Will better implementation of known evidence be more effective than 'moonshots'?

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Published: 29 Mar 2017
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Dr William Mackillop - Queen’s University Cancer Research Institute, Kingston, Canada

Dr Mackillop speaks with ecancer at EBMCI 2017 about achieving positive outcomes in treating patients with existing techniques and medications which do not rely on the 'Cancer Moonshot' scheme of accelerating research.

He contends that improving access to preventative strategies and wider availability of best care currently available would have greater impact in the near future, rather than deepening the divide between cutting edge research and the wider world of health care.

I was asked today to comment on the proposition that it’s more important to apply evidence about treatments and prevention strategies that we know actually work than to wait for ‘moonshots’ to provide us with new innovative treatments that are going to cure cancer. So that was my debating point, really. The question was rhetorical because it was clear from the way that it was phrased that the writer believed, in fact, that there were other things that could be done than simply wait for our ultimate salvation by the finding of a single universal cure for cancer.

What were some of the key points from your talk?

Most of the recommendations of the Blue Ribbon Committee that Joe Biden established to develop a strategy to increase the pace of cancer research in America, most of them were recommendations to do things that would lead to fundamentally new discoveries about cancer and new technologies that would increase the effectiveness of cancer treatment and decrease its toxicity, leading to a higher proportion of cures.

I don’t think you need to wait for a ‘moonshot’, for the discovery of some fundamental new discovery that is going to cure cancer to improve the outcomes of cancer in the near future. Making better use of the knowledge and the technologies that we have available offers a much higher chance of yielding real benefits for the community in the next 10-20 years. In fact, my view is that if everyone by the year 2030 had the best access to the best preventive strategies and treatments that were available in 2010 that that would have a huge impact on the burden of cancer. I speak there from the perspective of someone in the developed world where I think there’s a twenty year gap often between what could be achieved for patients with cancer and what is actually achieved. The gap is obviously even wider in the developing world. It’s absolutely true that if everyone in a country like India had access to the best types of preventive strategy and treatment that were available in 2000, if they were in that situation by 2030 that would have a huge impact on the burden of cancer. So we don’t need to wait for ‘moonshots’.

Recognising, of course, that all this knowledge that we want to apply more fully was originally developed by yesterday’s ‘moonshots’, by discovery research that was done in the past. So I don’t want to devalue the initiative to increase the scope of fundamental research; I just think it’s really important that we should do health systems research to learn how we can better use the things that we know work and we have available already.

Is there anything else you would like to add?

In Canada, for example, and I think in India too, most of the money that is spent on research is spent on fundamental research. It’s spent on biomedical research and some of it is spent on clinical research and very little is spent on health systems research and population health research. That’s a problem because if Canada, if my own country, were actually to stop doing biomedical research altogether that would be a significant loss because Canada does punch above its weight as a fairly small nation. But we are still a very small contributor to the global pool of research on cancer biology. So it’s not actually imperative that we do biomedical research in Canada but it is utterly imperative that we do health systems research because health systems research is very non-generalisable. We can’t borrow information about how Britain’s health systems work and apply them directly in Canada because our system is fundamentally different. So the health services research is context specific and if you don’t do your own health services research no-one will do it for you. So if one wants to improve the functioning of India’s health system there must be Indian health services research that is knowledge generated in that context and about that context. Without that you don’t know where to start to improve the system.

In contrast, you can borrow biomedical knowledge and the results of clinical trials from elsewhere and they probably do apply in your own country. So health services research, it’s got a very high chance of generating immediately useable product, so you get immediate benefits out of it, but that’s knowledge that doesn’t travel very well. You have to do your own, so that was what I advocated for here, that it should be part of the research strategy for the nation that they should do health services.

I was advocating for making health systems, health services, research a high priority in India. I’m not advocating that one should take away resources from the excellent biomedical research that happens here but there has to be a recognition that health systems, health services, research  provides knowledge that is essential to the improvement of the cancer system in India. Generating more of this knowledge would help the country to achieve what is achievable in cancer control within the limits of existing knowledge and technology and without waiting for the fantastic new treatment that’s going to be the result of the Moonshot Initiative, or might not. So that provides some certainty of benefit in the short-term rather than uncertain benefits in the long-term.