More than 50 years since the United States declared a war on cancer, the disease remains the second leading cause of death among Americans.
According to federal data, cancer killed nearly 608,000 Americans in 2022, behind only heart disease.
Yet researchers, oncologists and advocates say the scientific and political landscapes today are dramatically different than in 1971, when then-president Richard Nixon signed the National Cancer Act into law.
In the early part of the 20th century, cancer was misunderstood, especially compared to infectious diseases, and rarely talked about in public. Federal spending on research was minimal, and there was barely any focus on treatment.
Cancer was an "uninterpretable black box" throughout much of that period, said George Demetri, an oncologist and director of the Sarcoma Center at the Dana-Farber Cancer Institute in Boston.
But that's changed in recent years.
"The thing about cancer is we're starting to understand it so that we really can engineer a solution. That's what's so exciting," Demetri said. "We get down to the mechanism of how cancer works. We see the short circuits. And then we can say, how do we fix that short circuit so that people can live much longer or we can even cure this disease?"
The National Cancer Act was introduced and signed after a decades-long campaign by activists and lobbyists to pressure lawmakers and raise support in the media for increased funding.
In his State of the Union address in January 1971, Nixon called for $100 million to launch a campaign to cure cancer, saying "the same kind of concentrated effort that split the atom and took man to the moon should be turned toward conquering this dread disease."
He signed the National Cancer Act in December, which allocated a record $1.6 billion for cancer research over a three-year period. But the investment and rhetoric led to unrealistic expectations— lawmakers crafted the bill with the plan to find a cure for the most common types of cancer within five years.
The law launched a new era of government investments into cancer research and prevention, but progress was slow in turning that research into advances in treatment. The death rate climbed steadily.
Cancer’s ‘high water mark’
According to Centers for Disease Control and Prevention data, the death rate hit its peak in 1991 at 215 deaths for every 100,000 people, largely because of a rapid increase in lung cancer deaths among men as a consequence of the tobacco epidemic.
That year was "the high water mark" for the death rate, said American Cancer Society chief executive officer Karen Knudsen.
In the years following, Knudsen said the government "significantly doubled down" on its investments in research.
The National Cancer Institute’s (NCI) annual budget increased from $227 million in 1971 to $1 billion in 1980, $6.01 billion in 2019 and $7.3 billion in 2023. President Biden proposed $7.8 billion in his FY 2024 budget.
Cancer is personal for Biden, and he has made a point to prioritize funding for research. Biden's son Beau died from brain cancer in 2015, possibly linked to his time spent in Afghanistan near a toxic burn pit.
Biden launched the Cancer Moonshot as vice president in 2016, and then reignited it last year.
He pledged to "end cancer as we know it," and reduce the death rate from cancer by at least 50 percent over the next 25 years.
Some cancer researchers and health experts questioned the specific language and goals, afraid of overpromising and repeating the mistakes of the Nixon era.
"I don't like the idea of moonshots. Moonshots are when you really understand something, like we understood engineering in the 1960s ... so that by 1969, we could have a person walk on the moon. We don't understand cancer yet to that degree," said Demetri of Dana-Farber.
Still, Demetri said the goals of the initiative are laudable and he appreciates that it has bipartisan support. The $1.8 billion authorized through the 21st Century Cures Act runs out this September and Congress seems interested in keeping up the momentum.
Since 1991, the death rate of cancer has declined by 33 percent. Advances in treatment and novel therapies have steadily improved survival.
The five-year relative survival rate for all cancers combined has increased from 49 percent for diagnoses in the mid-1970s to 68 percent for diagnoses during 2012 to 2018, according to a report from the American Cancer Society.
"There is every reason to feel that the national investment in cancer research has resulted in breakthroughs that are saving lives," Knudsen said. "We are in an unprecedented time, looking at strategies for prevention as well as early detection and more personalized treatment. It's a completely new era for the pace of discovery, and also for the impact of discovery."
Progress and ‘pockets of success’
In the past 30 years, scientists have developed effective treatments for lung cancer, breast cancer, testicular cancer and Hodgkin’s lymphoma. Researchers have also developed vaccines that prevent HPV, which can cause cervical cancer, and hepatitis B, a leading cause of liver cancer.
"We've gone to monoclonal antibodies which didn't exist [50 years ago]. Second of all we've gone to cellular therapies, which didn't exist. Third, we've learned a lot about cancer cells ... there's a huge amount of progress that's been made in understanding cancers and ... developing interventions that are effective for them," said Ezekiel Emanuel, an oncologist, professor at the University of Pennsylvania and former White House adviser.
The treatments being developed are "not just a new drug. They're totally new ways of treating cancer," Emanuel said.
Some of the advances are treatments that help to lower the death rate and improve the quality of life of cancer patients, while others are more about preventing cancer in the first place.
"The best strategy is not to get cancer where it's avoidable," said Knudsen. "So some of the declines are due to prevention. Tobacco cessation all on its own has led to significant reductions in lung cancer," and awareness of the dangers of prolonged sun exposure has led to decreases in melanoma.
Despite the advances, progress overall is uneven and significant racial and economic disparities remain. Survival rates are lower for Black individuals than for White individuals for almost every common cancer type.
Health insurance also makes a big difference — people who have insurance are more likely to survive cancer.
"We are having pockets of success for those cancers that we have been able to better understand. A lot more needs to be done," said Jeff Allen, CEO of Friends of Cancer Research.
There are about 200 different kinds of cancer, and the diagnoses for some of them are still grim.
Pancreatic cancer, for instance, is the third leading cause of cancer death in men and women combined, according to the American Cancer Society. Patients typically only live a few years.
"Unfortunately, not many new treatments have been successful in treating pancreatic cancer,” Allen said. “That is a particularly difficult tumor type to penetrate due to the biology of that tumor, that seems to be unique from many other tumors. And so we still need to think about what new approaches will be necessary for future success.”
The death rate for women with uterine cancer has also remained high over the last 40 years, suggesting not just a lack of advances in treatment but also a lack of research in general.
And studies have shown gynecologic cancers are significantly underfunded compared to other types of cancer.
According to the most recent figures available, the NCI spent about $17.5 million on uterine cancer in 2018 — 24th on the agency's list of research areas — and an estimated $13.6 million in 2020. That’s despite Uterine cancer being the fourth most commonly diagnosed cancer in women or people assigned female at birth, and cases are rising.
Experts have also noted that advances in cancer treatment exacerbate existing disparities. Targeted, cutting-edge therapies can be enormously helpful, but not if they only benefit the wealthy.
"We have a lot of good treatments. We have to make sure everyone gets them, and financial toxicity is a main problem there. The out of pocket costs are still really high," Emanuel said.
"You're saying a cancer treatment should be twice the average salary of an American family? There's something wrong with that equation," he said.
Geographic disparities also play a role. Cervical cancer can now be virtually eliminated because of the development of the HPV vaccine, but there are wide differences in coverage from state to state.
Emanuel said he thinks the U.S. has made great advances in developing new treatments, but there's still more that can be unlocked.
"We need additional new treatments, especially for some of the harder-to-solve cancers — sarcomas and glioblastomas and gastric and other cancers. So yeah, I think both of these things are true. We've made a lot of progress with new treatments, and we need additional new treatments," Emanuel said.
"We have to recognize that we're building on strength. We have to accelerate it, but we're building on strengths and I think the fruits of the National Cancer Act, you know, after 50 years, are finally coming to bear."
