The third panel of the Nixon National Cancer Conference featured:

Mauro Ferrari, Ph.D., Former Special Expert on nanotechnology for the National Cancer Institute, Professor of Pharmaceutics, University of Washington

Stephen Hahn, M.D., Chief Medical Officer, Preemptive Medicine & Health Security, Flagship Pioneering, Former Commissioner of the Food and Drug Administration

William W. Li, M.D., Chief Executive Officer & President of The Angiogenesis Foundation, New York Times Bestselling author of “Eat to Beat Disease”

Larry Norton, M.D., Medical Director of the Evelyn H. Lauder Breast Center at Memorial Sloan Kettering Cancer Center

Moderated by – Anna Barker, Ph.D., Former National Cancer Institute Deputy Director

If you weren’t able to watch this panel’s discussion live, you can watch it here.

The full transcript is listed below.

Dr. von Eschenbach: Welcome back. Welcome back. Hope you enjoyed the lunch. Hope even more that you’re enjoying some of the opportunity for dialogue among each other about how you’re a part of this story of the progress that we’ve made in the future that we can still achieve. We’re delighted to now move to the third panel. And in order to introduce that panel, it’s my pleasure to introduce someone to you, who, if anybody noticed, the sidebar that just occurred when she shooed me up here on the stage and said, “You’re on,” you realize in many ways is kind of my boss.

Dr. Ellen Sigal has an amazing history. She has a PhD in Russian history as I remember it. And so, one might ask why should someone who had chosen that career be now coming up on the stage as the founder and co-chair of Friends of Cancer Research. And it’s because she represents a story that many of you and us all share, and that cancer impacted her life. It impacted her sister and her family in a way that she understood the tragedy of cancer and chose to be able to make a difference. She began that difference by service, and she has played numerous roles that I can’t even begin to recount for you, in terms of service on the advisory board for MD Anderson, service on the National Cancer Advisory Board. She, as head of forensic cancer research, is on multiple programs that are influencing policy today. She is on the board of the foundation for the National Institutes of Health.

And where I say she’s my boss is because I sit on the board of the Reagan-Udall Foundation of the Food and Drug Administration, and she has been the chairman of the board of the Reagan-Udall Foundation. So when she says, “Get up there, get up there.” I get up there. So it’s my pleasure to introduce a transformational woman who has made such a huge difference in healthcare policy, both at the FDA, and at the NIH, and at the NCI, Dr. Ellen Sigal.

Dr. Sigal: Thank you, Andy. It’s actually not true. I’m not his boss. Madeline is his boss and his friend, but I am his good friend and adore him. I chair Friends of Cancer Research, and I’m honored to have our vice-chair here, Marlene Malek, who you heard from before. Interestingly enough, Friends of Cancer Research was started 25 years ago when we were both serving on the National Cancer Advisory Board. And Rick Klausner, the director of the NCI asked me to do something about the National Cancer Act for the 25th anniversary. And if anybody knows Rick Klausner, he has 3,000 ideas. And I said to him, “Give me one.” And the one was really the importance of basic research. So I recruited Marlene and we started Friends for one year, and now 25 years later, we’re here, but it was really to deal with the importance of cancer research.

And we wanted the politicians to know that the funding of National Cancer Institute happens in their community, that patients in their community are the ones that need help and that money is distributed and the science happens not just in [inaudible 00:03:48.985] but all over. So, we heard a lot about the enormous accomplishments of the National Cancer Act. It’s been transformational. And without that, we really wouldn’t have the cancer programs we have today. We wouldn’t have the research and more importantly, the treatments that are really making a difference for patients.

It’s very interesting that a Republican President, Richard Nixon introduced that act, but he did it with bipartisan support and with the deep commitment for research and for the importance of bipartisan work. It’s become very sad in Washington and we all experience it and see how really polarized we are. And it’s extremely sad, but there is one area of hope. We are not polarized on the importance of research, health, and NIH funding, and the importance of helping patients. That’s one area that we all agree on. Cancer is not partisan. It affects all of us, Republicans, Democrats, poor, rich, and it has an enormous impact on people that are underserved and we need to do better. But we’re very proud of the accomplishments, but we have a lot more to do.

So this panel is going to be moderated by my dear friend Anne Barker, who we have been in this battle together for a very, very, very long time. She’s a dear and close friend, committed her life to cancer research. She, too, like me, lost her sister from breast cancer and has a long list of accomplishments. She was deputy director of the National Cancer Institute. She serves with Larry Ellison now at the USC. And I can’t even begin to enumerate her accomplishments because we wouldn’t get to the panel, but what we would get to is her humanity, and her passion, and her drive. And now we’re gonna go through the future. We’ve talked a lot about the past, but now we need to look at where we’re going and what we need to accomplish. So thank you very much.

Dr. Barker: Thank you, Ellen. Truly a transformative individual with no lack of passion. And I have to tell you just a quick story. When I first met Ellen, we met through our common interest in cancer, and I never will forget this, because she called me up and said, “I don’t know you, but I’d really like to know more about the way you think about cancer.” So she said, “Will you meet me for lunch?” And I said, “Sure,” in Washington. So, I went into the restaurant and I said, “I’m here to see Ellen Sigal.” And they said, “Well, let me take you to the Sigal table.” I said, “Oh my God, she has her own table.” I mean, that was very impressive, I’ll have to say. But Ellen and Marlene Malek and Friends of Cancer Research are, without a doubt, a real gift to cancer research because many of the policy issues that you’ve seen and heard talked about here today have come out of Friends of Cancer Research. And it’s been my pleasure to be on the board since it was founded. And it’s really made a difference.

So I wanna thank the organizers for inviting us, and I really am looking forward to this panel. This is essentially the future of cancer research, how we might change it. And I wanna make very clear, we’re interested in changing it for the better. So we’re gonna be talking today about the future, and I’m not sure if our other two panelists are coming up on screen. There they are. Welcome. We can see you well, and I’m gonna introduce everybody first, but I wanna make a couple comments about this panel. I think Mark Twain actually said this first, “Making predictions is hard, especially about the future.” So that was not Yogi Berra, which he’s given a lot of credit for that I think, but it actually was Mark Twain.

I was listening today very carefully, I think we are at an inflection point in cancer research and the overall conquest of cancer that was foreseen by the National Cancer Act. And I would argue that we are in about the same position, for different reasons, that President Nixon was in 1971. Why do I say that? Well, we’ve had a long history now of a lot of accomplishments, and we find ourself in an area and at a time where the opportunities have never ever been more profound. It’s staggering as you’ll hear from our panelists today. And there are resource issues that were very much on the mind of President Nixon in 1971. And when you have this level of opportunity and cancer isn’t the only disease that we have to worry, obviously, there are lots of others, as well as infectious agents like COVID 19.

So our questions, I think, today are gonna deal with, you know, at this inflection point, how do we go forward and make the most out of what we have gained from the National Cancer Act, which is unbelievable as you’ve heard? I love the first panel this morning. You know, when you have three Nobels who are still thinking what they’re gonna do next as this panel is, it’s pretty exciting. So, the other thing that struck me when I… I was asked to do a Ted Talk on, can the government cure cancer? That was my question that I was given. And I went through the whole thing. And then, you know, I didn’t actually address the question of can the government cure cancer until someone stood up and said, “Dr. Barker, you haven’t said anything about whether the government can cure cancer.” I said, “Well, no, the government can’t cure cancer. But the resources that are provided by the government, and the convening power of the government, and the issues that the government can bring forward can certainly enable the brilliance that we have in our scientific communities to cure cancer.”

And I think we’ve seen that play out and we have that opportunity again. And the other thing that struck me if you’ve read the history of the National Cancer Act, that we had just put a man on the moon. So Mary Lasker reasoned, “If we can put a man on the moon, we can cure cancer.” And we just put a whole bunch of people in space, right? If you’re a billionaire, you can go to space. So, you know, we’re kind of there again, you know, we’re putting average, you know, pretty… Well, those aren’t average people, but we’re putting people on in space now, and we’re talking about going to Mars. The similarity just can’t escape us. So, somebody else should write a book on maybe the new 1971 Nixon Cancer Act 2.0.

So let’s get started. Let me introduce our panel, and I wanna say one thing about this panel. I know them all, and it’s interesting that all of them are people who think outside the box. They are pioneers in their field. They challenge dogma. And many of them, all of them actually are passionate to a fault about this disease and how we can change the future. So, I’m gonna start with Dr. Steven Hahn who’s on camera. And he is the chief medical officer of Flagship Pioneering. That will give you some sense of what he’s doing now, but he’s actually in the preemptive space in terms of cancer. I mean, he’s thinking now about how do you actually do more upfront about cancer. He was the 24th commissioner of the FDA from I believe around ’19, ’18 to 2021, something like that. And before that, he was at MD Anderson, and there, he was the chief operating officer for some time. I know him best because of his work in radiation oncology, and because he’s a extraordinarily thoughtful, compassionate, and very, very smart physician. So welcome, Steve. We’ll get back to you in just a minute.

I wanna now introduce Dr. Will Li, and I’ve known Will for a long time. But he is remarkable in that he almost singlehandedly has brought something to the foreign cancer research that was actually I studied under Judah Folkman, and it’s one of the transformational kinds of things we have learned about cancer. Cancer can grow its own blood vessels. Who knew? And so, Will wisely founded the Angiogenesis Foundation several years ago, and he was the founding director of that society. He has made a huge difference in what we know about what could happen with cancer and its blood supply.

And if you think about this, you know, this is one of the most important aspects of cancer. I mean, essentially everything that you see and everything you think about in cancer is somehow influenced by angiogenesis. So he has a new book. I read it because I’m always one of these people looking for more health in my life. And this is… The name of the book is “Eat to Beat Disease.” Actually, I saw it out there. So if you wanna sweet the pot here for, you know, you could go out and buy a copy, I guess. So, he also actually is known for thinking about how you starve cancer, so we’ll come back to that. And I think that’s an interesting concept because one thing about cancer and we now have known for decades is that a lot of cancer is caused by poor nutrition. And we haven’t really done enough about that.

Next is my colleague and friend Dr. Mauro Ferrari. He’s affiliate… First of all, he’s a polymath. I should tell you he’s trained in engineering and mathematics. And he went late to medical school, and he’s a polymath, you know, from beginning to end. He’s now at the University of Washington as an affiliate professor. He’s a serial entrepreneur, loves to take things from the lab into patients, and he has real passion about cancer for personal reasons, as we all do. He was previously the President and CEO of the Houston Methodist Hospital research institute. He is an expert in nanotechnology and was of great help to me at the National Cancer Institute and Dr. von Eschenbach to help us to plan our nanotechnology initiative and put it on the ground all those years ago in 2004. And it’s really made a difference. So I have thanked him many times for that.

Last, but certainly not least, is my longtime friend and colleague, Dr. Larry Norton. Hello, Larry. He look as you can tell, he is very intellectual with all those books behind him there. So, we know that he’s going to have wise to say. Larry is the senior VP and actually is in the Office of the President at Memorial Sloan Kettering Cancer Center. He is the Evelyn H. Lauder Breast Cancer Center director. He actually is somebody I’ve known for a long time because we have a common in the mathematics of cancer. And he’ll say something about that, I hope.

He’s also, because of his work in the mathematics space, he is known for the Norton-Simon model of cancer growth. And essentially, that’s helped us understand how to treat cancer better because all cancers don’t grow the same. Small tumors actually grow faster than large tumors. And so, knowing this has helped Larry to actually help us to build better regimens for cancer patients. And so, I’m gonna start with Larry. And yeah, so this will sets the bar pretty high, right? So, I wanna know, Larry, what you think is going to really, in the next decade, going to change cancer research and cancer, as we know it, for patients?

Dr. Norton: Well, first of all, it’s a great honor to be part of this panel. I’m sorry, I can’t be there in person. But I’m delighted for the invitation to join this panel, and thank you, Anna, for the introduction. We discussed before…those of us on the panel had a call before, and I think there’s a certain concept that I think we all sort of share, which is that we have lots and lots of pieces of the puzzle lying on the floor in front of us or on the table in front of us right now. Because of the National Cancer Act, because of the funding of the National Cancer Institute, because of the cancer centers, because of the development of science, because of the evolution of science, we know lots and lots of pieces about what makes cancer tick and how to treat it sort of properly.

I think the thing that we’re not very good at is getting those pieces together into one big picture. Some of this is just historic. Some of this is just because of our training. Steve and I were talking earlier about in academics, you know, you get your kudos from learning more and more about less and less in terms of actually digging into certain topics, that there are relatively few people that are experts in looking at the big picture and putting the pieces together. Most of us don’t understand each other’s area of science even. It’s to that degree. The people who do mathematics certainly don’t understand molecular biology, the people who do molecular biology don’t understand clinical medicine as well. Clinical medicine people have their own subspecialties in terms of drugs and surgery and imaging and so on.

And we all get together and we all like each other. Matter of fact, I think that’s one of the major, major things that the National Cancer Act has accomplished is it’s created a community, and the cancer centers are an example of that community, where we all get to know each other and work together, but we don’t necessarily speak the same language. And because we don’t speak the same language, we could be actually studying the same problem and not recognizing that. And I think a very good example of this is what we’re seeing now with the excitement around artificial intelligence and machine learning, which is computer science with a little bit of mathematics. And I think could actually benefit from a lot more basic mathematics actually in that field. Because now we’re seeing that artificial intelligence, machine learning is getting into all of this, getting into pathology with digital pathology and in the image analysis, even in drug design. And it shows that there are connections between our various disciplines that actually make a whole lot of sense and that can be glued together into a bigger picture, where what we learn in one area could help us learn from another area.

And there was actually a science that’s called convergence science. There’s a philosophy of convergence. And I think that the biggest changes are going to happen by the convergence of various fields. And I even brought in, you know, digital medicine, patient-reported outcomes, revolutions in that field as well. And bringing this all together in one big picture, I think is really what’s going to make the difference. Many people have said over the years that we probably already know the answer to cancer. We just don’t know that we know it because we haven’t actually seen the connections between these various things, and I think that the next decade or two is going to bring a convergence of these ideas and we’re gonna see really a dramatic change in our ability to diagnose and treat, prevent cancer.

Dr. Barker: Larry, really, you and I are on the same page on this. And we work together, actually, Stephen Hawking said some time a few years ago that this century, the century on now is gonna be the century of complexity. And so, I have this thing on my wall that says to embrace complexity if you work in cancer research. And you’re right. We have lots of pieces and the parts actually are part of a complex system. So, I’m gonna come back to that. Steve, I want to come to you with the same question. We are seeing this absolute just transition in terms of advanced technologies. Imaging is one of those, but so, I really just wonder what you think about, you know, what is it that you think will be most important to change cancer research for the better in the next decade?

Dr. Hahn: Well, thanks, Anna. It’s great to be here. And again, really, I wanna echo what Larry said, just appreciate the opportunity to be here and be part of this incredible group of individuals. So, the National Cancer Act and the investments that we’ve seen in cancer, biology, basic science, translational research, I think one of the key aspects is not just the advances that we’ve seen in cancer but with other diseases. And I’m gonna argue here that the investments that we’ve made in biology and understanding the basics of biology, and the genomics, etc., of cancer have led to our understanding of DNA, RNA, etc., translation. And I believe we wouldn’t have had mRNA platforms that would’ve led to two of the most successful vaccines that we’ve seen and really helped us move forward in COVID. So, to me, this investment we’ve made, the science that we’ve facilitated provides hope. And I love the tagline underneath the 1971 to ’21, “Bringing hope,” because I think that’s what this is about.

So this era of biology and biotechnology, I think it’s gonna open up a whole new approach to diagnostics, imaging therapeutics. I agree with Larry, a 100%, the data are the key component here, and how we pull this all together, how we make sense of it, how we make these connections is going to be of primary importance. And it’ll be complicated, but I think by necessity it’s complicated because there’s so much heterogeneity out there in disease and in cancer. So I think that’s number one, and it will help us draw conclusions, generate hypotheses to test in the clinic, etc. That new frontier is here. For example, we’re using machine learning and artificial intelligence to predict kind of what the next pathogens are gonna be as they emerge throughout the world. And I think we’re gonna see more of that. We just have to be clear about how we do that and have a very structured approach that allows us to investigate but make sense of the data.

I’m gonna ask the question, what if we’re entering a world where cancer can be diagnosed very early, perhaps even before it’s visible on a scan? Biology and science have enabled us to do that. It’s within our reach and this opens up whole new avenues of research, and diagnostics, and imaging, and in therapeutics. And imagine that situation then being extended to other diseases. What if we could diagnose Parkinson’s disease, hypertension, cardiovascular disease, other diseases before someone becomes sick? We will solve so many problems, prevent so much morbidity and mortality. And again, this is within our reach. It wouldn’t have been done without the investments that we’ve made in science and in biology, and if we weren’t in this biotech era. And again, it’s gonna be a matter of getting the data together, understanding how to put it together, making those connections that Larry pointed out.

Wanna make two other comments. One is we’re also gonna have to think about new approaches to interventions if we approach diseases early. And I’m so glad Will is on the stage because I believe that we’re gonna have to really look at the issue of nutrition, supplements, other interventions, and really apply scientific rigor to that. Take them through the process of scientific investigation and make sure that we have the regulatory framework in place that, number one, allows us to draw valid, scientific conclusions, but also doesn’t slow it down so that it takes us 20 years to develop these interventions.

And my last point is we learned from COVID that perhaps many of us and perhaps the most vulnerable have fallen behind in cancer screening and cancer identification. And ironically enough, those who benefit the most from science might be those who are most mistrustful. And so I’d say, in addition to all the things that we have to do to push science forward and to translate that into the benefit of humankind and identify disease early, we really have to make sure that everything that we do for the advancement of science and the treatment of disease is available to everyone including those who are most mistrustful of us and those who have the least access to care.

Dr. Barker: Thank you, Steve. I really think that last point is so critical. I had a good friend once who reminded me every time that I saw him that if we, in fact, apply advances in cancer research unequally, everybody loses. And in fact, that’s true. So I’m gonna…Mauro, I’m gonna turn to you next to ask you from your various disciplines in the way you think about cancer, what do you think…believe actually, knowing you, is going to actually change cancer research and cancer for cancer patients in the future?

Dr. Ferrari: All right. Can I shake it up a little bit? Okay. Respectfully and lovingly, we need theory, we need math, we need definition because we don’t even agree what it is that we are fighting, and we need technology platform. And all of the above, not in a way that is antagonistic to what has been biological cancer research that is of course is necessary, it’s fundamental, but these four additional pieces are every bit as key to get into the other side. Changing cancer the way it is today for the better, in a way that would bring to a true resolution.

Let me give an example, if I may. All right. So if you are looking at the history of therapeutic intervention against cancer, the drugs that we have, the therapeutics that we have, be they chemo or bio-based, if you inject them in the bloodstream, as we do with our patients, the percentage of the drug that will actually reach the tumor is very, very small. One percent if you’re lucky. That’s the on a good day. And of course, if you’re reaching whatever you’re reaching with an intent to kill with cytotoxic agent, for instance, if the stuff goes someplace else, then you’re gonna be hurting something else. And the balance between beneficial effects and adverse side effects that you don’t want goes against what you’re trying do.

Now, we have, in the history of cancer research, discovered agents that are more and more and more specific to the cancers that we want to treat to the cancer cells. And, of course, we have to do that because we don’t know how to steer the therapeutic agents that we are injecting to the right place. We already know the 99 plus percent of what we put in is gonna go in the wrong places. So, of course, we need to work on specificity. We did that by going from chemo to, of course, small molecules to biological molecules that have a recognition capability. And through that process, we have learned so much about cancer biology that it just been wonderful, but we still have the problem of balancing out to the beneficial and the adverse effects.

And now, keep in mind that killing cancer cells is very easy. Killing any cell is very easy. You can get a drop of water from the tap, no matter where you are. It’s not a statement about the quality of water. I mean, it’s very easy to kill cancer cells, but you need to get the stuff in the right place. So, the example that I was talking about is in the paradox that we find ourselves in, if you come from a different world, such as myself, from the world of math and engineering, you’re looking at this as a problem of transport. It’s a problem of mass transport. How do I get the right stuff to the right place and make sure they set the sanctuary parts of the body that you don’t want to hit are not damaged? How do you do that?

Well, you know what? This notion of the specificity of the intervention really boils down to how your therapeutic agent interacts with a very tiny, minute piece of biology that you want to hit so that you can generate certain things downstream in the cancer cells. That is the last part of the journey, getting there is 999 parts outta 1000. And we do a very minute note investment in study of that part of the journey. So we only work with the end combat once we reach the enemy, but we do almost nothing about getting to the right places, which to me is a bit of a paradox. Nanotechnology that was mentioned is one of the possible platforms to address some of these things. This is one piece, which I think in many ways has already been bypassed by more exciting, more evolved technologies even though it continues to bring, of course, nano drugs around and they’ve been used now for treating hundreds of thousands, perhaps millions of people.

So that has been good, but that is just a step of the journey. So the platform part, nanotech and stuff like this, but the math part allows you to tell you what you need to work on. The process of transporting the body has incredible complexity. It is governed by what we call the biological barriers in the body and how they get modified in the process of cancer growth. We know almost nothing about those. We know a little, little tiny sliver or something about those. And to me, unless we have a holistic mathematical description of the entire process, we can just solve one little piece while the rest of the problem remains unsolved. This is gonna get you through the window, even if you close the door. So we need a tremendous amount of math. That’s where I spent the last 10, 15 years of my life. One of the things that came out of that is the thing that now is called transport oncophysics.

But the flip side of that is not only it can give you better interventions, but it helps you with definition. What is cancer? What is cancer is the question, right? We have the famous hallmarks, tremendous breakthrough, incredibly deep science on understanding what cancer is, but that’s a descriptive, of course, a rendition of what cancer is. If you have a comprehensive theory in physics, we call them a unifying principle of something. All of a sudden, the various pieces make sense in a more holistic sense. And not that I’m going to be advocating that there is, or that we will never find a master equation of cancer. That is probably a pipe dream. That probably is never gonna happen, but by seeking one, we are going to be able to pose hypothesis with the right instruments. We are going to be able to then answer and discover more breakthroughs on the science side and the clinical side. And that’s my story.

Dr. Barker: So you know I agree with you, right? So, you understand that Mauro lacks enthusiasm for this issue, right? So, he’s actually on the same page with Larry in terms of this overall integration of other types of science into oncology. And I’m gonna come back to that because I think that is one of the revolutions that we are just starting, and it’s going to be transformative.

So I’ve saved Will for last. And why did I do that? Well, because if you read Will’s book, what you will find out is despite his enormous contributions to cancer research, basic cancer research in this space of angiogenesis, he writes about the state of wellness and he writes about the state of the human, if you would, in terms of cancer and how…and other diseases actually, and how you can actually take this kind of information, say angiogenesis, and use it for your own wellbeing. And so, I think I might know the answer, but I’m not sure. So I don’t know what he’s gonna say. I’m really curious. But Will, what do you think will be the major change that could occur, hopefully, will occur as you see it, in cancer research and cancer that would change the future of cancer research and cancer?

Dr. Li: Well, first of all, I think that recognizing what the National Cancer Act allowed us to do over the last 50 years is to dive deeply into that complexity to generate the bits of information that now we need to aggregate back together. And that is to, in part, to answer the question, why do we get cancer? Now, what’s interesting about that is we have also begun to identify the common denominators across different cancers, rendering this disease from this perception of a series of organ-specific predators that are out to take us out to actually understanding that these are normal cells that have gone awry. Now, those pathways of normal cells gone awry is more than the cell, the cancer cell, but the microenvironment, which has then led us to understand more the human as a whole.

Given the fact that we know that mutations, genetic abnormalities are part of the cause of cancer and our environment plays a substantial role in it, including our diet and lifestyle. One of the questions that I think the future is going to bring up and we’re gonna address is not, why do we get cancer, but why don’t we get cancer more often? And if you think about it, on average, the human body makes 10,000 genetic mistakes every single day, DNA errors, and yet, we don’t develop cancer every day. When we fill our car with fuel, for those of us who still drive a car with gas, I always ask, “Do you stand upwind or downwind of the pump?” And when people scratch their head, I say, “If you smell the fumes, you’re breathing in solvents that actually can cause genetic damage.”

So, one of the interesting things that have come out of the angiogenesis field, where I started, was the idea that, in fact, the body has incredible health defense systems. Our ability to regulate blood vessels so they help feed healthy organs but don’t feed cancers led to the idea of an angiogenesis inhibitor, which led to more than a dozen FDA-approved drugs for solid tumors and some liquid tumors that cut off the blood supply to cancer. And I took part in that. But one of the interesting things that I started to realize is that, number one, all of the cancer patients that I was involved with treating asked me, not what treatments should I receive. They asked me, “What I should be eating, doctor?” And I realized I had less than a month of education in nutrition in medical school, and I felt that was wrong.

So I went back and wondered, could we use the same tools, same rigorous tools that Steve was talking about for drug development and actually study food using those same systems. So that’s really kind of the emerging field of molecular nutrition or food is medicine in a more colloquial sense. So if I told you that we could actually identify substances within food, food compositions, food extracts, we can actually identify the same ability to be able to inhibit angiogenesis that could starve cancers or to be able to target cancer stem cells, which we cannot actually do with drugs right now. That’s a holy grail, but we can…there’s evidence that foods can actually target cancer stem cells, like green tea studies have been done, purple potatoes have been studied to look at that. This is a highly dispersed field, early field of research that use the same tools of molecular biology and cancer research to take a look at what foods can actually do. And then, we take a look at the gut microbiome, which is influenced by the food we eat and antioxidants, which, you know, can…

Dr. Barker: Could you remind us, Will, what percentage of our bodies are made up by bacteria?

Dr. Li: Pardon?

Dr. Barker: What percentage of our bodies are really… We’re really mostly bacteria, right?

Dr. Li: Well, there’s about 40 trillion human cells by last count, and our bodies can take 39 trillion bacteria, most of which live in our gut. And if 70% percent of our immune system, which we talked about some of the breakthroughs this morning, live in our intestinal wall, our gut basically communicates with our immune system, which is critical for immunotherapy. And in fact, we now know that basically, if you are deficient of in at least several gut bacteria, your chances of responding to a checkpoint inhibitor, immunotherapy is diminished greatly. So how do we actually restore that ecosystem? This is a systems biology and a complexity question that we need to be able to address. For DNA, it’s not just antioxidants, but it’s actually DNA repair. It’s actually helping to control the telomeres, the caps and end caps protecting our DNA.

And of course, immune systems, this delicate balance between inflammation, which can be chronic, and not just for cancer, but actually for a whole series of other diseases, versus immunodeficiency versus autoimmunity, finding that right sweet spot, which we actually been able to do in some cases. By the way, I have to personally thank the work of the National Cancer Act because my mother at 87 is a long-term survivor, cancer-free from metastatic endometrial cancer. So we’ve been able to do this. I’ve felt personally how important this is, but to truly gain…to make a breakthrough for the future, to make equality and access available to everyone, we cannot simply rely on chasing the horse out of the barn using expensive drugs that we have to get an ROI on, but look at prevention as the ultimate leveling of the playing field for cancer. And I believe that food and nutrition is part of that solution.

Dr. Barker: So I wanna pick up right there. Talk a little bit about, Steve, what you brought up, which is, essentially, can you really think about preemptive oncology? In other words, we have a test. We have several tests now, some approved actually when you were FDA commissioner, that can detect cancer very, very early before there’s any sign of cancer anywhere. We now have a test out now, you know, that’s from Roche that’s going to predict 50 different types of cancer. It’s in trial now, very big trial, and the data actually looked pretty interesting. So, how do you think that’s gonna work? I mean, those tests are probably not gonna tell us much about how aggressive that cancer is or, you know. So what’s next in this field?

Dr. Hahn: So this issue of multi… Oh, are you asking me, Anna? Sorry.

Dr. Barker: Yes, I am, Steve. Because all in all these places, so you have to know the answer to this.

Dr. Hahn: This concept of multi-cancer early detection, I think is an important one. And the question you first ask is, can it be done? And I think the answer is pretty clear that, yes, it can be done. The real question is what are we gonna do with the information? And this all ties together what we’ve heard about in this panel so far. So, I think the science and the biology is there to ultimately get to the point where we can detect a cancer before it’s visible. And when you think about that and I was talking to a colleague from my old hunt at MD Anderson. They said, “Well, so what? What are you gonna do about it?”

But if we don’t actually make the step to make that diagnosis, we’ll never figure out what to do about it. Now, it’s gonna take obviously understanding of what those signatures mean and the basic biology of how cancers develop and progress, because you brought up a really good point, which cancers need to be treated, which don’t, and that’s certainly a basic underlying aggressiveness issue. But it’s also an issue of… I don’t know who said it, it might have been Larry, but we might have a cancer develop in one of us every week and our immune system takes care of it, or we’re exercising and we have the right diet and it goes away spontaneously. I mean, I’m just conjecturing here, but the point is, we need to understand that and apply rigorous science and understand it is that leads to the progression of a cancer from detecting it in the blood, ultimately, to the formation of a tumor. When we understand that biology, we’ll better be able to intervene.

And one last…and so it’s really investment in research there, but it’s actually taking these measurements and then beginning to understand what happens to these people. And we’re gonna have to address issues like the aggressiveness, lead-time bias, overdiagnosis, all those issues. We can’t be afraid of them because I think science will allow us to get out of that and figure the answers to that. One last point, Will’s point about molecular nutrition. We also have to intervene with therapeutics that have a very wide therapeutic index that don’t cause a lot of toxicity but have the appropriate intervention, and we will need to invest in some of these approaches that I think will get us to a place where we can give safe, effective therapies early before cancer develops.

Dr. Norton: You know, Anna, there’s a common theme here.

Dr. Barker: Oh, Larry.

Dr. Norton: I don’t wanna interject, but go ahead.

Dr. Barker: There you are.

Dr. Norton: Yeah, no. I just, I’m very excited about this panel because there’s a common theme here that we’re all really talking about, but I think it has to be said. One of the areas in biology that where we have one of the greatest lacks, and where we have a great need, and where physics has really surpassed us, is that we’re very good at measuring absolute states, but we’re not very good at measuring and understanding rates of change. And the big revolution in physics, you know, calculus was all about rates of change. We don’t have a calculus. And I agree with Mauro, there won’t be one equation for cancer or even one equation for biology, but I think there will be a class of equations. There will be an area of mathematics, and that mathematics is gonna have to talk about rates of change.

And that’s not something that we are good at, that we talk about a lot, that we know how to measure, that we had the tools to measure until now. But I think now with modern imaging, with cell-free DNA, for example, with other tools in assessing the finely-tuned immune system, and even in looking at the progress of medicinals through the system before it actually gets to the target and the cancer cells. All these are topics related to rates of change. And I think that we have to start thinking more about that in biology and bring a mathematics to it. And I think it’s gonna be a different mathematics than calculus because it’s much more complicated. It’s gonna involve other topics. And so, we’re gonna have to bring people to the table who understand some of the real advances that have happened in modern theoretical mathematics that have not been brought to the table to really make sense of everything that we’ve been talking about, all these sort of topics that we’ve been addressing.

Dr. Barker: So, I’m trying to think through a little bit some of the things we heard this morning, and it strikes me that we incessantly, in oncology, always talk about very early detection. And I think we’re moving toward very early detection. I’m not quite sure we know what to do with it when we find it because it’s gonna be interesting because patients will want interventions. If they think they’re going to get a cancer, they’re gonna want some kind of intervention. And it probably more than genetic counseling. It’s gonna have to be something substantive. So that’s an issue that I think the cancer world has to deal with.

The other thing that strikes me as came up this morning and it’s come up…and I think Larry mentioned this, I think Mauro mentioned this, the time it takes to develop a therapeutic in this country or any country actually is ridiculous. I mean, it costs a billion dollars, and it still costs more than billion dollars. And the therapies are, to be honest, I mean, we talk about precision medicine, but we don’t have that many truly targeted therapies. And we’re sequencing patients now. We’re giving them a profile, right, with a lot of genes that are altered, but then we have to go and pick something off the list where we’ve had some success, maybe. So, how do we bring that… Because we have two sets of problems here. You know, one is preventing cancer obviously, or detecting it early enough that, you know, we really can do something about it. And I think that’s right on the horizon. But I honestly think our biggest headache and our biggest problem is going to be how we develop the therapies that we need for patients right now? Mauro?

Dr. Ferrari: Can I take a little bit of that? Combining your great question here and the observation that Larry put forth a second ago. Now, going back to this notion of transport oncophysics. So the definition is you look at cancer. What is cancer? Cancer is, starting point is, the hypothesis is, if you will. Cancer is a proliferative disease of mass transport disregulation. It’s a multiple level. The transport disregulation can be cellular, subcellular, tissue level, organ level. They are all connected anyways, and they are all mediated by disruptions in biological barriers, which are the vehicles through which you change the rates of transporting to different parts of the body if you will. Okay. So that’s the definition. Once you have a definition, and of course it’s not gonna work for everything, but it’s gonna work for a certain number of things.

At that point then, you define an envelope. This says when I hit that envelope, it’s a multidimensional envelope. That’s the point where I get a certain risk level that corresponds to the likelihood of developing a disease that has a certain degree of aggressiveness, and that’s where you want to start intervening. Of course, that’s the framework of this and is all driven by mathematics. But now coming to your question, how do we make sure that we can move things to the right way? Well, transport is governed in the body by passive mechanisms, by active mechanisms, but the laws of physics are the laws of physics. If you go back to those, you develop, like engineers would, the considerations of design that are like those that engineers use for making helicopters or planes or boats or whatever it is, you can start to look at ways to concentrate what you inject in the body by making changes to your therapeutic agent that have to do with the physics of transport.

So by making those small modifications, you can concentrate preferentially in certain tissues. And some of the tissues that are easiest to reach, obviously, enough would be the tissues of this, say, reticuloendothelial system, the filtering parts of the body. So not everything, not the brain, but I can do pretty well in the lungs and the liver. And, of course, in other parts of the body. So coming back to your question is, you know, if we go with this discrete approach, that is, of course, what molecular biology does. Either you have a pathway or you don’t, either you have a variation or you don’t. You have a certain number of them, and there is no in between. So every time you have to hit something, you have to come up with a different drug and it takes you billions of dollars, and it takes so many years.

Look at the physics approach and the math and physics approach. You define your design parameters for the drug that you are developing, the therapeutic agent you developed with some degree of variability in each of the components. FDA allows for that. There’s a certain degree of variability that allows you to do that. And all of a sudden, staying within that range of change that is possible, that is allowable by the regulatory body, you really get different distributions in the body, different degrees of penetration, different rates of actions, and all that stuff, is in a way of looking at this is no longer discrete as biology has to be. It’s continuum but it’s discretized in a way that the regulatory agency will approve. So, it’s an entire different way of looking at things.

Dr. Barker: Yeah. So, we’re gonna come back to this and probably toward the end, but Larry and myself, all of us have actually worked when I was at NCI. And since on…and Phil Sharp brought it up this morning, you know, how do we in oncology beginning to enable the convergence of disciplines? How do we bring physics, mathematics, engineering in to help us understand? You do know that you’re all three-dimensional creatures, right, walking around and everything is going on in your body in real time. It’s all dynamic. All dynamic all the time, three dimensions. Now, how do we study cancer? As you heard from Larry, we’ve been studying the parts of cancer. And as you heard from David Baltimore this morning, it’s important we continue to study those parts. It’s to continue that we understand the fundamental nature of this disease.

However, we are at an inflection point where we need to bring these other disciplines in, and we need to welcome them in. And we need to set up a communication system so that biologists, and physicists, and engineers, and mathematicians actually begin to respect and understand each other. And I had some experience with that when I was in NCI. We set up something called the Physical Science and Oncology Centers. Most of the people you see in the country that work in that space actually trained in those centers. And they will tell you, this is a very tough, tough barrier for us to overcome in oncology. But oncology, again, as you heard from Phil Sharp today, is information. Cancer is information. It’s digital. It’s essentially just like your computer. There’s two kinds of information in your computer, the digital information, which is in you, its DNA, right, that gets translated. But the second type of information, which is more important, is the kind of information that Will works on, is the analog information. It’s the context in which you set that cancer. And he talked about context.

So, I want to use that as an entry point and anybody can work on this that wants to, and I don’t have an answer myself. But I’m trying to think about the barriers we’re trying to overcome in oncology. One is early detection. Other one is better cancer therapies and delivered more appropriately and at less money. We’re not gonna deal with the less money today, but they have to be more affordable because we have to get them to all the populations. But the big elephant in the room is metastasis, isn’t it? We have not, in these 50 years, conquered metastasis. And if you have metastatic disease, we are really still stuck. And I want to know what you think about what we could do to move the needle on understanding and controlling metastatic disease. Because we can cure a lot of cancer right now, but I know the man who’s gonna speak up on this first, who spent a lot of his life thinking about that, and Will spent a lot of his life thinking about this, and Mauro has as well. So what do you think? Let’s hear it. Larry, let’s go.

Dr. Norton: Let me just jump in because I’m not on the stage so I can’t see if who else is ready to talk. So, I’ll just sort of jump into this, I think. Anna, you’re amazing because every time you’re saying something and I write down a word that I wanna bring a new word into the conversation, you already hit that new word in your next sentence. So, you’re always a step ahead of me. And when you talked about the fact is that we’re thinking very digitally about biology now, which makes a whole lot of sense. But it’s really an analog process, and an analog processes have different mathematics than digital processes, so that’s gotta be taken into account.

But there’s one thing I’d like to just throw into our thinking gear, which is we haven’t really touched on yet. There’s actually two things that I hope we’ll get to the second one little bit later, but it’s about monitoring. When you think in internal medicine, if I have a patient with high blood pressure, what I do is I measure the blood pressure, I give a pill and I see if the blood pressure changes. And if it doesn’t change, I either give a higher dose or I change to a different kind of medicine. Eventually, I find something that lowers the blood pressure, which lowers the incidence of heart attacks and strokes. And we don’t do that for the most part in oncology. We have very, very gross ways of telling if our drugs are gonna work. It’s got to shrink enough that we can actually see that in an image, where we should be able to tell what’s happening really in real time.

And the same thing, you know, it goes in the prevention space and the relationship between food and the microbiome in the gut, and its relation to the immune system. We’ve got to get better at measuring things that are of clinical relevance or clinical importance and of actually trying interventions and seeing if they change those intermediate markers before the ultimate happens. And that is not something we’ve spent enough time on as a field. And I think that a tremendously important growth area. And just one example in cancer therapeutics, if we can measure cell with DNA or circulating tumor DNA, we should be able to tell in a very short time if a drug is working. And if it’s not, change the schedule of the drug, which may be a factor, gets back to kinetics, or add a drug or subtract a drug and go to a new drug and do it in real time. And that way, we can get on top of the cancer sequences of drugs.

I’ve got a strong suspicion. We’re working on Memorial Sloan Keterring that sequences of certain drugs may make a whole lot of sense using one drug first and then another drug at the proper moment, but that requires sort of monitoring. So, that’s a very, very important area that we need to address. And I think putting it to the mix of everything else that we’re talking about here, it’s part of that convergence science. Part of convergence is actually doing something, perturbing a system, seeing how it’s perturbed, and reacting to that perturbation in a meaningful way.

Dr. Hahn: And Anna, just to follow up on, Larry said…

Dr. Barker: So, Steve, I wanna ask you if you think imaging could make a big difference here?

Dr. Hahn: Yeah. Just gonna jump in and say that, you know, we’re seeing now reports of cell barcoding being a way of following tumors and monitoring, just like Larry said. So, our whole concept of imaging, I believe, and understanding the temporal and spatial relationships of these cells, where they are, where they come from, it’s going to change and it’s going to change. And I think as we push the diagnosis even earlier, it must change. So, I think imaging will have to be part of this. And it could be called monitoring, it could be called imaging, but whatever it’s called, where’s the cancer? Where does it come from? What’s it telling us about the response to the treatment, its interaction with the immune system? Those answers are there. We just have to be able to detect them and monitor them. And I believe that we’re on the cusp of being able to do that.

Dr. Barker: Can you say a couple things about digital pathology? For example, we’re all used to going in for diagnosis about the pathologist is looking through his microscope or her microscope, and that’s how we got her diagnosis, but that’s changing, isn’t it? And what do you think is gonna be sort of the next revolution in pathology?

Dr. Hahn: So again, I think we can screen patients, if you will, with these MCED tests. And we can say that this person is at risk for a cancer. We need to understand what would be potentially the natural history of that, but ultimately, we need to make a diagnosis. And that diagnosis may not be by performing a biopsy of a tumor in the lung that we see on a CT scan. So, we can think of what that name might be, but we have to have ways of identifying. And I think this is the next hurdle we have to have, and again, you know, we see reports in the literature of being able to identify single cancer cells from a very low level, and being able to actually look at those and identify where that cell comes from, whether that’s from a morphologic approach or from a genetic approach.

And again, this going back to barcoding, that’s another part of this because the very simple, naturally-occurring mutations that are used for barcoding are, again, another clue to tell you potentially where the cell comes from and what part of the tumor it is and where it’s located, etc., and the environment and the spatial relationships, all influence that. So, our understanding of that will eventually get us to the point where we can use very simple, I believe, blood-based approaches to make diagnosis. Whether you end up calling that digital pathology or genomic pathology or whatever, I think that’s probably the next step we have to take. So, this will open up new areas of both imaging and diagnostics.

Dr. Barker: Yeah. Will, I wanna ask you a little bit about this, because I think you can’t worry much about metastatic disease unless you know and worry a little bit about what’s happening with angiogenesis in terms of how the information is actually laid down for this kind of change in a cancer for it to become metastatic. So, how can angiogenesis influence that in the future? I mean, are there approaches that we could think about that might be prohibitive of angiogenesis?

Dr. Li: Well, it’s interesting. The seminal paper that my mentor, Judah Folkman actually published in the New England Journal about tumor angiogenesis appeared in 1971, the same year that the National Cancer Act was signed. So, I think there was sort of this great resonance about the potential of thinking about angiogenesis. I want to talk about metastasis in one second, but I wanna address one of the things first about this obstacles that you and everyone’s been talking about. First is more people need to come into the sandbox, the mathematicians, the physicist, the data crunchers. But the second thing I think is we need more sandboxes to be put together as well. So, for example, not only do we need to be able to look more deeply and collaboratively within the cancer research field by bringing others into it. Cancer researchers could look to how progress made from the National Cancer Act led to the discovery of angiogenesis, the unraveling of the immune process, the stem cell research and how it’s obligated to other fields of medicine as well.

So, what can we learn in addressing cancer and metastasis from ophthalmology where, for example, anti-angiogenic therapy is the dominant, or from wound healing where we know that stem cells and we know that angiogenesis is critical physiologically, but that actually a chronic wound, the vessels in a chronic wound look remarkably like a tumor vascular network as well. So, if we can actually go across these vertical silos, we may be able to extract from existing progress or emerging progress to be able to make what we do in cancer more efficient.

So, as it relates to metastasis, not only are microscopic cancers do they have a requirement for vascularization to be able to be fed by oxygen and nutrients and then to be able to invade, but those same vessels that feed the cancers allow cancer cells to escape. It’s not the only way the cancers can spread, but it’s one of the ways that cancers can spread. And then, those microscopic spreading cancer cells need to be able to implant into the next environment where they are still microscopic until they can actually replicate that process again. So understanding the primary and the pre-primary, which is really pre-medicine, which is pre-cancer is gonna give us a lot of clues to understanding how to actually chase metastasis. So, I would actually argue that the best way to think about how to wrangle metastatic disease is to really invest heavily in looking at that pre-cancer state so we can intercept the metastasis in a way that we would intercept the primary, and then look at who’s at high risk, and then for out how to diagnose and how to monitor, and then bring all those tools that we’ve been discussing.

Dr. Barker: So change the process, essentially. Yeah. Mauro, I was very enthusiastic and thought by now we would have a nanodevice or a nano construct that would actually prevent metastasis. What have you been doing with your time?

Dr. Ferrari: Okay. All right. All right. All right. Nanotechnology has been happy to join the ranks of everything has ever tried anyway, anytime, anywhere in the history of humankind and been unable to do that. And I think we share that burden. Now, but to talk about metastasis and think that they consider post-nano, an evolution of nano. If you go back to this notion of transport or using that as a paradigm, we can do similar conversations on other modes of physics, if you will. So, I spent about 20 years thinking about what makes a lung metastasis a lung metastasis? Are there characters in common regardless whether that metastasis come from the skin to a melanoma to a sarcoma, from sarcoma, from a breast cancer? The majority of cancer deaths are all to liver and lung mets. So let’s focus on those. Is there anything that is special about them?

And going through a bunch of years of work and some of which you funded. Thank you very much. We found this that transport is really different. Mass transport, drug transport, transport of metabolites, transport of nutrients, everything has to do with masses. It comes across those biological barriers is really different. And that is where we started thinking, okay, can we take advantage of those differences to design something that will filter preferentially into the cancer in certain parts that all that are particularly important, [inaudible 01:03:00.431] that all that are particularly important. So one solution that I’m sure there is smarter people out there that come up with the solutions. But what we came up with is this drug that has four components. Three components ain’t enough. It’s got to have four components.

Three of which have to do with transport. There’s sequence of passages that you need to be able to make happen. So three of those is transport. It’s the journey to the point, if you will. And the fourth is actually cytotoxic agent. Of those three, one can be modified in terms of his physical parameters, size, shape, charge, density, all these things, so you can design it. And with that, we published this in Nature Biotech, was it three, four years ago. In animal models, which as we well know, not the whole story, but they are, in many ways, a necessary starting point. We were able to provide complete cures to a majority of animals that had different mice models. There were a chop full of lung and liver mets that otherwise would’ve died. So we were encouraged by that. And again, that shows, if you will, that there may be a different approach that you can take to solve part of the problem.

Now, if I can make…and again, nano is a piece of the action. It’s not the entire story. Nano has done wonderful things, including providing the foundations for the vaccines. They use RNA, right? The mRNA. Of course, those vaccines require two components. There is the great biology mRNA, and then you gotta bring it someplace somehow and protect it when you inject it, and that’s all nano. And that, in many ways, the vast majority of work done on nanoparticle has come from the program at the National Cancer Institute, talk about something that crosses over. So, it is a platform approach to make reference to what I was talking about earlier on.

So, these are notion here of using transport allows you any definition of what type of subtypes of cancer you’re working at. Those that are defined by that. Because if I can have a little provocation just for the fun of it, again, lovingly and respectfully, I remember back when I was studying the history of medicine at a certain point, there was this disease that was one of the most prevalent causes of death at the time and in the place. And it was called in French, hydropsy, hydropsy. Dropsy in English, swelling of tissue as a cause of death, regardless of whether that was an indication of, I don’t know, congestive heart failure or ovarian cancer or failures of the kidneys. It was all summed up into this presentation, which was the swelling of the tissue, and that would be considered cause of death. One of the dominant causes of death throughout history. I am wondering if, as we start looking deeper and using definitions, not collections of immunologies, even if they’re at the molecular level and very sophisticated, let’s look at definitions of what things are, and that will identify subsets of these many, many, many diseases that we call cancer. I wonder if this whole notion of one word for covering everything over time will disappear. And my impression is that it will. It is a thousand different diseases, if not more.

Anna: Okay. I think that’s a good place to transition. I wish we had two hours for this panel because I think there are that many great ideas to be discussed today, but I just wanna read a quick list here. I could say multi-omics, but I could also say genomics, transcriptomics, proteomics, metabolome. I could go through the entire list, but the point is there’s all kinds of sources now of digital information and we’re collecting it all, and we’re collecting it on many more patients, but probably not enough. Big data, sort of a whole range of advanced technologies from imaging to nanotech, and you could go through a long list. Liquid biopsy, a very transformative tech on the certainly already in process and in the clinic but with enormous potential.

Larry brought this up, this field is going to be dominated by information and artificial intelligence. That’s the way it is. Information is gonna come together in ways from all the omics and all of that analog information, it’s gonna produce the data sets. And ultimately, the data sets will be converted to information, which will be interrogated by artificial intelligence. So, get used to that idea because you’re gonna hear more about that. And when Steve was actually at FDA, they led the entire sort of revolution by starting to approve those kinds of biomarkers and diagnostics, and ultimately, it’s gonna be therapeutics as well.

So you heard from our panel today a lot about convergence science. I think that’s one of those areas that’s going to…I think it’s the area that’s gonna change everything. And if you can follow up on Larry, we’re all talking really about the same thing. We’re talking about the convergence of all of these areas of science that are so complementary to oncology and oncology to all of those areas. And we need to figure that out. So there’s so much coming in terms of quantum computing and areas that we’re not even getting into today, that people will say, “Oh, it’s so far over the horizon.” But how many people have one of these who didn’t have one of these 10 years ago? Right? I mean, technology changes everything in biology. And I would argue that the next decade is gonna be transformational.

I think we are at an inflection point. I think we need to bring these disciplines together. The convergence is going to be everything. But there’s been another revolution aside from the genomics revolution, We’ve had a revolution in cell biology and molecular biology, and now we’re having a revolution in data science and information, but we’ve had another revolution, and that’s the patient revolution. So patients and patient advocates are very much a part of our process now in oncology. They sit on our panels, they involve in our research. They’re making a difference. And so, we talk about precision medicine and personalized medicine, but in just one sentence, what do you think, in the future, is…what do you think that the role of patients is going to be in changing the future of cancer? Will?

Dr. Li: Well, I think patients are at the heart of why those of us in medicine went into medicine. I wanna bring two contextual things that resonate with…

Anna: We have to close quickly, so you have to go quick.

Dr. Li: Yeah. The National Cancer Act is sort of at, you said inflection point. Today, we… Actually, I think we’re facing with the pandemic. We’re beginning to discover the inflammation regarding…that involve with COVID is likely to actually open new doors of opportunity and new patient needs to study the risk of cancer and people who have recovered from COVID. Number two, I think patients, people need aspirations, including patients of where to go next. You mentioned the space program, the National Cancer Act in Richard Nixon actually was framing the context within space exploration. I’ve been involved with some of this as well. In the future when humans become extraterrestrial and we leave Earth orbit, and we actually wind up encountering galactic radiation…

Dr. Barker: You’ve heard it here first, we’re leaving. We’re leaving.

Dr. Li: We encounter galactic radiation. One of the big risks is gonna be damage to our genomics. And so, what can we do, anticipating the future, that’s aspirational for humanity that we can bring down to Earth today.

Dr. Barker: All right. Quickly, Mauro, what do you see as how patients could change the future of cancer research?

Dr. Ferrari: All right. This is only about the patients. Thank you tremendously. Exactly. And to me, I’m reflecting back to the National Cancer Act, and the National Cancer Act, we have been talking in the session and in the prior sessions, essentially, comes down to building bridges, bridges between disciplines, between approaches. It’s all about bridges. But the most important bridge of it all is the bridge between the research laboratory through the clinician to the patient. And that is what the National Cancer Act of ’71 established most effectively, creating a paradigm for the future. So again, one more time, as we look at the future, the future is inspired by the past. This is on the shoulder of a giant and the giant is this 1971 great accomplishment of humankind that we are here to celebrate because it puts focus, in so many ways, it puts it on the patient.

Dr. Barker: Agree. Steve, how can patients change the future of cancer research?

Dr. Hahn: By helping us get out of our own way and removing us from our blind spots, by emphasizing what’s important, because what’s important to the patient is ultimately what we need to focus on in addition to the science. And then finally, every day we meet with patients and patient organ advocacy organizations, it reminds us that hope is necessary. Hope for a cure, hope for moving forward, and that science brings that hope. So it all comes together with the patient.

Dr. Barker: That’s actually what I think our 21st century is about right now is hope as it was in 1971. Larry, we started with you, we’re gonna close with you. Nobody I know has had more impact on cancer than this man right here, by working with patients.

Dr. Norton: The thing that patients bring to the table, which is not often identified, is that patients think big. As scientists, we tend to think small. We tend to think about our particular area of focus. And the question that the voice of the patient at the table is always, “Okay, that’s a very nice piece of science. How does it affect me? How does it affect my family? How does it affect the rest of the community?” And thinking about the totality of the problem, including all the social aspects, and psychological aspects, and environmental aspects is something that the patients bring to the table.

But they also bring something else important. And I wanna close with Mark Twain because you opened it with Mark Twain. My favorite Mark Twain quote from one of the books is, “It’s not what you don’t know that gets you in trouble. It’s what you know for sure that turns out to be wrong.” The patient voice is makes us question what we’re sure of, and by questioning what we’re sure of, it makes us think differently about the processes, and in that, comes creativity. It all boils down to creativity, and what’s gonna energize us, and what’s gonna move us off to the future, and what’s gonna cure these diseases and prevent these diseases is our curiosity, our imagination, our creativity. And motivating us in that direction, I think, is one of the most important thing that patient voice accomplishes.

Dr. Barker: And you’ll hear a lot about real-world evidence coming from patients. And it turns out that we’re doing clinical trials now powered by real-world evidence. The world has changed in the whole of cancer research for the better, and everything you’ve heard today says it’s only gonna get much better in the next decade. So, thank you very much, Larry and Steve, Mauro and Will. You’ve given us a whole new lease on life, and so we go out prepared to change the world. So, thanks to the panel.

Dr. Li: Thank you.

Dr. Ferrari: Thank you.