,
  • 20:52the United States only directs
  • 20:54less than 3% of its health care
  • 20:58expenditures towards prevention.
  • 20:59Even though the return on investment
  • 21:01from public health interventions is
  • 21:03incredibly high, about 15 to one.
  • 21:06So specifically regarding tobacco.
  • 21:08For decades,
  • 21:09tobacco use has been the leading cause
  • 21:12of preventable mortality worldwide
  • 21:13and is associated with 13 cancers
  • 21:16and is responsible about a half a
  • 21:18million deaths per year and about
  • 21:2050% of all cancer deaths in the US
  • 21:23are attributable to smoking 50% of deaths.
  • 21:28What's concerning?
  • 21:28Those at higher burdens and lower
  • 21:31socioeconomic status groups are driving
  • 21:34substantial health disparities.
  • 21:35The good news?
  • 21:36So is that over the past 20 years
  • 21:38smoking rates have fallen from about 25%
  • 21:41in the 1990s to currently around 14%.
  • 21:45In much of this is due to
  • 21:47tobacco control policies,
  • 21:49so advertising restrictions,
  • 21:51anti smoking campaigns,
  • 21:53cigarette taxes,
  • 21:55smoke free indoor air laws which was
  • 21:57critical and then now most recently
  • 22:00minimum tobacco sales age of 21.
  • 22:03So these policy changes point to
  • 22:06substantive reductions in tobacco.
  • 22:08Overtime,
  • 22:08but they have been uneven across populations.
  • 22:12Fortunately,
  • 22:13the Biden Moon shot initiative
  • 22:16addresses cancer inequities
  • 22:17and improving access to care
  • 22:19including tobacco treatment,
  • 22:21so that hopefully we'll
  • 22:22see continued improvements.
  • 22:25Our chapter also focuses on obesity.
  • 22:27Recent reports estimate that obesity
  • 22:30could overtake smoking as the primary
  • 22:33modifiable cause of cancer mortality
  • 22:36and what's most concerning is as cancer
  • 22:39mortality rates have dropped to by
  • 22:41about 30% since the peak in the 1990s.
  • 22:43During that time,
  • 22:44we've seen an increase in obesity rates,
  • 22:47so there's concern as whether the the
  • 22:50decrease in mortality will be attenuated
  • 22:52because of the increase in obesity.
  • 22:54Rates at present,
  • 22:5640% of US adults are defined as obese,
  • 23:00a BMI of 30 or greater,
  • 23:02and this is a sixfold increase in
  • 23:05obesity prevalence since the 1970s.
  • 23:07We know obesity is associated with
  • 23:1013 cancers and the incidence of 13
  • 23:13cancers in mortality from cancer for
  • 23:1614 different cancers and obesity
  • 23:19also might be associated with worse
  • 23:22adherence to adjuvant treatments.
  • 23:25As well as reduced cancer treatment efficacy,
  • 23:28there are a number of lifestyle
  • 23:30interventions that have been completed
  • 23:32that have shown benefit of these on
  • 23:34various cancer outcomes and currently
  • 23:36there are a number of large scale
  • 23:38trials of lifestyle interventions
  • 23:40on disease free survival and when
  • 23:42those findings are made public
  • 23:43in the next three or so years,
  • 23:46it's hopeful that this will.
  • 23:49Hopefully they'll be positive and
  • 23:51it will cause a shift in how we
  • 23:54deliver lifestyle interventions.
  • 23:55In the clinic of note though,
  • 23:58what is really concerning is
  • 23:59Medicare currently reimburses
  • 24:01for weight management services,
  • 24:03not specific to cancer,
  • 24:05but only 3% of patients who are
  • 24:08eligible are referred for these
  • 24:11weight management services.
  • 24:13So I think the research that we need
  • 24:15to do going forward is really the
  • 24:17dissemination and implementation of
  • 24:18these evidence based findings into the
  • 24:21clinic and community so that we can
  • 24:24improve referral rates as well as treatment.
  • 24:27I'm switching to environmental carcinogens.
  • 24:31These have been identified for more
  • 24:33than two centuries over 200 years and
  • 24:36about 10% of instant cancer cases are
  • 24:40caused by occupational chemical exposures.
  • 24:44However,
  • 24:44certain racial and ethnic groups
  • 24:47in lower socioeconomic populations
  • 24:49experience higher exposures to
  • 24:51known and suspected carcinogens,
  • 24:53so we we must improve and
  • 24:55expand the monitoring.
  • 24:56Infrastructure for chemicals in our
  • 24:59environment and harness the tremendous
  • 25:01potential that we have with laboratory and
  • 25:05informatics based tools and technologies.
  • 25:07Thankfully, the Buydens infrastructure
  • 25:10law will help in improving.
  • 25:13Delivering clean water and
  • 25:16cleaning up polluted sites.
  • 25:19Lastly,
  • 25:19our chapter focuses on HPV vaccination.
  • 25:22Much of this work done by Linda
  • 25:24Niccolai here at the School of Public
  • 25:26Health and as many of you know,
  • 25:28this vaccine helps to prevent six
  • 25:30types of cancer in women and men.
  • 25:32How and there's three vaccines available,
  • 25:36but our HPV vaccination coverage is
  • 25:39a suboptimal in our population and
  • 25:42there's numerous reasons for this.
  • 25:45The primary one might be vaccine hesitancy,
  • 25:48which we're learning a lot about
  • 25:49now with COVID-19.
  • 25:50A key factor might be related to
  • 25:53the lack of middle school entry
  • 25:57requirements for HPV vaccination,
  • 25:59yet schools the schools have had
  • 26:02vaccine requirements in the US
  • 26:05since the 1800s and currently,
  • 26:07even though this this has been made
  • 26:11for other vaccines for children,
  • 26:14only three jurisdictions in the
  • 26:17United States require HPV vaccination
  • 26:20for school entry in contrast to.
  • 26:2251 jurisdictions for T DAP,
  • 26:25so there's a lot of debate over how to
  • 26:29do these school entry requirements as
  • 26:32it infringes on individual freedoms and
  • 26:34parents ability to choose for their children.
  • 26:37But I think there is significant room
  • 26:40for improvement here, so the last
  • 26:43inclosing the point I want to make is I.
  • 26:47I was so incredibly impressed how colleagues,
  • 26:49scientists and clinicians
  • 26:51here at Yale pivoted.
  • 26:53With COVID-19,
  • 26:53with their research efforts and whatnot,
  • 26:56and I believe that as a scientific community,
  • 26:59we need to pivot and double down
  • 27:01on efforts towards improving
  • 27:03access to cancer care and fixing
  • 27:05the structural and systems levels.
  • 27:07Factors impeding equitable care.
  • 27:08And if every one of us prioritizes
  • 27:11HealthEquity and cancer care,
  • 27:14it's likely I think that we could
  • 27:16reach Biden's goal of seeing a
  • 27:1850% reduction in cancer mortality
  • 27:20rates over the next 25 years.
  • 27:23Thank
  • 27:24you. Thank you Melinda.
  • 27:26So I'm next and I wrote this chapter
  • 27:31with Neil Merola colleague of many
  • 27:33years who used to be the chief of
  • 27:36hematology oncology at Case Western,
  • 27:39and now works at Flatiron.
  • 27:42And Neil and I have had some
  • 27:44shared interests over the years,
  • 27:46and we primarily focused on
  • 27:49how cancer has changed for both
  • 27:52the doctor and the patient,
  • 27:54mostly thinking about the patient.
  • 27:56But but since the patient is affected
  • 27:58by the doctor and other clinicians,
  • 28:00that was part of this as well.
  • 28:03When we both started our
  • 28:04careers in the 1990s,
  • 28:06indicating that we are both somewhat old,
  • 28:10cancer was a little
  • 28:11different than it is today.
  • 28:13It tended to be diagnosed in later stages.
  • 28:16There was much more secrecy
  • 28:18around the diagnosis of cancer.
  • 28:21We still see occasionally patients who
  • 28:23don't want to talk about having cancer
  • 28:26and who conceal diagnosis or simply
  • 28:29can't come forward with with with.
  • 28:32Seeking medical treatments,
  • 28:33but that was much more common back
  • 28:3630 years ago and not surprisingly,
  • 28:38both because of later diagnosis and
  • 28:41because of less effective treatment,
  • 28:44the outcome was worse.
  • 28:46Today there are 17 million cancer survivors,
  • 28:50a pretty impressive number,
  • 28:51both in terms of all those
  • 28:53people who have survived cancer,
  • 28:55but the fact that there's
  • 28:56just been so much cancer,
  • 28:58and I think Kerry raised a very
  • 29:00important point that there is in many
  • 29:03situations the over diagnosis of cancer,
  • 29:06particularly in older individuals,
  • 29:08and that has certainly increased that number
  • 29:11and is another problem we need to address.
  • 29:14But as Charlie pointed out,
  • 29:16mortality has has clearly decreased.
  • 29:18Cancer hasn't gone away,
  • 29:20but I think that most of us in the
  • 29:24field see a time when it'll be possible
  • 29:27to say to a man or woman with cancer.
  • 29:31That if they are able to access
  • 29:33medical treatment and if they
  • 29:36consent to medical treatment,
  • 29:37that death is not something that
  • 29:39should be part of a cancer diagnosis.
  • 29:42And the closer we get to making a
  • 29:45cancer diagnosis like the diagnosis
  • 29:47of a strep throat where you take
  • 29:49an antibiotic and it gets better.
  • 29:52Of course the better it will be in,
  • 29:54the less it will be so greatly feared.
  • 29:59Treatments have changed.
  • 30:01They're more targeted.
  • 30:02Sometimes we think targeted
  • 30:04means no toxicity.
  • 30:05That's certainly not the case.
  • 30:06We still deal with very real
  • 30:09toxicities and and immunotherapy,
  • 30:10which of course has been the rave
  • 30:14for the past five plus years,
  • 30:16and which is clearly very effective
  • 30:19and is very appealing because it
  • 30:21harnesses one's own immune system to
  • 30:24kill the cancer can also be very toxic,
  • 30:28and we have.
  • 30:29As we develop,
  • 30:30new treatments need to pay close
  • 30:32attention to the fact that we want
  • 30:34treatments that are both effective and
  • 30:37do not require patients to sacrifice a
  • 30:40great deal to receive that treatment.
  • 30:44The other day I focused a lot on
  • 30:46the doctor patient relationship,
  • 30:48but I'm going to expand that
  • 30:50to talk about the clinician
  • 30:51patient relationship because in
  • 30:532022 ruling not talking about just doctors,
  • 30:57we're talking about doctors and nurse
  • 30:59practitioners and nurses and social
  • 31:01workers and pharmacists, and it's really
  • 31:03a team approach that's so critical.
  • 31:06I do think that there is
  • 31:08something very special about the
  • 31:10clinician patient relationship,
  • 31:11and I don't think that that has
  • 31:14necessarily changed so very much.
  • 31:16And when a person has cancer,
  • 31:18there is the opportunity for a
  • 31:20clinician to walk in through a door into
  • 31:23someone's life and their families life.
  • 31:26And it's a very special moment,
  • 31:29and I've always been.
  • 31:30I've always been moved by the
  • 31:32fact that this is a time when
  • 31:35you can have a huge impact,
  • 31:37and if you choose to walk through that door,
  • 31:39it's a rich experience both
  • 31:41for you and for the patient.
  • 31:42And I don't think that's changed.
  • 31:45That said,
  • 31:46there are things that have changed.
  • 31:50Shared decision making is much
  • 31:52more common than it once was.
  • 31:54I even think about decision making as
  • 31:57similar to eating at a restaurant in a
  • 31:59country where I don't speak the language.
  • 32:02So imagine that I don't speak
  • 32:04a word of French and Frances,
  • 32:06like perhaps a particularly good
  • 32:08example because they they won't probably
  • 32:10try to explain anything to you,
  • 32:12but if I go to that restaurant in France.
  • 32:17I can just take whatever they give me,
  • 32:20which is in my mind the paternalistic
  • 32:22approach to cancer care.
  • 32:24The doctor makes all the decisions.
  • 32:27Alternatively I can I can say, well,
  • 32:32give me whatever you would take yourself,
  • 32:34which is perhaps a little bit better
  • 32:39than than than some other situations.
  • 32:41But if I say that it's not
  • 32:44necessarily individualized for me,
  • 32:46but what I really need is for the
  • 32:49for the person serving me to say,
  • 32:52what do you like to eat at home?
  • 32:54And I'll fix your menu appropriately
  • 32:58to work here.
  • 33:00And in my mind,
  • 33:02that's where that's shared decision
  • 33:04making and it's matching my
  • 33:06preferences with what's available
  • 33:08and that has become ever more common.
  • 33:11But that takes more time for clinicians
  • 33:15and it in many ways can add more
  • 33:18stress to the clinicians life.
  • 33:21Patients are more knowledgeable
  • 33:23than ever before.
  • 33:24The Internet is both a wonderful and
  • 33:26a hopelessly dangerous place to go.
  • 33:28When you have cancer,
  • 33:30particularly if you have a little
  • 33:32knowledge and physicians and
  • 33:35other clinicians.
  • 33:36Have these new stresses in dealing
  • 33:39with patients coming in with many,
  • 33:41many questions,
  • 33:42sometimes with questions that that
  • 33:45they don't feel that they can answer,
  • 33:48and this I think is one of the
  • 33:50factors that has led to the
  • 33:52concern about burnout burnout with
  • 33:53doctors and nurses and others.
  • 33:55But I think it's something that we've
  • 33:57seen particularly in the oncology space,
  • 34:00and it's worrisome.
  • 34:01And we have to think about how
  • 34:04we're going to get past this.
  • 34:06I think one way is to make sure that
  • 34:08we're working with teams of people and
  • 34:11not trying to do everything ourselves.
  • 34:14And then I just want to touch on
  • 34:15very quickly on 2 themes that have
  • 34:17been brought up and one is cost and
  • 34:20one is health care, disparities.
  • 34:22And of course, they're related.
  • 34:24The cost issue is huge and it is
  • 34:27just crazy what some of these new
  • 34:31therapies and new procedures cost.
  • 34:34And as Charlie was saying,
  • 34:36it makes no sense to maximize
  • 34:39reimbursement from a drug so that
  • 34:42you can provide palliative care.
  • 34:44There needs to be appropriate
  • 34:47reimbursement for each and
  • 34:50every one of these therapies.
  • 34:53And finally.
  • 34:54I think health care disparities
  • 34:56is going to become the biggest
  • 34:59challenge we face because as our
  • 35:01therapies get better and better,
  • 35:03it becomes more and more of a travesty
  • 35:06that people can't get those therapies.
  • 35:09And that's true around the world
  • 35:11and it's true in New Haven,
  • 35:13CT and it's something that that
  • 35:16desperately needs to be addressed.
  • 35:18So I think there's a lot that
  • 35:20needs to change in the future,
  • 35:22but I think that we can make progress
  • 35:25if we keep remembering that the
  • 35:28patient needs to be the center of
  • 35:30clinical care the patient needs to
  • 35:32be the center of research questions
  • 35:35and at the same time we have to pay
  • 35:37attention to the well being of those
  • 35:39who are who are taking care of this patients.
  • 35:42So with that I'll end.
  • 35:45Alright,
  • 35:46thank you and fine.
  • 35:48We have two more speakers and next is
  • 35:52Abby who has been briefly introduced,
  • 35:54but I'm going to do a somewhat longer
  • 35:56introduction because unlike the rest of us,
  • 35:58you don't know her as well.
  • 36:00I think so.
  • 36:01Professor Glock is the Alfred M Rankin
  • 36:04professor of law and founding faculty
  • 36:07director of the Solomon Center for
  • 36:09Health Law and Policy at Yale Law School.
  • 36:12She's also a professor of
  • 36:14internal medicine at our.
  • 36:15Medical school and a professor
  • 36:17in the Institution for social
  • 36:19and Policy Studies at Yale.
  • 36:21From November of 2020 to 2021,
  • 36:24she served in the Biden administration
  • 36:26as the lead lawyer for the White House.
  • 36:28COVID-19 response.
  • 36:29I would have been loved,
  • 36:31loved to be there, watching her,
  • 36:33that must have been incredible.
  • 36:35But first for the Biden Harris
  • 36:37transition and then in the White House,
  • 36:39special counsel for the White House
  • 36:41COVID-19 response and that capacity.
  • 36:43Professor Gwac also served as a member
  • 36:46of the White House Counsel's office,
  • 36:48where she was additionally
  • 36:49responsible for health care issues
  • 36:51across the administration,
  • 36:52including the Affordable Care Act.
  • 36:54She's a member of the affiliated faculty
  • 36:57of the Yale Program on Addiction Medicine,
  • 37:00Executive Committee member of Yale's
  • 37:02ISP S Health program and founded
  • 37:05and directs the Yale Law School
  • 37:07Medical Legal Partnership Program.
  • 37:09She joined Yale Law School in 2020 if I
  • 37:13remember from looking her up on Google.
  • 37:15She also went to Yale College and and
  • 37:18and was educated at Yale Law School.
  • 37:23And before coming here was
  • 37:26on the faculty at Columbia,
  • 37:28so I'm I'm going to ask Abby to just
  • 37:31sort of fill in some of the gaps in
  • 37:35the in terms of the chapters that
  • 37:37that we don't have representation for.
  • 37:39And Abby, it's it's really a
  • 37:41pleasure to meet you and to have
  • 37:42you on the panel. Doctor
  • 37:44Weiner, thank you and it's my pleasure,
  • 37:46Richard, welcome you back and I look
  • 37:49forward to many more collaborations.
  • 37:52I I joined the law school in
  • 37:542012 at Doctor Weiner is,
  • 37:56I think juxtaposed the numbers.
  • 37:57So I'm sorry. What did I say?
  • 37:59I want everybody to think I was
  • 38:00hanging around for the last year
  • 38:02as an interloper when I wasn't
  • 38:03actually part of the faculty.
  • 38:04So I've been around for a decade.
  • 38:07But I did just come back last month,
  • 38:09and where I had the privilege of
  • 38:11working with my wonderful friend
  • 38:13and colleague Marcelo Nunez,
  • 38:14Smith worked with all of you.
  • 38:15As well and so thank you for
  • 38:18the generous introduction.
  • 38:19It's it's wonderful to be here.
  • 38:21It is wonderful to be part of this
  • 38:23project and to work with all of you.
  • 38:24You might have heard me saying in the
  • 38:26beginning that the Cancer Center and
  • 38:28ysm in general is my favorite client.
  • 38:29My favorite partner.
  • 38:30I hope we have many more
  • 38:32opportunities to collaborate,
  • 38:33so please come find me if you
  • 38:35ever need a lawyer for anything.
  • 38:36We are here for you.
  • 38:38Working with Charlie has been just a
  • 38:40dream come true and I count my lucky
  • 38:42stars every day to have made a friend
  • 38:44in Charlie to have learn from Charlie.
  • 38:46And part of this project.
  • 38:47So thank you, Charlie for everything.
  • 38:49So,
  • 38:50as Eric noted,
  • 38:51I am the cleanup batter before
  • 38:52Greg and I am just gonna fill
  • 38:54in from some of the chapters
  • 38:55that we wanted to mention to you
  • 38:57that haven't been talked about,
  • 38:58but actually my wonderful Co authors
  • 39:00did an incredible job hitting on a
  • 39:02lot of the high points of the book,
  • 39:04so I think I'll be able to be very
  • 39:06brief 'cause I don't want to bore you.
  • 39:08You know Charlie,
  • 39:09emphasize this first that our approach,
  • 39:12the title a new deal for cancer,
  • 39:13is aimed to evoke an approach
  • 39:15that is much more holistic.
  • 39:16Adjust the science.
  • 39:17The scientific advances in the last 50 years,
  • 39:19so giving us the luxury of
  • 39:21being able to think more broadly
  • 39:23about these kinds of issues,
  • 39:24like equity like financing,
  • 39:26structure or like insurance
  • 39:27and now is the time.
  • 39:29And that is a role for lawyers and non
  • 39:32scientists to play in this cancer space.
  • 39:34Once you take a 360 degree approach,
  • 39:37there's room for more people to
  • 39:39be involved in the progress.
  • 39:41So that's where our book comes in.
  • 39:42And as I noted, a lot of you have
  • 39:44already talked about this broader land,
  • 39:46so I'll just head on a few.
  • 39:47One thing I did when I hit
  • 39:49on was health insurance.
  • 39:50We have a great chapter from Robin.
  • 39:51Yeah, brown at ASCO and the.
  • 39:55Her chapter is about the fact that
  • 39:57health insurance is a significant
  • 39:59predictor of cancer outcomes,
  • 40:01and you know,
  • 40:02while the Affordable Care Act
  • 40:03did a great job on this front,
  • 40:05including eliminating copays for many
  • 40:07kinds of preventative screenings,
  • 40:08including getting more than 20
  • 40:10million people newly insured,
  • 40:11including on eliminating discrimination
  • 40:13based on pre-existing conditions
  • 40:15for more than 100 million Americans,
  • 40:18we still have 12 states that
  • 40:19haven't expanded Medicaid, right?
  • 40:20And that is incredibly low
  • 40:22hanging fruit for cancer progress
  • 40:24that we have to do better on.
  • 40:26The Biden plan has a plan to
  • 40:28try to close that Medicaid gap,
  • 40:30but it has to get through Congress
  • 40:31and we really need to focus on
  • 40:33that when we're thinking about
  • 40:35disparities and things that we can
  • 40:36do quickly in the name of progress.
  • 40:38Second equity.
  • 40:39I'm so glad my colleagues have
  • 40:41already talked about equity.
  • 40:43It's obviously incredibly important,
  • 40:45just as universal health insurance wasn't
  • 40:47front and center on the radar in 1971,
  • 40:49and those conversations you know,
  • 40:51surprisingly,
  • 40:51equity wasn't either a well known
  • 40:53report came out six months after
  • 40:56the National Cancer Act passed.
  • 40:58Highlighting egregious health
  • 40:59disparities and obviously,
  • 41:01COVID has shined a light on
  • 41:02healthcare equity in a way it
  • 41:04wasn't has ever been shined before,
  • 41:06but that doesn't mean that it wasn't there.
  • 41:07And of course it has been there
  • 41:09in the cancer space all along,
  • 41:10and I'm very,
  • 41:11very proud that you know this
  • 41:12project with the six years in the
  • 41:14making was thinking about equity
  • 41:15from the beginning and we have a
  • 41:17couple of just fantastic chapters.
  • 41:182 I want to highlight Otis Brawley,
  • 41:21who had hoped to be here with us today,
  • 41:23but it could not.
  • 41:24What a wonderful chapter detailing
  • 41:26disparity is not just across race.
  • 41:28Put across genders, geography,
  • 41:30and socioeconomics centers,
  • 41:31he cites a statistic that 30% of
  • 41:33Americans with college education
  • 41:35have a lower death rate for cancer
  • 41:37than those without an interesting
  • 41:39fact that education such a predictor
  • 41:41of cancer outcomes he knows
  • 41:43connections to Melinda's chapter.
  • 41:44The fact that cancers that we
  • 41:46can prevent often hit low income
  • 41:48populations and professions more
  • 41:49than other professions,
  • 41:51and he also points out a tragic
  • 41:53irony of our progress,
  • 41:54which is that take this example
  • 41:56he offers which that in 1975.
  • 41:58Black and white Americans had
  • 42:00relatively equal death rates from
  • 42:02breast and colorectal cancer,
  • 42:03and why disparities have emerged
  • 42:05and not been remedy.
  • 42:06And he points out that this is almost
  • 42:08a failure of our progress because
  • 42:10advances in screening diagnostics
  • 42:12and treatment haven't been made
  • 42:14available to everybody equally.
  • 42:15In a companion chapter by Blaise
  • 42:17Polite and Lindsey Wiley,
  • 42:18they talk about efforts in certain
  • 42:20governments to actually address
  • 42:22those very kinds of disparities.
  • 42:23NYC and Delaware both had experiments and
  • 42:27colorectal cancer aimed at increasing.
  • 42:29Access to screening in a very aggressive way.
  • 42:32Both of those cities states were
  • 42:34able to close the gap in screening
  • 42:37across race and in Delaware.
  • 42:39They were actually able to close
  • 42:40the gap and incidents,
  • 42:41which is quite remarkable and
  • 42:43shows what governments can do
  • 42:44when they put their mind to it.
  • 42:453rd Congress.
  • 42:46My own chapter with Rosa De Lauro,
  • 42:49our own congresswoman here in Connecticut.
  • 42:51I've great supporter of the cancer space,
  • 42:53so Doctor Reiner will no doubt get a lot of
  • 42:56time with on his role details.
  • 42:58We detail the role that
  • 43:00Congress has in this space.
  • 43:02Funding is obviously huge as a weapon,
  • 43:04but also as a signifier of what's important.
  • 43:06So I'm obsessed with the statistic
  • 43:08that the entire budget of the
  • 43:11CDC is basically the same.
  • 43:13As NCIS budget for cancer therapeutics,
  • 43:15but that includes everything the CDC does,
  • 43:18COVID prevention, non cancer stuff.
  • 43:20The cancer pieces $300 million
  • 43:22of the $7 billion budget right?
  • 43:24So that's a signal of how unimportant
  • 43:27Congress thinks prevention is.
  • 43:29It's also a signal how hard
  • 43:30it is in the matter of budget
  • 43:32scoring to enact prevention bills.
  • 43:33I can talk about that more
  • 43:35people are interested,
  • 43:35but it's the way Congress scores
  • 43:37bills or the matter of the budget.
  • 43:39D incentivizes investments in prevention
  • 43:41in ways that are very unhelpful.
  • 43:44Congress also has a role to play
  • 43:47in speeding innovation in areas
  • 43:49of R&D where there are many
  • 43:51market failures like rare cancers,
  • 43:52pediatric cancers.
  • 43:53We have several chapters on that,
  • 43:56and just as Charlie mentioned,
  • 43:58as cancers become more individualized
  • 43:59as we start to think of more cancers,
  • 44:02the population for each of those cancers
  • 44:04is going to get to be fewer and fewer,
  • 44:05and we're going to have to find a way to
  • 44:07compensate for market failures or in drugs,
  • 44:09or only go to effect a small amount of
  • 44:12the population and not be as lucrative.
  • 44:16Charles Sawyer chapter as Charlie mentioned,
  • 44:18talks about need for hippo reform and the
  • 44:21data privacy space to facilitate sharing
  • 44:23of genomic data so we can actually make
  • 44:25progress in the data that we collect.
  • 44:27And finally economics.
  • 44:28My colleagues have already talked about this,
  • 44:30so I'll just briefly wind up with it
  • 44:32to say that you know, the book talks
  • 44:34about the landscape of cancer care,
  • 44:36the shuttering of individual practices,
  • 44:38the role that community hospitals
  • 44:39play as both a local Cancer Center,
  • 44:41but a network to a larger big
  • 44:44cancer hospital like Yale.
  • 44:45Some extra interventions are needed
  • 44:47and Ed Vance is absolutely terrific
  • 44:50chapter on cross subsidization in
  • 44:52cancer care as both Doctor Weiner and
  • 44:55Charlie both mentioned this idea that
  • 44:57we subsidized research second opinions.
  • 44:59Palliative care social supports with high
  • 45:03priced therapeutics and diagnostics.
  • 45:05And if Congress is going to insist
  • 45:07on cutting drug prices, as it must,
  • 45:09it absolutely has to be aware of these
  • 45:11connections across the whole cancer space.
  • 45:13We're going to have unintended
  • 45:15ripple effects.
  • 45:16That are going to hurt those least
  • 45:18fortunate and connecting all the
  • 45:19dots this way is exactly what we
  • 45:21hope to do with the book,
  • 45:23and it's been just a privilege
  • 45:24to be part of it.
  • 45:25So with that,
  • 45:25let me just say thanks to Charlie.
  • 45:27Again,
  • 45:27express my enduring affection and
  • 45:29to 2nd his thanks to Eugene Rusyn,
  • 45:31who's just been a phenomenal
  • 45:32support on the book.
  • 45:33OK,
  • 45:34all right back to
  • 45:35you. Thanks thanks thanks that was great.
  • 45:40So our last speaker is Greg Simon
  • 45:43and he has held senior positions in
  • 45:45both Chambers of Congress served in
  • 45:482 presidential administrations was
  • 45:50a senior strategy consultant to a
  • 45:52variety of international technology
  • 45:54CEOs co-founded with Michael Milliken
  • 45:56and LED Fastercures co-founded and LED
  • 45:59the Melanoma Melanoma Research Alliance
  • 46:01and was the senior vice president,
  • 46:04advisor for worldwide policy and
  • 46:06patient engagement and the CEO Holy
  • 46:09Wauka Financial Services company.
  • 46:11Creating unique capital market
  • 46:13opportunities and and and indices
  • 46:15in healthcare and life sciences,
  • 46:17he's developed a reputation as
  • 46:20a visionary strategist.
  • 46:21A dynamic public speaker and writer,
  • 46:24and as an expert analyst of
  • 46:26emerging trends in healthcare
  • 46:28information technology technology,
  • 46:30innovative drug research and
  • 46:32development and patient advocacy
  • 46:34most recently and importantly,
  • 46:36Greg was the President of the
  • 46:38Biden Cancer Initiative and
  • 46:39served as the executive director.
  • 46:41Of the White House cancer Munshaw taskforce,
  • 46:44Greg. Black, glad to have you here thanks.
  • 46:47Thanks for joining us.
  • 46:51Thank you so much, Eric.
  • 46:52And thank you Abby for asking me
  • 46:55to do this many years ago now.
  • 46:59It's a it's a real pleasure.
  • 47:03I want to talk just briefly
  • 47:04about the chapter in the book,
  • 47:06and I've been asked to talk more about
  • 47:08what's coming potentially in the
  • 47:10cancer moonshots recently announced.
  • 47:13The take away from what we did in the
  • 47:15cancer Moon shot may surprise you,
  • 47:17but I think we got more done in
  • 47:19nine months than many people
  • 47:21expected because we weren't doing
  • 47:23it all inside the government.
  • 47:25The reason we were able to get so much done,
  • 47:27in my opinion, is because of the
  • 47:31patient communities engagement.
  • 47:32If you I don't know if I can share my screen.
  • 47:34Am I able to share my screen?
  • 47:37Let me try if you wonder why it's
  • 47:39difficult to track in the government.
  • 47:41Let me give you an example.
  • 47:44Nope, didn't come up. Never mind,
  • 47:46I'll do it later if you want to have
  • 47:48a good time go to the NCI website,
  • 47:50look on the implementation of
  • 47:52the Moon shot link and you will
  • 47:55find the most overwhelming chart.
  • 47:58Of dots and arrows and squiggly
  • 48:00lines that you will ever see.
  • 48:02I have no idea how well the NCI did
  • 48:04in implementing the original cancer.
  • 48:07Mention it is a little hard to tell
  • 48:10if this is new or if this is just
  • 48:13moving the boxes from traditional
  • 48:15R 01 grants and relabeling them.
  • 48:18Cancer Moon shot grants.
  • 48:19That is the first challenge for the
  • 48:22current moon shot is what did the
  • 48:24government actually get done in a
  • 48:26number of these technical programs?
  • 48:28Overseen by literally 100 subcommittees,
  • 48:32that's the first challenge.
  • 48:34How well did we actually do in
  • 48:36the government?
  • 48:37Because I can tell you from the
  • 48:39standpoint of the patient community
  • 48:40whether it's financial toxicity,
  • 48:42caregiver support, transportation,
  • 48:44and help with the day-to-day
  • 48:46expenses of being treated for cancer.
  • 48:48All of those things were bubbled
  • 48:50up from the patient community.
  • 48:53Those efforts,
  • 48:53including the first Cancer Center on an
  • 48:56Indian Reservation and make the Navajo.
  • 48:59Nation Cancer Center staffed by an
  • 49:03oncologist couple from here in Maryland,
  • 49:06those efforts that were that
  • 49:09were engaged in cooperation,
  • 49:11collaboration with the local
  • 49:13communities where the greatest success
  • 49:16stories of the Cancer Moon shot.
  • 49:18And yes, we got $1.8 billion.
  • 49:20And yes,
  • 49:21there were 100 subcommittees at the NCI.
  • 49:24And yes,
  • 49:24the VA and the DOE all had wonderful
  • 49:27programs that they did implement.
  • 49:29But progress is never over and
  • 49:33progress is never permanent.
  • 49:35There is a real challenge today
  • 49:37to move all of this forward.
  • 49:39So where is the next moon shot going?
  • 49:41Well,
  • 49:42I have to say if you're talking
  • 49:44to the patient communities,
  • 49:45you get a very different story than if
  • 49:48you're talking to the cancer community.
  • 49:50The traditional institutional
  • 49:52cancer community asks one question,
  • 49:55where's the money?
  • 49:57That's the least important
  • 49:59question in the future of cancer.
  • 50:01It is not.
  • 50:02Where's the money, it's where's the ideas.
  • 50:04And where are the people?
  • 50:06And I'd like to make a bold
  • 50:08prediction about this.
  • 50:09I have been working for the last year,
  • 50:11focused on AI based drug discovery
  • 50:13companies in the economy,
  • 50:15and trying to bring some of them public.
  • 50:17I think we will have more progress
  • 50:20in cancer treatment and outcomes
  • 50:22from private entrepreneurial
  • 50:24startups then we will from NCI
  • 50:27investment over the next 10 years.
  • 50:29You can come back in 10
  • 50:31years if I'm still here.
  • 50:32God willing and tell me I was wrong,
  • 50:35but from what I see the questions
  • 50:38that need to be asked the
  • 50:39barriers that need to be broken,
  • 50:41the inequities that need to be
  • 50:43destroyed are happening faster in
  • 50:45the private sector and the public.
  • 50:48And as a public servant for
  • 50:49many of my years on this planet,
  • 50:51and someone who believes deeply in
  • 50:53public service that is troubling to me.
  • 50:55So what should we do?
  • 50:56Well, Biden starting off on the right foot,
  • 50:59we we can reduce age adjusted death rate.
  • 51:02That's the critical phrase I
  • 51:05have leukemia since I was 64.
  • 51:07If I'd had leukemia 20 years earlier,
  • 51:09I wouldn't be here.
  • 51:10So I've had a whole decade almost of
  • 51:13bonus years from what I would have had
  • 51:16if we hadn't developed the first FDA
  • 51:19breakthrough accelerated drug in Brewton,
  • 51:21which I've been on for two years,
  • 51:23and I I picked it.
  • 51:24And I say this with great
  • 51:26humor because he's a friend.
  • 51:27I'd made a decision a long time
  • 51:29ago to always take the other
  • 51:31side of the argument from Zeke.
  • 51:32Emanuel, I don't think we need to
  • 51:35put 75 year olds on an ice floe,
  • 51:37and I don't think that just the
  • 51:39price of the drugs is the problem.
  • 51:41The problem is who pays it,
  • 51:43and I was very happy to see in several
  • 51:45chapters we need to take Co pay burdens
  • 51:47off of patients for cancer treatments
  • 51:49and other treatments that require
  • 51:51you to be on a drug to save your life.
  • 51:54We need to take the price of the
  • 51:56drug outside of the people who can
  • 51:58afford to pay and charging more
  • 52:00for the people who can't afford
  • 52:02to pay and reverse that scenario.
  • 52:05And in terms of how we're going to do that
  • 52:09and how the cancer Moon shot can do that.
  • 52:11This is not necessarily a
  • 52:13government solution I think,
  • 52:14and I have been working on for many years,
  • 52:16but private solution,
  • 52:17you know,
  • 52:18we spend $21 billion a year on migraines.
  • 52:22That's the same amount we spend on wheat.
  • 52:25There is a massive futures market
  • 52:28and derivative market for wheat
  • 52:30that stabilizes prices that
  • 52:32keeps bread from costing $10.
  • 52:34A loaf that keeps farmers from
  • 52:35going out of business when there's
  • 52:37a bad year or too good of a year.
  • 52:39We don't have that in healthcare,
  • 52:41but we will soon and I'm hoping
  • 52:43that we'll we'll see an immediate
  • 52:45change in the problems that drive
  • 52:48prices higher and higher and higher.
  • 52:50Now the RPH program,
  • 52:52which has been much ballyhooed
  • 52:54by people like me for 10 years.
  • 52:57Is in grave danger because we have
  • 52:59nobody who is currently leading the charge.
  • 53:01The tragic resignation of Eric
  • 53:03Lander after a series of bad
  • 53:05incidents has left the movement in
  • 53:07the White House somewhat leaderless,
  • 53:09and I'm hoping that the Congress
  • 53:11will take the reins,
  • 53:12put it independently of the United H,
  • 53:15and give it the mandate we
  • 53:16all want it to have.
  • 53:17Do wonderful hard things,
  • 53:18and if you fail, it's OK.
  • 53:21Don't do anything anybody else would do.
  • 53:24That's the mission for a DARPA like agency.
  • 53:27And as far as the moon shot goes,
  • 53:29although everybody thought Eric
  • 53:30Lander was going to run it,
  • 53:31it's really always going to have
  • 53:33been run by Daniel Carnival.
  • 53:35My deputy in the first man shot
  • 53:37and the challenge for the current
  • 53:39moon shot is how do we get people
  • 53:41to stop talking about money and
  • 53:42what's going to go into the cancer
  • 53:44centers and the NCI and start talking
  • 53:46about how are we going to engage with
  • 53:49the innovators in the private sector
  • 53:51and the patient groups who are being
  • 53:54very innovative today to build a new?
  • 53:57Institution for Cancer Research
  • 53:59that encompasses all of society,
  • 54:01not just the campus here in Bethesda,
  • 54:04that to me is the biggest challenge.
  • 54:06It is time to rethink our institutions.
  • 54:09We have had them the same way
  • 54:12since Vannevar Bush's contract,
  • 54:13and that is not right.
  • 54:15It is time to rejuvenate to to redecorate
  • 54:19and to bring younger people in.
  • 54:22And it might as well say it.
  • 54:24I wish we would give it an early
  • 54:26out to everybody at NIH and NCI.
  • 54:28Who's over the age of 70.
  • 54:30It is time to bring the next
  • 54:32generation into the building,
  • 54:33but they can't get there for all
  • 54:35the seats are taken so I know
  • 54:37I've sort of expanded my time
  • 54:39and maybe expanded my license,
  • 54:41but I've I work with this everyday.
  • 54:44One last point I found out yesterday
  • 54:46two different people I know have cancer.
  • 54:48One of them found out from a text.
  • 54:52That was sent by an AI engine
  • 54:54because his medical report showed
  • 54:57he had metastatic colon cancer.
  • 54:59He's a cancer doctor.
  • 55:01He was shocked that he could
  • 55:03get a text without a human being
  • 55:05attached to it to tell him that.
  • 55:07Another young woman in her 30s was diagnosed
  • 55:11with CLL during a breast cancer exam.
  • 55:13They didn't give her any
  • 55:15information about what happens next.
  • 55:17She called me and I had to do.
  • 55:20Both of these are wrong.
  • 55:21Both of these have to be fixed.
  • 55:23We have got to provide people
  • 55:25and environment to deal with the
  • 55:27cancer diagnosis that does not put
  • 55:29them on the on the on the spot
  • 55:32to do everything themselves.
  • 55:33Whether you're a cancer doctor
  • 55:35or a mother in their 30s,
  • 55:37we must do a better job.
  • 55:39And in 2022 I would have hoped
  • 55:41we would have done it by now.
  • 55:43But with your help and all the people
  • 55:45on who wrote chapters in the book,
  • 55:46we can get there.
  • 55:48But we have to be very honest
  • 55:50about what the problems are today.
  • 55:52Thank you.
  • 55:56Thanks, thanks very much Greg.
  • 56:00I think we might have time for one
  • 56:03or two questions Max, so I guess
  • 56:06I'm supposed to look in the chat,
  • 56:09but I don't know that I see any Renee.
  • 56:13There was one question Eric, about.
  • 56:16Their fear about moving too fast on
  • 56:18cancer progress because it will feel
  • 56:20politicized like the COVID vaccine.
  • 56:21I don't know if Greg you want
  • 56:23to take that or somebody else.
  • 56:24I already already responded to that
  • 56:26text in the chat and said no and no.
  • 56:29I don't think the public is
  • 56:30generally aware of the time it
  • 56:32takes to develop new cancer cures.
  • 56:34And when things happen fast in cancer,
  • 56:36it's still slow in the real world
  • 56:39in terms of politicizing cancer,
  • 56:42all I can tell you is that we
  • 56:44helped during the cancer Moon shot.
  • 56:46People ask for our help from
  • 56:48both sides of the hill from both
  • 56:50sides of the political parties.
  • 56:52I have never in all my speeches
  • 56:55where I'm pretty obviously
  • 56:56my politics are pretty clear.
  • 56:59I have never had anybody accused me
  • 57:01of having a democratic view of cancer,
  • 57:03so I think this is 1 Safe Harbor
  • 57:07that we can all work on together.
  • 57:10Yeah, I don't think people would accuse you
  • 57:13of not being clear about your thoughts.
  • 57:15We appreciate it. You know,
  • 57:18I think that the the theme of disparities
  • 57:21has come up over and over again.
  • 57:23I think it's really an important take
  • 57:26away from this and I'm just going to
  • 57:28reiterate what I what I said before.
  • 57:30I think that both in terms of clinical
  • 57:33care and in terms of research,
  • 57:35if you put the patient in the center and and
  • 57:38reformulate everything around that concept,
  • 57:42I think we would.
  • 57:43We would do ever so much better.
  • 57:46In terms of clinical care, Greg,
  • 57:47you brought that up and you did.
  • 57:49In terms of research as well,
  • 57:51it's it's really key.
  • 57:54I devoted the epilogue of my chapter
  • 57:56in the book to exactly this point, and.
  • 57:59I don't think as a liberal from the
  • 58:0360s I thought we had made a lot
  • 58:06more progress than we had in racial
  • 58:08and equity and as a cancer patient,
  • 58:11and I realize how fortunate I have been.
  • 58:13I really understand now how
  • 58:15little progress we've made.
  • 58:17It is the most important thing we can do.
  • 58:20One small example, the head of the
  • 58:22national Minority Quality Forum,
  • 58:23was told by CMS that he could not
  • 58:26have access to all the Medicare
  • 58:28data like other people can.
  • 58:29Only 20% of it and he told them
  • 58:32I can't do a study of racial
  • 58:35inequities on 20% of Medicare.
  • 58:37It won't show up because
  • 58:39it's so small in that sample.
  • 58:41So my friends and I raced into
  • 58:43action to give him access to all
  • 58:46of the Medicare data other ways,
  • 58:48but this is an example of unthinking
  • 58:51discrimination of unintended discrimination
  • 58:53that has the effect of discrimination.
  • 58:57Thanks Charlie, I just wanna give
  • 58:59you a chance to sort of wrap up.
  • 59:02Eric, I really appreciate you giving
  • 59:05us the opportunity to share the
  • 59:07book and thanks to the authors.
  • 59:09I mean frankly, hearing from me should
  • 59:12view is really inspiring and I frankly
  • 59:14really appreciate the opportunity to
  • 59:17reconnect with all my friends and
  • 59:19colleagues at at Yale and Smilow several,
  • 59:22or have been texting me during the session.
  • 59:25I've been paying close attention, by the way,
  • 59:27but it's still great to connect and Eric,
  • 59:30I just want to say how fortunate.
  • 59:32Yeah, and smile OR to have you as a leader.
  • 59:36So looking forward to great things
  • 59:38from you and all the amazing
  • 59:41people at the institutions.
  • 59:43We all just do our best well listen,
  • 59:46thank you all.
  • 59:48It was really great today.
  • 59:50I think this was again as
  • 59:51I said in the beginning,
  • 59:52something a little different
  • 59:53and I hope people enjoyed it.
  • 59:55And thanks to the audience
  • 59:57for spending the time with us.
  • 59:59Bye bye.
  • 01:00:05Eric, thanks so.