At a Glance: NCI’s Division of Cancer Prevention

Transcript

• 00:00Hey everybody, I'm Kerry Gross
• 00:02director about cancer outcomes.
• 00:04Copper Center and also primary care doc.
• 00:08And with that background,
• 00:10it's a particular treat to welcome
• 00:13Doctor Philip Castle to join us today.
• 00:16Doctor Cassell's work has been
• 00:19foundational in our understanding of
• 00:21the etiology and prevention of HPV,
• 00:24associated cancers and cancer prevention
• 00:26with General Electric Castle received
• 00:29his PhD in Biophysics, actually.
• 00:31A masters in public health
• 00:33from Johns Hopkins,
• 00:35who was previously the Chief
• 00:37scientific officer at the American
• 00:40Society for Clinical Pathology.
• 00:42There's been a principal investigator for
• 00:44more than 15 years of self initiating,
• 00:46conducting and reading by several
• 00:49large NCI sponsored electoral
• 00:52and clinical research studies,
• 00:54both in the US and abroad.
• 00:56Is that the party is widely appreciated.
• 00:59It's contributed to virtually every
• 01:01major guidelines regarding regarding at
• 01:04cervical cancer screening and prevention,
• 01:06and his work really has extended globally.
• 01:09His papers have been cited more
• 01:11than 40,000 times in aggregate.
• 01:13Currently Dot the castle serves as the
• 01:16director of the Division of Cancer
• 01:18Prevention and Control at the NCI.
• 01:21Working overseas.
• 01:21The conduct and support our
• 01:23research in cancer prevention,
• 01:25early detection and screening.
• 01:28And now is a particularly
• 01:31relevant and timely setting for
• 01:33Doctor Castle to present to us.
• 01:35This is the 50th anniversary
• 01:37of the National Cancer Act,
• 01:39and as we reflect on the role of
• 01:42science in public health and society
• 01:44in general and in the efforts
• 01:47against cancer in particular,
• 01:49the role of prevention is a means
• 01:51to decrease the burden of cancer.
• 01:53This clearly is central work,
• 01:55so thank you for joining us today.
• 01:57Doctor castle.
• 01:58And we look forward to your comments.
• 02:01Thank you so very much.
• 02:02It's a real honor to be here and
• 02:04it's a real honor to lead the NCIS
• 02:07division of cancer prevention.
• 02:08Today I'm going to give you sort
• 02:10of a broad overview,
• 02:12recognizing as I learned that many of
• 02:14my colleagues don't actually understand
• 02:16what the division of cancer prevention does,
• 02:18how it's different from the other divisions,
• 02:21but also to.
• 02:23Highlight the work that we
• 02:25support and to engage you,
• 02:27hopefully in the future.
• 02:28In in some of these cancer
• 02:31prevention activities.
• 02:33So just a few disclaimers that get started,
• 02:36opinions expressed or mine should
• 02:38not be interpreted as representing
• 02:40official viewpoints of EU.
• 02:42S.
• 02:42Department of Health and Human Services,
• 02:44the National Institutes of Health,
• 02:45the National Cancer Institute,
• 02:47or the Division of Cancer Prevention.
• 02:50My comments are informal and should not be
• 02:52taken as a signal for funding priorities.
• 02:54I will speak in broad terms
• 02:55of what I think is important,
• 02:57where I would like to see the science
• 02:59of cancer prevention head towards
• 03:00in the future and my aspirations,
• 03:02whether and when I or we can
• 03:05implement those priorities depends
• 03:06on many factors beyond my control.
• 03:09I wish that weren't the case,
• 03:10but it is in fact the case I wanted
• 03:13to highlight the burden of cancer
• 03:14and I know you all know this,
• 03:16but it's it's.
• 03:17It's the starting point for this discussion
• 03:20or any discussion about prevention.
• 03:23Which sometimes I think UM, sort of
• 03:26gets put into the second row here, but.
• 03:30As you can see in the slide here on the
• 03:33in the left panel is the expenditures
• 03:36per billions of dollars annually for not
• 03:39seeing your slides, we need to share.
• 03:43See what's going on here, sorry.
• 03:59My apologies, can you see that now?
• 04:03Perfect thank you.
• 04:04OK so in the left panel is
• 04:07by cancer expenditures and
• 04:09billions of dollars annually.
• 04:11And then for the most common cancers
• 04:13are the most lethal cancers you
• 04:15can see that it's not billions,
• 04:16but it's tens of billions of dollars,
• 04:19and in fact the national costs of
• 04:21cancer were estimated to be 190 billion
• 04:23in 2015 and now 209 billion in 2020,
• 04:27an increase of 10% over that period of time.
• 04:30And that doesn't really even account
• 04:32for the hidden costs of cancer,
• 04:34which is a product approximated
• 04:36to be 100 billion.
• 04:37And as I'll show you the next slide,
• 04:40we've made a lot of advances.
• 04:41Certainly in the treatment of cancer.
• 04:43But we still have 1.5 million cancers
• 04:46and .6 million related deaths every year.
• 04:49And just to give you a perspective and
• 04:52on that as bad as COVID was and is a
• 04:57point 6 million deaths is almost two full.
• 05:02Not quite,
• 05:03but almost twofold more deaths than
• 05:05those than that caused by COVID.
• 05:08So, uh,
• 05:09what what's happened over the last 45 years?
• 05:13You can see that arguably,
• 05:16I'm here are there's a CDC data
• 05:18rate per 100,000 of the population.
• 05:20We've really not made any significant
• 05:23headway in the incidence of
• 05:26cancer in males and females.
• 05:28There's a sort of a peak
• 05:30in males in the early 90s,
• 05:31and that's come back down,
• 05:32but it's about the same level as it was in
• 05:361975 and in females it's gone up slightly.
• 05:40I mean partly in dude and
• 05:42aging population to be sure.
• 05:43But you know, these are not the
• 05:45kinds of numbers we'd like to see.
• 05:47Certainly we've made some advances
• 05:50in the management of cancer.
• 05:52In survival,
• 05:53particularly well in both in both sexes,
• 05:57maybe perhaps more in males than females,
• 06:00but I would say also here that even
• 06:04preventing cancer related death.
• 06:06It's a long life or longer life of
• 06:11significant morbidity and lower
• 06:13quality of life to live with cancer,
• 06:17as I know from my own family members.
• 06:20So the mission of the division of
• 06:23Cancer prevention is as follows.
• 06:25The NCI Division of Cancer Prevention.
• 06:28Lead supports and promotes
• 06:30rigorous innovative research and
• 06:32training to reduce risk burdens.
• 06:34Consequences of cancer to improve
• 06:36the health of all people,
• 06:37and you'll understand this a little
• 06:39better as I go through and give
• 06:41you a this at a glance of view of
• 06:44the division of cancer prevention.
• 06:45Uh,
• 06:46just to highlight that I almost do nothing,
• 06:48this everything that you're going
• 06:50to hear about it has to do with
• 06:52an amazing staff.
• 06:53Uhm,
• 06:54shown here we have groups focused on
• 06:58method more methodologic approaches
• 07:00or exposures and we also have organ
• 07:04specific areas of research as well.
• 07:06I will highlight some of these,
• 07:08but that is not to say that there
• 07:09I mean we could talk for hours
• 07:11about what everybody is doing.
• 07:15Uh, I put up this translational continuum,
• 07:17and again, you'll see why here in a
• 07:19moment to really sort of highlight this,
• 07:22the stepwise development of interventions
• 07:25and and, and therefore where we fit into
• 07:28that from basic science to translation
• 07:30to humans translation to patients,
• 07:32translation to practice and translation
• 07:35in their community. Showing up.
• 07:37This in terms of the divisions
• 07:39and these are approximations.
• 07:41I wouldn't say that any one of of
• 07:44these you know nobody's limited
• 07:46perception completely to this area,
• 07:49but I would say 90 to 95% of the work.
• 07:52Each of the division is sort of
• 07:54represented here and in over with an
• 07:57overlay of the translational continuum.
• 08:00We really focus on the.
• 08:03An innovation to prevent cancer
• 08:06and to manage symptoms.
• 08:08As I would talk about later
• 08:10and try to you know.
• 08:11So we identify and we do early
• 08:13validation work with the hopes that
• 08:15successful strategies then get more
• 08:17or less handed off to the division of
• 08:20Cancer Control and Population Sciences.
• 08:22So we really there really are two.
• 08:25Population science groups at the
• 08:27NCI were a little bit sort of.
• 08:30I would say the forgotten group or the
• 08:33the the other population science group.
• 08:36I think people are generally more
• 08:38familiar with cancer control
• 08:39and population sciences because
• 08:40it tends to dovetail more.
• 08:44More easily with the Cancer
• 08:46Center in the in those renewals,
• 08:48particularly related to.
• 08:51Uh, uh, outreach?
• 08:52Uh, we're actually probably more
• 08:54aligned in terms of the work we
• 08:56do with the division of cancer
• 08:58treatment and diagnosis, Albert.
• 09:01We spend a lot more.
• 09:03We invest a lot more in
• 09:05treatment and diagnosis.
• 09:06We work closely with the
• 09:07division of Cancer Biology,
• 09:09particularly on identifying pathways
• 09:11for cancer or carcinogenesis
• 09:12that can be then translated into
• 09:15prevention strategies and then
• 09:17the intramural program with the
• 09:19center of Cancer Research and
• 09:21division of cancer epigenetics,
• 09:23which we're increasingly working
• 09:25closely with to try to get
• 09:28their innovations into clinical
• 09:30practice and into public health.
• 09:33So and you all know this,
• 09:35but it's always useful to
• 09:37sort of declare these things.
• 09:40Cancer prevention is really, really hard.
• 09:43There's certainly an event
• 09:44bias or what I call an event by
• 09:47success is the absence of events,
• 09:48and therefore there are no champions.
• 09:50This is also referred to
• 09:52as the prevention paradox.
• 09:54Our first mission is to keep
• 09:56healthy people healthy.
• 09:56First do no harm,
• 09:58and I'd say this applies more to
• 10:01public health and even medicine,
• 10:03and I point out that you know when
• 10:05we do screening people think of
• 10:06screening as a one step process,
• 10:08but it's really a two step process.
• 10:10The first step in screening is
• 10:12to tell healthy people there.
• 10:13Healthy and they don't need to
• 10:15be screened again for whatever
• 10:16is an acceptable interval.
• 10:18And then among the positives
• 10:19we we try to rule in.
• 10:21Who needs immediate care.
• 10:23But it's also important to
• 10:25remember in the general population,
• 10:27most people at any one time will not be.
• 10:30Uh, you know,
• 10:31will not get cancer or particular
• 10:33cancer so 49 out of 50 women would never
• 10:36get cervical cancer if we did nothing of all.
• 10:38We didn't screen them.
• 10:39We didn't vaccinate them,
• 10:41etc etc.
• 10:41It's a high bar because of the rare
• 10:44events and the relatively small benefits,
• 10:47and there's very little tolerance
• 10:49for toxicity and and then the final
• 10:52barrier if you will, is there.
• 10:53I think there's a perception that
• 10:55there's no money in prevention and I
• 10:57I would challenge that only to say that.
• 11:00Nobody wants to get cancer,
• 11:01and so there's a lot of people out
• 11:03there that don't want to get cancer.
• 11:04I mean, uh, you know,
• 11:06so that I think that there's actually,
• 11:08you know, given the big denominator,
• 11:09there's a big opportunity for industry
• 11:12to get involved in and prevention.
• 11:14I think that what scares them off is
• 11:17the the the expense and difficulties
• 11:21of doing large trials to demonstrate.
• 11:24Efficacy and effectiveness and the very
• 11:28low tolerance for toxicity or adverse events.
• 11:32This is highlights sort of the
• 11:34causes of cancer and where they are.
• 11:36Some of the opportunities are.
• 11:37I wouldn't say that there it's comprehensive.
• 11:40This is from Scott Lippman in it at all.
• 11:43Obviously obesity is and tobacco or
• 11:47the main causes of cancer tobacco,
• 11:53you know,
• 11:53we we even do some work in this
• 11:56area, particularly for
• 11:57anti nicotine approaches.
• 11:59Obesity I think hangs over all of us in
• 12:02terms of how do we tackle this problem?
• 12:05How do we mitigate the effects of BC?
• 12:07What is the you know?
• 12:09What is the causal relationship
• 12:10of obesity with cancer?
• 12:12Is it inflammation?
• 12:13What kind of inflammation? Etc etc.
• 12:15And then a variety of other causes.
• 12:19Viruses are near and dear to my heart
• 12:21because of my work on human papilloma virus,
• 12:23which causes 5% of of cancers globally,
• 12:29so it's. And HPV been my training ground on.
• 12:34I started off as a lab scientist but
• 12:37moved into molecular epidemiology
• 12:3820 years ago and continue to learn
• 12:41from the study of HPV in many ways.
• 12:46So if we think about this causal model
• 12:50where we go from normal to initiate it
• 12:52to precursor States and invasive cancer,
• 12:54it really helps us sort of identify
• 12:56the roles of different groups.
• 12:58But also where we where the opportunities
• 13:00are for intervention now precursor states,
• 13:03I mean those are somewhat artificial
• 13:05slices of the of the pathway,
• 13:07and in case of cervical cancer that
• 13:10probably really aren't distinct states,
• 13:12just clinical diagnosis that fall
• 13:15within this area somewhere between.
• 13:17Initiated and pre cancer.
• 13:22So what can we do right now?
• 13:24Obviously and and I will say highlight
• 13:27that I recently published an OP Ed
• 13:29in Stat to talk about really these
• 13:32same strategies that are being used
• 13:34for COVID can be used for cancer
• 13:37prevention and that we really need a
• 13:39pandemic response for cancer prevention
• 13:41because of the annual burden of cancer.
• 13:44So avoidance is one strategy or
• 13:47primary prevention if you will,
• 13:50through tobacco prevention, HPV and HB.
• 13:54HPV vaccination treatment of
• 13:57H pylori potentially.
• 13:59And then sex sort of secondary
• 14:02prevention through tobacco cessation,
• 14:03screening and diagnosis.
• 14:05And those tools, avoidance vaccinations,
• 14:08bringing treatment,
• 14:09or the very things that we're
• 14:12using now to battle COVID.
• 14:13And really we need to highlight
• 14:16those and bring them back into
• 14:19the prevention discussion.
• 14:20Uh, we're working more and more in
• 14:22the area of interception of cancer and
• 14:24we'll talk more about this in moment,
• 14:26right?
• 14:26And this is sort of moving us
• 14:28towards what people refer to
• 14:30as precision cancer prevention,
• 14:32and I'll talk about that a couple
• 14:34times through this and even propose
• 14:36a broader definition of precision
• 14:39cancer prevention.
• 14:40But obviously,
• 14:41tamoxifen and its derivatives
• 14:42for breast cancer for those who
• 14:45are at high risk and seats for
• 14:47colon cancer immune modulators.
• 14:49Drugs that target oncogenic drivers and
• 14:52re activators of tumor suppressor genes,
• 14:55for example.
• 14:58So I'm going to present this
• 15:01this chart or this picture for
• 15:04our three main programs here.
• 15:06It's what I call our
• 15:08preventive agent R&D pipeline.
• 15:09And the thing that I want to
• 15:11point out is that people don't
• 15:13always recognize these programs,
• 15:14particularly in DCP.
• 15:15We gave a presentation for this
• 15:17new program called Capital,
• 15:19which I'll explain in a moment
• 15:22to the BSA members.
• 15:23The NCI Board of Scientific advisors.
• 15:27And one of the members didn't
• 15:28even know what prevented.
• 15:29So let me so I'm going to drag
• 15:31you through this because I want
• 15:33to engage you in the process of
• 15:35developing new prevention strategies.
• 15:37So cap it is a new program.
• 15:39It's a targeted agent identification
• 15:43program for preventive agents.
• 15:45Prevent is our preclinical development
• 15:48and validation program and even you know,
• 15:51to the extent of producing GMP grade
• 15:54drug for trials seek Tenet is our early
• 15:58stage clinical trials network and then core,
• 16:02which I'm sure everybody's heard of, is our.
• 16:04You know,
• 16:05our big clinical trials network.
• 16:07For primarily for phase three trials like T.
• 16:10Mist.
• 16:12We had a moon shot consortium
• 16:14on come on novel advents.
• 16:16You lack net is to look at prevention of
• 16:20HPV related disease in HIV and people
• 16:23living with HIV in Latin America.
• 16:25We have funding opportunities for cancer
• 16:28prevention and control trials and a new
• 16:31one hitting the street on in yellow.
• 16:33Here,
• 16:33cancer trials,
• 16:35planning and feasibility.
• 16:36It's kind of like a P20 funding opportunity.
• 16:39I can't remember what the the mechanism is.
• 16:42But the the basic idea is that these trials
• 16:45are very hard to do and to do denovo,
• 16:48and that if we spent some money investing in,
• 16:51we would.
• 16:53You know, get the get the planning done
• 16:57in the and test the feasibility before
• 17:00they came for an R1 level funding.
• 17:03Precision Cancer Prevention
• 17:04centers is is is the future.
• 17:07I hope it's my dream and fantasy
• 17:09that it would and it would
• 17:11dovetail with this R&D pipeline.
• 17:12But basically two engaged centers to kind of
• 17:18create their own pipeline that would move.
• 17:23Move from discovery to early
• 17:26translation to early human trials and.
• 17:29I emphasize here as shown below that
• 17:33although these programs sit at the NCI,
• 17:36they're open for investigator initiated
• 17:39research to take advantage of these programs,
• 17:42and we encourage it.
• 17:43We want you to come forward
• 17:45with new prevention strategies,
• 17:47and again I want to emphasize that
• 17:49what DCP focuses on innovation,
• 17:51new strategies that we haven't
• 17:53that you know are not.
• 17:55You know that need development
• 17:58and early validation.
• 18:01This just shows the CPCT net,
• 18:04which is really this early phase clinical
• 18:08trials group that's across the country.
• 18:11With data monitoring and uhm, uhm?
• 18:15A board that's a data management and
• 18:20that coordinates these activities,
• 18:23optimizes clinical trial designs,
• 18:25developed surrogate and
• 18:27intermediate endpoint biomarkers,
• 18:28test novel imaging technologies,
• 18:30and develop further insights into the
• 18:34mechanisms of cancer prevention by agents.
• 18:37And this is led by even zabbo.
• 18:41Here's a couple of the approved
• 18:43trials that are already underway,
• 18:45one on NAFLD,
• 18:47a HPV vaccine delayed booster trial.
• 18:52Uhm and prostate uhm.
• 18:54A management trial as well.
• 19:00These are some of the.
• 19:03Protocols that are under development
• 19:05a wide range from breast cancer to
• 19:09FAPA metformin as a chemopreventive
• 19:11agent for lung cancer and
• 19:13high risk of these patients.
• 19:15I'm not going to read through all these.
• 19:17You can have these slides and
• 19:19kind of see the the breadth and
• 19:22depth of the trials at the NCI.
• 19:26We're doing a number of studies
• 19:29on topical tamoxifen to look at
• 19:32whether we can sort of change
• 19:34the benefits to harms ratio,
• 19:36and I'll I'll come back to that point.
• 19:39By delivering tamox into that issue at risk,
• 19:42and in this case breast cancer.
• 19:44Looking at some biomarkers
• 19:47in DCIS breast density.
• 19:49Measuring inter individual variation
• 19:54and looking at serum and tissue
• 19:57concentrations of of of the
• 20:00drug being delivered topically.
• 20:06Are you lacnet which I mentioned before?
• 20:08Is our HPV prevention clinical trials
• 20:11network in Latin American Caribbean,
• 20:14and there are three consortium members
• 20:17working on a variety wide variety of
• 20:20interventions from some vaccination
• 20:22work to screening to pre cancer
• 20:25therapeutics and people living with HIV.
• 20:31So then that leads us into discussions
• 20:33of screening early detection,
• 20:35which we've done a lot.
• 20:36Obviously, Plco is one of the major U S
• 20:39trials that was sponsored by the Division
• 20:42of Cancer Prevention and here above,
• 20:45here in the yellow.
• 20:46I just wanted to state that we are
• 20:48more and more thinking about what
• 20:50I call risk informed screening,
• 20:52so using risk to decide who and when
• 20:54people need to be screened or to modify
• 20:57the management of the screen positives.
• 21:00And it also provides a possible
• 21:02or potential for intervention with
• 21:04targeted preventive agents if we know
• 21:07the biology of what that risk is,
• 21:09then we could then combine both screening
• 21:13strategy with a preventive agent strategy.
• 21:17So this is our screening early detection
• 21:20R&D pipeline at the core of this is Dern,
• 21:23which has been just renewed and is
• 21:27now 20 years in the making or in its
• 21:30in its in its life and it continues.
• 21:34I will present a few slides on that,
• 21:36but we have some related projects
• 21:39around pancreas cancer, PCDC,
• 21:41liver cancer, TLC,
• 21:42L we have a liquid biopsy consortium
• 21:45and we have an image ingane.
• 21:48Biomarkers consortium T bells and
• 21:50new program to help us differentiate
• 21:53between indolent and aggressive cancer.
• 21:57I'm sure many of you have heard
• 21:59of H Tan which is the human tumor
• 22:01Atlas network and we built off of
• 22:03that a pilot study called the Pre
• 22:06Cancer Atlas which we're hoping to
• 22:08renew in the subsequent year or so.
• 22:11Uh.
• 22:12One of the big gaps that we need to fill is
• 22:15a screening and early detection network.
• 22:17Not that Encor doesn't do some of that,
• 22:20but.
• 22:20We really need to engage the primary
• 22:23care providers to recruit average
• 22:25risk populations into our trials,
• 22:28and so that's why I showed that in purple.
• 22:30We're developing a new lung
• 22:34cancer image library for improved
• 22:37interpretation of those images I
• 22:40mentioned you lacnet several times
• 22:42were now have on the street at Cascade,
• 22:45which is a another consortium
• 22:48to look at best practices for.
• 22:51Screening women living with
• 22:53HIV for cervical cancer.
• 22:56How best to screen them?
• 22:57Manage them and treat them.
• 23:00Last Mile is a project that
• 23:02I'm Co leading on getting self
• 23:05collection and HPV testing approved.
• 23:08For routine screening in the
• 23:10United States and so forth.
• 23:14Uh,
• 23:14we're hoping to stand up some risk
• 23:17informed screening for cancer trials,
• 23:19or what I call risk trials,
• 23:21and we have a large trans NCI liquid biopsy,
• 23:25multi cancer early detection
• 23:27program that I've initiated and
• 23:29we will be working on that,
• 23:30including what I hope is a large
• 23:33platform trial to look at some of
• 23:35these technologies going forward.
• 23:37This just gives you a sense of end
• 23:40core which is involved in all of
• 23:42those activities that preventive
• 23:44agent development program as well
• 23:46as the screening early detection.
• 23:48There are over 1000 clinical sites,
• 23:5146 centers and affiliates and
• 23:53more than 4000 investigators.
• 23:55This is led by Warden Mckaskle
• 23:58Stevenson who's doing an
• 23:59incredible job of.
• 24:01Herding the cats if you will.
• 24:03Uh, I'm sure you've heard of a team nest,
• 24:06which is a randomized clinical trial
• 24:09to compare 2D versus 3D mammography.
• 24:12I'll show you some of the not results,
• 24:15but there are recruitment in our
• 24:18recruitment struggles during COVID.
• 24:19We've just launched Forte,
• 24:21which is to look at best
• 24:24rap best management of.
• 24:26You know low, fairly low risk.
• 24:30Populations who have wanted
• 24:31two non advanced polyps.
• 24:33And then a management trial
• 24:37for pancreatic cysts.
• 24:41You can see here the team missed was,
• 24:44as was many of our activities adversely
• 24:48affected by the COVID pandemic,
• 24:51shown here highlighted down here,
• 24:53you can see that the enrollment almost went
• 24:56to zero during the height of the pandemic.
• 25:00It's now come back and exceeded
• 25:03the monthly recruitment levels.
• 25:04So we're very excited about that and
• 25:07over time will start getting some
• 25:09readouts from the trial itself on.
• 25:113D versus 2D mammography.
• 25:15Uhm, this just highlights the cascade,
• 25:18which is a global multicenter
• 25:21cooperative agreement.
• 25:22Clinical trials network.
• 25:23To optimize this cervical cancer
• 25:25screening and treatment cascade
• 25:27for women living with HIV.
• 25:29Looking at all these issues in
• 25:31the care continuum care of care.
• 25:34From screening uptake to management
• 25:36of positives,
• 25:37pre cancer treatment and so forth.
• 25:40Although this will be a will
• 25:42have sites in the United States,
• 25:44we will also include sites in
• 25:46low and middle income countries.
• 25:50A last mile, as I mentioned,
• 25:52is really going to, we hope,
• 25:55bring HPV testing of self collected
• 25:58samples online in the United
• 26:00States and we're working very
• 26:02closely with the FDA on this.
• 26:04And just to say that.
• 26:06I've spent 15 years working on
• 26:09this topic more than 15 years.
• 26:11I know I look young,
• 26:12but it has been more than 15 years
• 26:15working on this particular one,
• 26:17that the idea that we can democratize
• 26:20screening by bringing screening to
• 26:23the homes or to convenient areas for
• 26:27participation in screening, I think,
• 26:29is going to be a game changer,
• 26:32not just nationally but globally.
• 26:34Although most countries don't
• 26:36necessarily take FDA approval.
• 26:38Directly in consideration,
• 26:39it is a big deal to have an FDA approval
• 26:43for a particular intervention so.
• 26:46We're very excited about this initiative,
• 26:49which we're hoping to launch
• 26:51in the next year or so.
• 26:53And and the other thing to say about
• 26:56this is from the meta analysis that
• 26:58I've participated in and others
• 27:00we know that women prefer this.
• 27:02I mean,
• 27:03it's kind of a no brainer and
• 27:05using a PCR based HPV test there's
• 27:08really little or no decrement
• 27:10in clinical performance,
• 27:12so this is a big deal.
• 27:14If we can get it underway.
• 27:15And it's a big deal in the global
• 27:19battle against cervical cancer.
• 27:24ERN was established in 2000, UM,
• 27:28to support investigator initiated
• 27:29research for the development
• 27:31and validation of biomarkers,
• 27:32foster interaction cooperation
• 27:34between academic, clinical,
• 27:36industrial partners or leaders.
• 27:40Furnish and apply standardized biomarker
• 27:42validation criterion quality assurance
• 27:44and facilitate regulatory process to bring
• 27:47biomarkers rapidly into clinical use.
• 27:49This is really our core
• 27:51biomarker for you know,
• 27:53screening for prevention and early detection,
• 27:56and Sudhir has done an
• 27:58amazing job on this program.
• 28:01This just gives you a sense of the of
• 28:03the of the different components of this.
• 28:06There are four main research
• 28:07groups shown here.
• 28:08On the left there's a steering executive,
• 28:11committees that oversee and review
• 28:13the program on a regular basis.
• 28:17We have a consulting team and then
• 28:19earn because of its breadth and depth,
• 28:21is really started to come.
• 28:24You know, permeate all areas related to.
• 28:30Early detection biomarkers related to
• 28:32early detection and prevention projects.
• 28:35Collaborations with Japan, India,
• 28:38France.
• 28:40Uhm, we've gotten Co funding
• 28:42from a variety of organizations.
• 28:44As I mentioned,
• 28:45there are tangential collaborative groups
• 28:48that expand on particular areas of EDR,
• 28:51and many associate members,
• 28:54federal partners,
• 28:55and we engage directly with
• 28:58pharma biotech industry.
• 29:02These are just some of the
• 29:03tests and I won't go over them.
• 29:05Obviously the perhaps the
• 29:06one that you're you know.
• 29:09Hearing a lot about his cancer seek
• 29:11which is a multi cancer early detection
• 29:13which was supported by the DRN.
• 29:16But there are many more and with this
• 29:18next round of renewal we're really
• 29:20hoping to push more things to FDA
• 29:22approval and into clinical practice.
• 29:24And that's really going to be our
• 29:26metric going forward is how much
• 29:28of this gets into routine care?
• 29:32Uh, I sort of alluded to this before,
• 29:34but the idea that we could bring
• 29:36these two pipelines together
• 29:37one is biomarker discovery,
• 29:39as well as and as well as bringing
• 29:44a preventive agent into the mix
• 29:47and so that you could detect
• 29:48and mitigate cancer risk, but.
• 29:52As I will talk about later,
• 29:53I really want to expand what we call
• 29:56precision cancer prevention and I will
• 29:58talk about that a little bit later.
• 30:00We also do symptom management,
• 30:01which seems odd, but that's the way it is.
• 30:04And actually I'm very excited about this.
• 30:06I think there's tremendous
• 30:08opportunity to improve symptom
• 30:10management and supportive care.
• 30:12What's really important about this
• 30:13to me is that the prevention and
• 30:16treatment of symptoms from cancer
• 30:18cancer treatment really has a profound
• 30:20effect on the quality of life.
• 30:22Of patients,
• 30:23but also their ability to survive
• 30:25the cancer and cancer treatment
• 30:27if we can manage symptoms better.
• 30:29As you well know,
• 30:30many of you are oncologists.
• 30:32The clinical performance remains
• 30:33high and so patients really not only
• 30:36get their first line of treatment,
• 30:38they get their second and third
• 30:40line treatment and even treatments
• 30:41that haven't been invented today
• 30:43but will be tomorrow.
• 30:46So we have a very broad portfolio,
• 30:49big and broad portfolio and and
• 30:52in symptom management shown here.
• 30:56Uh, those are the number in the
• 30:58upper left hand panel is the
• 31:00number of grants per per year.
• 31:05Are we really the only group at the
• 31:07NCI that focuses on pain management?
• 31:10And much of these activities happen
• 31:13within our clinical trials network,
• 31:15now called Encor. It used to be sikap.
• 31:19So this is again the pipeline and I use
• 31:22this as a is a sort of a platform for
• 31:25thinking about where we want to go.
• 31:27We have a lot of. You know,
• 31:31activities in our clinical trials,
• 31:32but what's really lacking is an
• 31:34investment in the biology and genetics
• 31:36of symptoms and symptom management.
• 31:38What we'll call here is precision
• 31:40symptom management, or symptom science.
• 31:43Uh, and so we really.
• 31:45I'm hoping in the next couple years to make
• 31:47to get some NCI investment in this area.
• 31:50There's no reason for trial and error
• 31:53related to symptom management anymore
• 31:55than there is for cancer treatment itself.
• 31:58Uh, we've been doing a lot on, UM.
• 32:01Defining patient reported
• 32:03outcomes and standardizing them,
• 32:05which is important for a sort of a base
• 32:08for doing anything to improve symptom
• 32:11management if we can't measure the outcomes,
• 32:14then there's not much for us
• 32:16to do and not much.
• 32:18We can't show anything.
• 32:19So the this moon shot that tolerability
• 32:22consortium focused on analyzing,
• 32:24interpreting,
• 32:25clinician and patient adverse event
• 32:27data to better understand Taler ability.
• 32:30Doing so by creating a consortium to
• 32:33share analytic approaches and so let
• 32:36me conclude with a few slides here and
• 32:40then it will open up for questions.
• 32:42These are certain my informal,
• 32:44UM, unofficial priorities,
• 32:46really understanding biologic risk and
• 32:49using that to guide what we do for patients,
• 32:54but also population risk to
• 32:56decide who gets screened and how.
• 32:59How to screen,
• 33:00how to screen positives are
• 33:02managed and how to harmonize care.
• 33:04What I call equal risk equal
• 33:06care for equal risk,
• 33:08which is an idea that we had promulgated
• 33:10over 15 years ago in the cervix.
• 33:12World,
• 33:13as we saw that there were the all
• 33:15these new tools coming and there
• 33:16was going to be a great deal of
• 33:18heterogeneity in the population.
• 33:20Risk to their vaccination.
• 33:22We really needed a organizing principle here.
• 33:25Obesity, as I mentioned before.
• 33:29Causes so much of the burden of cancer
• 33:32and we really don't understand it.
• 33:35If we did,
• 33:36we could mitigate its effects.
• 33:37Obviously,
• 33:38changing lifestyle behavior would be ideal,
• 33:40but I think it's a real challenge to get
• 33:42people to change their their lifestyle
• 33:45behavior over a course of decades.
• 33:48And so I'm not saying that
• 33:49we shouldn't invest in that,
• 33:50but I'm saying complementary to that.
• 33:53We really should understand the
• 33:55pathways and how obesity contributes
• 33:58to carcinogenesis so that we can.
• 34:01Combine that with changes in
• 34:03lifestyle and behavior.
• 34:05I think I've said enough about precision,
• 34:07symptom, prevention,
• 34:09and management, but I you know,
• 34:11just to emphasize that I,
• 34:12I think we need to move away from
• 34:14the trial and error that often
• 34:16occurs in clinical management.
• 34:17That's not a criticism of
• 34:18the clinicians at all,
• 34:19it's just that we haven't.
• 34:21We haven't really taken this as seriously
• 34:23as we should in terms of bringing the
• 34:26same kind of focus on precision medicine
• 34:28to this area as we have in other areas.
• 34:31Health disparities I. I think there's
• 34:34a lot of opportunity for innovation.
• 34:37I mentioned self collection developing point
• 34:40of care testing like for HCV. You know,
• 34:43bring the bring the tests to the people,
• 34:45or bringing the intervention of
• 34:47the people rather than just relying
• 34:50on them to come to the clinic.
• 34:52I know that persistent reality is
• 34:54a major risk factor for cancer,
• 34:57and then we're being bombarded
• 34:59with new technologies,
• 35:00AI multi cancer, early detection,
• 35:02synthetic biomarkers, etc etc.
• 35:04We really the NCI plays a pivotal
• 35:06role in sort of getting out in front
• 35:08and figuring out what's good and
• 35:11what's not without bias without.
• 35:13And gender and and I think we need
• 35:15to do that more and more as these new
• 35:19technologies rollout faster and faster.
• 35:21Uhm, I wanna pose something that
• 35:24might be a little bit controversial,
• 35:27which is a broader definition
• 35:30of precision cancer prevention.
• 35:32To achieve equitable care for all.
• 35:35And the core principles here are the
• 35:37benefits to harms ratio and understanding.
• 35:39All causes of differences,
• 35:41not just biological,
• 35:43which informs how we can be more precise.
• 35:45So what we've typically figured
• 35:47on is the what,
• 35:48which is based on an understanding
• 35:50of carcinogenic processes.
• 35:51Target early changes via
• 35:53screening or interception,
• 35:55but I want to add The Who into this,
• 35:57which isn't always integrated into this,
• 35:59which is who's at risk and how much risk.
• 36:01And that really tells us, not just.
• 36:05What age but what kind of screen?
• 36:10To use or what kind of intervention
• 36:12to use and what's the follow-up care?
• 36:15Where a?
• 36:17Alternative delivery strategies,
• 36:19like I mentioned home based sample
• 36:22collection collection of testing,
• 36:23app based interventions and so forth
• 36:26and then how benefits and harms can be
• 36:29manipulated by alternative routes of
• 36:32administration like topical tamoxifen,
• 36:34maintaining effective doses more
• 36:36consistently through sustained release
• 36:39to reduce toxicity and perhaps even
• 36:42increase improve the benefits.
• 36:44The cancer prevention,
• 36:46benefits and even strategies.
• 36:47For immunization and we we often
• 36:50focus on active immunization,
• 36:52but sometimes you can't develop a good
• 36:54response or a sufficient response.
• 36:56So maybe we have to make antibodies
• 36:59like anti nicotine antibiotics
• 37:01which we are supporting right now
• 37:03to give people the immune spot
• 37:06immune response that they need.
• 37:08I think this is my final slide,
• 37:10which is just a call out for our
• 37:12cancer prevention fellowship program,
• 37:14from which I spawned.
• 37:15So how bad can it be?
• 37:18This is a multidisciplinary,
• 37:19diverse,
• 37:20and highly competitive postdoctoral
• 37:22training program that provides flexibility
• 37:24for fellows to generate and pursue
• 37:27original scientific ideas and structure,
• 37:29to develop competencies,
• 37:30support their future as leaders in the field.
• 37:34But I'm very proud of is we've
• 37:37got now cancer prevention fellows
• 37:39from Costa Rica and we are working
• 37:42towards the idea of having an ongoing
• 37:45international training component to
• 37:47this cancer prevention fellowship.
• 37:49And then the Cancer Prevention
• 37:52Fellowship program has alumni across
• 37:54all across the country in the world.
• 37:57You know it's been around for 35 years
• 38:00now and fellows are at major cancer
• 38:05centers and leadership positions.
• 38:07Government agencies, research firms,
• 38:09foundations, and policy organizations,
• 38:11and the website for the Cancer
• 38:13Prevention Fellowship program.
• 38:15Shown there at the bottom.
• 38:17So with that, I'll say thank you
• 38:19and I'll take any questions.
• 38:22From the audience and thanks again for
• 38:24the invitation to Yale Cancer Center.
• 38:29Thank you very much.
• 38:31Doctor Castle and Great talking,
• 38:32kind of a whirlwind overview.
• 38:36What's been going on with
• 38:38exciting preview of next steps?
• 38:42So I'll ask people to send questions
• 38:44via the chat button while we're waiting
• 38:46for some other questions that they
• 38:49had one just to get the ball rolling.
• 38:51So. In your position,
• 38:54the decisions need to be made
• 38:56with regarding prioritization of
• 38:58large scale efforts forward in
• 39:01overarching strategies at the center.
• 39:04Beneath that there are four
• 39:06tactical decisions which.
• 39:08Which plans to find out which teams he
• 39:11grants or program projects so for WhatsApp.
• 39:14So my question to you is how do
• 39:18you track success that how do you?
• 39:19How do you know five years from now
• 39:21whether you made the right decisions or that?
• 39:24Like if you imagine an alternate universe
• 39:25where you could have been focused,
• 39:27you know the center could have been
• 39:29focusing on completely different things
• 39:30are completely different strategies.
• 39:32They can have different outcomes, so I don't.
• 39:34I'm just curious how you think about
• 39:37how you know how to evaluate the
• 39:39progress of the centers making it both.
• 39:42So what's the time horizon is one of
• 39:44the metrics for evaluating success.
• 39:47Boy you've touched it.
• 39:47I mean you went right to the heart of it,
• 39:49right?
• 39:50Not just from a programmatic standpoint
• 39:51but from a prevention standpoint,
• 39:53because it often takes more than five
• 39:55years to show any of this stuff works,
• 39:57and I think.
• 39:58That is sort of one of the major
• 40:02barriers for researchers getting
• 40:04into the prevention field because.
• 40:08It's just hard, you know,
• 40:08even you know and and the more
• 40:10successful you are like for screening,
• 40:13even harder it is to do a prevention trial,
• 40:15right?
• 40:15'cause then you start extending screening
• 40:17intervals to the point where you
• 40:19can't even study it within an hour one.
• 40:22So I mean some of these things.
• 40:24You know,
• 40:25that's why we have to do things more,
• 40:26sort of directed by the NCI
• 40:28as a clinical trial,
• 40:30rather than just relying on our one.
• 40:32I know everybody wants to put
• 40:33all the money into the R1,
• 40:34but my calling is to come up with
• 40:36the best prevention strategies
• 40:38and sometimes it just doesn't fit
• 40:40within the the framework of an R1.
• 40:42There's no way that I can know in
• 40:44advance whether my guesses are good.
• 40:46And as you pointed out,
• 40:47I have to make guess I have to make informed.
• 40:50I hope. Informed guesses.
• 40:51About where we should put our energies.
• 40:55I think what I've been trying to impress
• 40:58upon my staff and through my staff to
• 41:01the extramural investigators we want to
• 41:03ground this in the best science possible,
• 41:06knowing that even that may not be good enough
• 41:08and and one of the challenges and we were,
• 41:10we have an ongoing workshop
• 41:13the last couple days is that.
• 41:16We rely particularly for
• 41:18preventive agents on mouse models.
• 41:20But there's a lot of issues
• 41:23with mouse models.
• 41:24You know?
• 41:24How well does it recapitulate human biology?
• 41:28How much can we rely on that?
• 41:30Because what happens,
• 41:31of course,
• 41:32is then we go to, you know,
• 41:35human trials based on those results.
• 41:37Even the phase one phase
• 41:39two trials are expensive.
• 41:41They take a long time and and
• 41:43don't have an efficacy readout.
• 41:45So let's say the toxicity is OK.
• 41:47Then you go into a five or
• 41:49seven or ten year trial.
• 41:51And only at the end there do you figure out,
• 41:54Oh my God, this doesn't work.
• 41:55We've just spent $100 million for something
• 41:58that's not going to help anybody.
• 42:00So it really is a challenge
• 42:01and I don't have a good answer.
• 42:03I would say that one of the.
• 42:05Ways forward is we really
• 42:07have to think hard about.
• 42:09Surrogate endpoints for cancer
• 42:11risk or cancer mortality.
• 42:13So screening trials are
• 42:15particularly challenging because
• 42:17right now the only thing that we,
• 42:19I think everybody can completely agree
• 42:21upon is if it reduces cancer mortality.
• 42:24It works,
• 42:25but stage shift doesn't
• 42:27necessarily translate,
• 42:28at least right now into benefit,
• 42:31and you can see the UK ovarian cancer
• 42:34screening trial is an example of that.
• 42:36Although I I believe.
• 42:38Eventually stage shift should
• 42:40translate into mortality benefit,
• 42:42but until we've shown you know,
• 42:45until that becomes a reliable.
• 42:47Sarah did endpoint,
• 42:49it doesn't.
• 42:50It's hard to then recommend
• 42:52something for general use,
• 42:53so are you know one of our challenges,
• 42:55whether it's and I've been
• 42:58challenging the nutritional science
• 43:00group within our that we can't
• 43:02go into this black box of like.
• 43:04Eat this we you know we can get people
• 43:06to do this and then we're going to
• 43:08go into a clinical trial to show you know,
• 43:10reduction of cancer incidence,
• 43:11which will take years and years
• 43:13and years and years to do.
• 43:14We need intermediate endpoints
• 43:16that we can rely on that at least.
• 43:20Push us in the right direction,
• 43:21right?
• 43:22The screen out the you know some of
• 43:24the things that aren't going to work.
• 43:27I do think that we have because of the
• 43:29time and the expense we're going to
• 43:31have to be more specific than sensitive.
• 43:34We can't chase after everything,
• 43:36so we have to place a sort of higher
• 43:38bar in this development process
• 43:40and and recognizing that we're
• 43:43going to miss some opportunities.
• 43:45But the the opportunity costs of
• 43:48chasing after our tail are really
• 43:51significant and and problematic.
• 43:53So there is no good solution.
• 43:55If you have one, please tell me because.
• 43:57You know, we talk about this all the time.
• 44:00It's just hard.
• 44:01It's hard to do prevention and
• 44:02yet everybody knows I mean.
• 44:05Even the most ******** oncologists
• 44:07would tell you no.
• 44:10You know,
• 44:10prevention is our first line of defense,
• 44:13and if you know and I always
• 44:15say this to my audiences,
• 44:16they walk down the street after Kovid
• 44:19when it's safe and ask the first
• 44:21hundred people you walk into and say,
• 44:23would you like your cancer
• 44:25prevented or treated?
• 44:27You know,
• 44:27I'll take that bet with odds that
• 44:29every one of them is going to say.
• 44:32Of course, I want my cancer prevented so.
• 44:35We all know it's important we
• 44:37all want it to go forward,
• 44:39but there are some real challenges to
• 44:40it and you know, as I mentioned before,
• 44:42the other challenge, of course,
• 44:44is very low tolerance for toxicity if
• 44:48you're primarily dealing with average risk.
• 44:50People who are on that day,
• 44:52most of them healthy.
• 44:53You can't. You know,
• 44:55you just can't do bad things to them,
• 44:56understandably so you know the the
• 44:59cervix world is sort of the outlier.
• 45:02In a way, it's it was the low
• 45:04hanging hanging fruit you have.
• 45:06You know you have relatively
• 45:08easily accessible tissue.
• 45:10You have a single causal agent.
• 45:13And you it takes 20 to 25 years ago
• 45:16from infection on average to cancer.
• 45:18I mean that you know,
• 45:20if we if I want to be honest about them,
• 45:22that one was supposed to be successful
• 45:24and and the other ones are much harder.
• 45:26So.
• 45:30Thank you, no, I don't have a clear answer.
• 45:32That's why I asked,
• 45:34you know, I, I believe me.
• 45:35If I had an answer I would share
• 45:37it with you, but I I don't.
• 45:38We struggle with this.
• 45:39I think the best thing we can do is brown.
• 45:41Listen better science, right?
• 45:43Understanding the molecular mean
• 45:44people wanted the magic bullet, right?
• 45:47If you eat this.
• 45:49This is going to work and I'm
• 45:50not saying that that won't work,
• 45:51but let's look at nutrition for a
• 45:53second here and I apologize to any
• 45:56nutritional epidemiologists or scientists.
• 46:00But the challenges of going
• 46:01from eating something into a
• 46:03clinical trial or profound right?
• 46:05So likely it's going to
• 46:07be a low penetrance thing.
• 46:09Even if you can measure it and the
• 46:11the ability to show it both at the
• 46:13lab level and if you go through the
• 46:16hill criteria and say we've got to get
• 46:18to a certain number of those before,
• 46:20we're going to go into a clinical trial.
• 46:21And then in most cases,
• 46:23you're really talking about a low
• 46:25penetrance or weak penetrance
• 46:27of or weak effect, right?
• 46:28So then you're talking about a huge trial.
• 46:31You know, you're really rolling the dice on,
• 46:34you know, 50 to $100 million trial
• 46:36to get the kinds of endpoints.
• 46:38And that's and we failed.
• 46:40We've had a number of failures
• 46:42and and you know,
• 46:43the other one that people have been
• 46:45chasing after his metformin and were or.
• 46:47And that's really turning out to not not
• 46:50be relevant in the prevention space,
• 46:52or it's so it's such a weak effect
• 46:54that we can't measure it, right?
• 46:55So that's the other problem.
• 46:56It might have a modifying effect,
• 46:59but we can't.
• 47:00Measure it and therefore we
• 47:01can't recommend it.
• 47:02And more importantly EU S Preventive
• 47:04Services Task Force can't recommend it.
• 47:06So and and you know that.
• 47:09So I mean part of it is we want
• 47:11something that's so cheap that
• 47:12you can get it off the shelf or.
• 47:13Or you can go to the grocery
• 47:15store and eat it.
• 47:17That has not panned out and and and
• 47:19there can be a lot of reasons for that.
• 47:22And it doesn't mean that it doesn't work,
• 47:24but it's hard to show it, and it's hard
• 47:26to invest that money in showing it.
• 47:29So follow up question thinking about
• 47:32the challenge of small effect sizes.
• 47:34Or it could be a large sample size
• 47:37of getting needed and create expense.
• 47:39Just thinking about the experience
• 47:41during COVID, but the UK.
• 47:44Some kind of ran circles around
• 47:46us as a nation with regard to the
• 47:48facility with conducting these large
• 47:50trials so that they have the recovery
• 47:53trial which actually enrolled 10%
• 47:55of all patients across the country
• 47:57who are hospitalized in the UK were
• 48:00involved in this large sent.
• 48:02You know, it's large,
• 48:04centrally coordinated trial randomization.
• 48:05It is generated a great deal of prompt.
• 48:09Really informative information is kind of.
• 48:11People have subsequently been
• 48:12saying or what can we learn?
• 48:14Post code it's not covered child.
• 48:16The more centralized approach,
• 48:17so you know building and and you
• 48:20mentioned is that the screening and
• 48:22early detection network and what
• 48:24are the strategies for creating
• 48:25this large amount of people.
• 48:27That and other things out there
• 48:28for large systems where we could
• 48:30be running multiple trials at the
• 48:32same time and have like a single
• 48:34infrastructure that's really, really big.
• 48:36Well we've,
• 48:37I mean to some extent we've done that
• 48:39with enkor, but that tends to be,
• 48:41you know,
• 48:42a cancer centers and you know
• 48:44oncology services.
• 48:44I mean,
• 48:45so some of the things that we're
• 48:46doing like Team Nest where you
• 48:47have to have radiology anyway,
• 48:49that that kind of works in that network, but.
• 48:52We have other networks that are
• 48:54in place that could be leveraged.
• 48:57It's a matter of coordinating
• 48:58them and being willing now.
• 49:00Some people would say Kaiser,
• 49:02though my experience and I've worked
• 49:04with Kaiser Permanente Northern
• 49:05California for 15 plus years.
• 49:07They're not really set up
• 49:08to do clinical trials,
• 49:10but one could imagine some combination
• 49:14of FQHC's and other providers,
• 49:17but starting to link them now.
• 49:20Between you and me,
• 49:21and I'll deny this if if anybody quotes me.
• 49:25If you start doing that,
• 49:26you start building a a public health.
• 49:28Infrastructure which I think
• 49:31COVID revealed we didn't have
• 49:33in the United States so.
• 49:35It is easier to do some of the stuff
• 49:37in Europe because they have organized
• 49:40programs they have organized health care.
• 49:42They have organized screening.
• 49:44We do not.
• 49:46But I think we can start pushing
• 49:47along those ways and it would be hope.
• 49:49My hope you know,
• 49:51probably long after I'm gone,
• 49:52but that by doing these kinds
• 49:54of activities where he showed
• 49:56networks can work together that
• 49:58you start to build the an informal
• 50:01organized screening program we know.
• 50:04There's a lot of data now to suggest
• 50:06that organized screening really
• 50:07makes a difference in terms of
• 50:09the effectiveness of the program,
• 50:11and I've had the privilege and
• 50:13just reviewing another paper
• 50:15from them of working with Norway
• 50:17for the last eight or nine years.
• 50:19And that's been a real pleasure to
• 50:21like what they can do to you know,
• 50:24and how they can make switches,
• 50:26how they can really get high coverage
• 50:29and and identify people for whom
• 50:31the system is not working right.
• 50:34And and come up with alternative strategies.
• 50:36So we know that screening like even
• 50:38for cervix we know that 2010 to 20%
• 50:41of people don't get their routine
• 50:43screening or don't get screened at all.
• 50:45And that's where half of the
• 50:47cervical cancers occur.
• 50:48So if we can bridge that gap,
• 50:50then we're making progress.
• 50:52So I mean, that's not the typical innovation
• 50:55that the division is focused on the past,
• 50:57but I'm a population scientist
• 50:58who's worked on some of this stuff,
• 51:00so that's why.
• 51:01I've sort of been thinking about my
• 51:04own definition of precision cancer
• 51:06prevention and trying to expand that
• 51:08to say it isn't just what we do like
• 51:12targeting carcinogenic pathways.
• 51:13It's also how we do it and where we do it,
• 51:16and for whom do we do it so?
• 51:22That's great baby. Let me pause, I do.
• 51:24I don't wanna turn this into a
• 51:26fireside chat would be nice I
• 51:27wanna try I like fireside chats.
• 51:29I'm happy to happen even separately.
• 51:31I can come back. Come.
• 51:35Well, I had one other question.
• 51:37No other questions from the groups.
• 51:38One other quick question is on.
• 51:41Mr. President.
• 51:43What are you thoughts about some form
• 51:45of a whole of government approach
• 51:47intersectoral approach were talking about?
• 51:50You know things like you know.
• 51:53Is it critical?
• 51:54So I wanted to find out which Ave,
• 51:56but you know we subsidized corn.
• 51:57So we our government on the one hand,
• 51:59is doing things that actually
• 52:01increasing the obesity our country.
• 52:02So just thinking are there
• 52:05avenues towards UM?
• 52:07Collaborating across sectors
• 52:09within the government,
• 52:10to, you know,
• 52:12think about changes at
• 52:13the policy level to come.
• 52:15I'm gonna change the diet or or you know,
• 52:19kind of incorporate.
• 52:21So we to evidence based policy change
• 52:23under some kind of demonstration.
• 52:25Part projects that could relate to things,
• 52:28which is the change in diet?
• 52:30You know population efforts to
• 52:31to address obesity or in see how
• 52:33that might affect cancer, right?
• 52:35Well,
• 52:36that's an interesting question of course.
• 52:39You know one of the things that
• 52:41I think about is, you know,
• 52:42this crossover of obesity and smoking.
• 52:44I mean,
• 52:45smoking suppresses diet,
• 52:46so is there going to be a point
• 52:48of crossover where where obesity
• 52:50becomes more important than smoking?
• 52:53But I'm not suggesting that anybody
• 52:55should start smoking to prevent recently,
• 52:57by the way.
• 53:00If you think about the successes of public
• 53:03health successes in the United States,
• 53:05they've really come.
• 53:07They've been driven.
• 53:09Sort of from the ground up, right?
• 53:11So if you look at smoking?
• 53:14You know it was lawsuits and you know,
• 53:16demands from the public to
• 53:18say this is this is, you know,
• 53:21we have to do something.
• 53:22Uh, even the you know one of the
• 53:24most successful public health
• 53:26campaigns has been HIV, right and?
• 53:29And and that's because.
• 53:32People demanded they got up on
• 53:34their soapbox and they said,
• 53:36you have to do something.
• 53:37And so I think you know one of my jobs.
• 53:40Although you know I'm not a implementation
• 53:43and dissemination person that's in DCCPS,
• 53:46but I've done that work for my entire career.
• 53:49And we can speak about the audit
• 53:51evening leading the division of
• 53:52cancer prevention if you want.
• 53:54But the I.
• 53:55I do think that we have to educate the
• 53:57public on the possibility of prevention,
• 53:59which is why I wrote that OP Ed to
• 54:01say if we can do this for COVID,
• 54:03we should be doing it for cancer prevention.
• 54:05That it's our first line of defense.
• 54:07Not that we're going to prevent all cancer.
• 54:09You know.
• 54:09I have no illusions of that,
• 54:11but I think there's a lot more and
• 54:12you have to make the investment.
• 54:14We invest three times just in the government.
• 54:17We invest three times more
• 54:18into treatment than we do.
• 54:19Prevention, let alone pharma.
• 54:21I mean pharma.
• 54:22It's got to be 20 to one or more,
• 54:26so I think it's it's getting.
• 54:30Getting voices to say.
• 54:31You know we need to make these
• 54:33investments in prevention.
• 54:35We need to understand obesity.
• 54:37We need to also have policies
• 54:40about you know what we make
• 54:43available for foods and and tax.
• 54:45You know one of the most
• 54:48effective strategies is taxation.
• 54:49So you know,
• 54:50I'm ten years ago I was sitting at
• 54:53the UN meeting on ends, you know,
• 54:55global warming CDs and you know,
• 54:56there's a lot of talk about the
• 54:59policy end and taxation, and you know,
• 55:03making sugary foods less available, right?
• 55:06If you want 'cause I think.
• 55:08This is my opinion and I I don't
• 55:11mean to be offensive in any way but.
• 55:13We are hardwired to eat.
• 55:16It is primal and I don't think we
• 55:18evolved to have unlimited access to food.
• 55:21But we do now.
• 55:22And so I know I have like no
• 55:25resistance and the fact that I'm
• 55:27sitting in home and I'm, you know,
• 55:30literally 20 feet away from
• 55:32my refrigerator is trouble.
• 55:34Like if I'm not around it,
• 55:35I'm much better off.
• 55:37I just am.
• 55:38But if and in fact, when I was at Einstein,
• 55:40I wouldn't take anything to work
• 55:41because I knew that, you know it just.
• 55:44If it's not there, I don't eat it,
• 55:46but if it's there,
• 55:47I will eat it.
• 55:47I have like no resistance and I
• 55:49don't think I'm unusual that way.
• 55:50I think I'm fairly represented
• 55:52despite my knowledge base,
• 55:53right? So I think you know.
• 55:56Our challenge is understanding
• 55:58fundamentally what we're hardwired to do.
• 56:01I mean, smoking is a little different
• 56:02because it's not a survival thing,
• 56:04but once you're addicted,
• 56:05you're addicted, right?
• 56:06Your wiring, you know, you've you've done.
• 56:09You've played.
• 56:10You know, it's haywire.
• 56:11You know you've messed with your,
• 56:13you know with the program.
• 56:15But food is fundamental.
• 56:17We eat to survive so.
• 56:19We evolved that capacity over,
• 56:22you know, millennia.
• 56:24To you know, and when we evolved it,
• 56:28we evolved it when we had to go
• 56:29out and hunt and gather, right?
• 56:31So there was a lot of exercise and
• 56:33the marginal difference between our
• 56:36caloric expenditure and our intake
• 56:39kept things in the right place.
• 56:40But now I can go down to
• 56:42the store and get you know,
• 56:44or to a restaurant and get 1000
• 56:47thousand calorie lunch easily.
• 56:49When we're not even supposed to exceed 2000,
• 56:52right? So one meal and I,
• 56:54you know.
• 56:55It's all haywire,
• 56:56so I you see what I'm saying.
• 56:58I think it really for the obesity thing.
• 57:00I mean,
• 57:00I do think that the NCIS responsibility
• 57:02to do research to understand and come
• 57:05up with strategies to mitigate it,
• 57:07recognizing that there are we may
• 57:08not get these other problems solved,
• 57:10but I think this is going to be a
• 57:12policy ultimately just like smoking.
• 57:16Thank you up and down.
• 57:19Actually, yeah, now I feel guilty about.
• 57:21I'm about to walk out and buy
• 57:221000 calories lunch right now.
• 57:24Thank you, but no thank you for so much for
• 57:26joining us and for your thoughts, were I.
• 57:29I hope it was provocative.
• 57:31I hope people got out a lot of it wasn't
• 57:33your typical scientific presentation,
• 57:35but I really wanted to get out and
• 57:37sort of encourage people to come to
• 57:39the division of cancer prevention
• 57:41with their new prevention ideas.
• 57:43We really need everybody in the boat.
• 57:46You know, coming up with new
• 57:49strategies to prevent cancer.
• 57:50I think the public deserves it.
• 57:54Absolutely well.
• 57:54Thank you so much all right.
• 57:56Good luck everyone.