Art of good writing. At 12 30 p. M. , the film inside of a superhero, the secret history of wonder woman. As 7 00, reading habits. At 8 00can history tv a. M. Eastern, the fall of the berlin wall with footage of president george bush and bob dole with his speeches from president john kennedy and ronald reagan. Fashion experts on first lady fashion choice. And then at 10 00, former nbc anchor tom brokaw is in good years of reporting on world events. That is this christmas day. A discussion about Cancer Research with dr. Francis collins, director of the National Institute of health and. R. Ronald depinho they talk about the latest cancer breakthroughs and some of the research challenges. It was cohosted in october by the Aspen Institute and friends of Cancer Research. Susan page is the moderator. And i am so glad when not only have a full house but cspan is here so well have an audience. Let me very briefly introduced dr. Francis collins. Director of the National Institutes of health, the larger Biomedical Research in the world. He is renowned for his leadership as the genome project. Many awards, the National Medal of science and president ial medal of freedom. Welcome. Dr. Ronald depinho, president of he university of texas where he was also the founding director of the belfry institute for applied Cancer Research. He has received many honors and awards and found this there will Biopharmaceutical Companies focused on cancer. Thank you for being here today. I will post questions myself in the later open the floor to questions from you all. Keep that in mind. We are going to answer the question, how close we are to curing cancer . Start lookingl back. Dr. Collins, you received your medical degree six years after president nixon declared a war on cancer. Tell us what the assumptions about curing cancer, addressing cancer, treating cancer. Would bessume cancer cheered by 2014 . What were your expectations . I remember when i was a medical student at the university of North Carolina and i was not a specialty at my school when i started in cancer. Inhappened during my 4 years a special unit focus on oncology was developed and someone was hired to write it. What a scary place because it seemed as if what we have to offer for most of the patients who came into that part of the hospital were very toxic, poisonous substances. Many of the individuals who had very types responded quite poorly. Mecertainly did not seem to at that point if somebody was interested in having to bring together science and medicine that they had gotten together very clearly in this space. Maybe hard to imagine but at that point, the underlying model we take for granted that cancer is the disease of the genome had not really been appreciated. Going back to the early part of the 20th entry suggesting that was something about the chromosomes. Seeing that emerge as a actionable, unifying approach to this disease that will lead us in the direction of what we now embrace as a remarkable resolution of targeted therapy, that wouldve been really impossible for myself or others to imagine happening during her lifetimes. It has been a breathtaking ride. The worm cancer was initially declared in the early 1970s, we do not have the tools or insight or understanding mechanisms to be able to move at the pace we now can. It was a good evening to draw attention to the problem that sods a solution and affected many people and the answers were going to have to climb out, research is expensive. Case, Research Cancer was taking far too many lives. Even though it took many years to try to figure out what should the approach me, it was a good thing to get the ball rolling in a significant way. About thisre we talk afternoon, we see the potential of really tackling the many types of cancer with a rational strategy with great hope of curing this disease. You say are we going to cure cancer . Lets just say cancer is not one disease. Disease. Dreds of we have already cured some of them. Theres a lot more. They are not all going to fall by the wayside at 1 00 on a thursday afternoon where someone says i have the answer. It will be a hardfought battle and every answer would have a different series of steps. Critics we want to talk we want to talk much about these desperate you received your medical degree a few years later in 1981. By attitudes have changed patients and their families, the diagnosis . How different is if or when you saw when you were getting your medical training . Cancer strike fear into the heart of cancers and bring does their two families. Patients who were subjected to treatments that been underwent disfiguring surgeries was a little reconstructive capabilities at that point. The chemotherapy was really harsh. Even back then as a result of those advances which really occurred in the 1930s, 1940s, in 1950s, we have significant reduction in cancer mortality with about half of the patients losing their lives to cancer. Now, its about 2 3 that survive with cancer. Nott of that has risen by just the treatment advances that we talking about but also the preventive strategies we understand a lot more about the indicators of cancer. Patients are more empowered with knowledge to prevent cancer in the first place. And enlisted increasingly into more screening strategies where the chances for cure his greatest. That has led to profound prostate, in breast, cancerer diseases ,colon in particular. Those are changes if you can do something about the disease to prevent or catch early and over half a dozen years in particular because of the insights that have been illuminated by a great deal of have a clearnow line of sight for many cancers as to how it really bends the art. Patients feel more hopeful as a result of the enhanced diagnostics, enhanced capabilities we have on the treatment friends and so on. As a result, we have increasing survivors with improved quality of life. We are nowhere near where we need to the. I remember my first newspaper job in the 1970s where we did an obituary on every person who died in the state of kansas. Families would ask you not to say or acknowledge it or someone died of cancer and we had a practice of which we would say they died after a long illness which was a code word. It was seen as so terrible to have had cancer. Talk about the turning point. Lastave talked about the decade or two, what has been the turning point that make so much difference . Is there one . The biggest was getting an understanding of the fundamental behave the way its supposed to and stops when is supposed to and starts growing despite all of the signals it shouldve shut it down. That really comes out of the recognition that there are genes in our book that is mutated in a certain way causes this to happen. Them, they activate make themselves grow when they shouldnt. Accelerator metaphor. Others which are supposed to apply the brakes, is like losing your front and rear brakes and keep going when it shouldve stopped. And then other variations on top of that. More recently, things we are learning by the genome. Basically, to have that kind of understanding about the mechanics of what controls cell growth was the essential step to move us into a war directed, more rational approach instead of him. Colin and les see what happens. Most of our strategies until we had the understanding where to come up with toxins substances. Lets wait and see what happens. And tried to dial in at the point where you were killing the cancer cells environment more than the regular cells. About the history. It is extremely important and you talked about one critical event, the initial paradigm. The genetic paradigm. And the 1960s, there was a vigorous debate as to whether or not mutations in genes had anything to do with cancer. Some of the most significant minds of the last century honestly thought that the mutations of genes of cells are not relevant to the development of cancer. There was an especial irony because a discovery of a virus that contains a gene that caused bishop to their breakthrough and 17 7 1976 that there are genes within us that look like the genes that cause cancer and viruses. Int year i was graduating 1980 one, we began to identify mutations in those jeans. They were translocated or mutated and changed in cancer cell versus normal sells. It took a wild for us to begin to develop those collection of genes that were real drivers of the disease. A real critical breakthrough occurred in the 1990s thanks to dr. Collins and the human genome project which gave us the blueprint for the human genome. 2007, when he the human cancer genome initiated under dr. Collins leadership and that has given us the periodic table for cancer where we know a lot, perhaps not all, but most of the genetic elements that are wrote that actually commandeered the cell. To me, the most significant advance against the back drop of the foundation i just described occurred within a narrow window of 2009, 2010 work across a broad front, a Critical Mass of knowledge that was prosecutable where we understood what caused certain cancers and we could do something about it and reduce the knowledge for practice. It also Game Changing technological advances. Sequence genomes not in a decade in 1990s with billions of dollars but for house of dollars in a time period you can make clinical decisions. That was Game Changing. Also advances in imaging. A couple of decades ago, the most common procedure in surgery was a laparotomy and you have to look inside to see what is going on and now we have noninvasive. The end and the advancing his profound. Our ability and aggregate large volumes of data and use very powerful analytics that allow us not only to understand a disease but to actually inform clinical decisionmaking on that disease is before us. What is exciting to me is that within a very narrow window, we now have a very we are in a good position to make more delivered his assault on the cancer problem. This is something that it not exist because it took decades of research fundamental for us to be able to really move that knowledge to a position where we can act on it to help patients. The breakthroughs that brought us to the point where we are now. What is the breakthrough ahead that will make a great difference . What are you looking for . Very articulately spoke about, we have the tools for any individual has developed cancer to read exactly what is going on inside of the tumor and what is making the cells grow. You to move what has been a onesizefitsall operation to a personalized approach. It is a good thing we can do that because every tumor, if you look closely, is a little different. You take 10 people who have lung whatr and you actually ask is driving the cancer in those 10 people and will be a different collection of these genes and tumor suppressors and other players. That means if you are trying to design a rational therapy, you ought to know that so you can choose your intervention accordingly. There is some complexities here, off course. That means making the old way of doing a Clinical Trial where you say anybody who has this particular cancer in this particular organ is an appropriate candidate. Not so much. You have a targeted therapy. A particular genetic change of people were going to the best chances of respondent and where you want to run the trial. It sounds vague but let me give you an example. Patients with lung cancer, which is a very scary disease and will not done so great on over the , there areany years individuals who have lung cancer who have a rearrangement are of a particular gene and it dries her cells to grow when they are not supposed to. There is a you recently and rapidly fda approved drug thanks to the trials that have been works in abasically very specific way to stop the growth of those sells that have but it isearrangement not doing thing for the rest of the patients who do not have a rearrangement. It is only about 5 6 . Different. Lly and the past, lung cancer, radiation and strong chemotherapy and everybody got the same ink. Not anymore. Thats why the long of that efforts, lung cancer getting this forward is a great example of where we need to go. Initially a Clinical Trial but so it out to the standard. Ought to be standard when you have a chance. Have a diagnosed to the base and figure out what that 3 billion instruction booklet looks like. Look at the menu of targeted drugs which are being developed at a phenomenal pace, about 1000 of them now. And he out the ones that will be and pick out of the ones that will be a match and that is where you want to go. One more thing, at the present time, we are in a circumstance drug that idea of rational treatment for cancer based on understanding what is that tumor is a single drug. That can give you dramatic responses but unfortunately, they usually do not last. They are not cures. We should not be surprised by that when you consider that by the time a cancer has been diagnosed, the number of cancer sells that person has is in the billions. Two to takes one or develop a different mutation and make them resistant to the drug to grow back and the trust targeted with that small number are resilient cells. How should we deal with that . Thing about hiv. Wheny similar situation people were diagnosed with hiv and we treated them with one drug and we got a response and they came back. The virus developed in resistance. Human selves have the same c sails have the same have theel same ability. You reduce the chancels. Cells have the same ability. You reduce the chance. But from my perspective, maybe that is our big, current challenge about our hope on the responses. I think when we think about reducing cancer mortality which is the bottom line and francis spoke to Precision Medicine and the promise of that. In fact, we have seen proof it is a way to go. When we end about cancer particularly in emerging countries, the challenges of limiting resources really means that we also have to approach the cancer problem on other fronts and be very aggressive. 50 of cancers can be prevented. The exciting thing is we understand a lot of the instigators of cancer and we can wise, education wise so we can really reduce the incidence in front of cancer and that is a great opportunity. Think hbv vaccinations for children hpv vaccinations for children. Tobacco, number one. Hepatitis and of excessive exposure. That is during childhood. These are all opportunities where we can then did the art and in the screening, the chances for hearing is much better especially solid tumors. We have proof that is the case. Ability tonhance our detect these cancers earlier stand on a path to doing it thanks to the nih, that will be one of the lowest of the low hanging fruit to really reduce cancer mortality. Treatment for it targeted therapy going after the genes that are at variance and a cancer cell. What is exciting now as this new dimension of immunotherapy which does not really speak to what is going on inside of the cell but instead, harnesses the power of the immune system in the hopes, reawakens it so it recognizes that cancer and can attack the cancer. Those therapies are giving responses in a large fraction of patients with advanced disease. Combineif we begin to the targeted therapies going , harnesses the power of the immune system, i think what you will see over the next 510 years are significant reductions in cancer mortality. We are seeing cap for melanoma. And a variety of other cancers across the bar for. It sounds extremely complex to do targeted therapy based on specific genetic mutations. Doctors, it is one greatto be at a institution, what if you are at some other place . Are doctors able to keep up and care that isind of made such a difference . Institutions, George Washington here in this area and so on and so forth, the issue is really the knowledge gap that you are referring to. It is a significant one. There was a report on the unevenness of cancer care throughout the United States. On average, for example, the cancer, whenung there was a new therapy it took on average in a community usedng for to be routinely in the public domain. That is a critical issue and is widening the cause of this staggering complexity where physicians do not have the chance to keep up with m. D. Anderson and we produce 10 papers a day. Find at m. D. Anderson on the oncology expert advice and be able to ingest data clinically in a community setting, not just in the walls of m. D. Anderson. And how that system being taught by the world experts. What would they do essentially a Second Opinion . That would then give advice to the treating physician that is what the world experts would do and it would be the Clinical Trials you should consider and so on. Will reduce once they get implemented. Informations age of and is in fact is going to be on a practical level as most impactful and reducing the burden of cancer in our country. Critics do you worry about this, dr. Collins . If so, what can you do . We do not have a good track record of taking research and finding how they integrate into the standard of care across the country. A few years ago, somebody look at that timetable and concluded 20 years and that is unacceptable. There arent good news aspects of the way things are going. Ron talked about some related to the cancer field. The best art of the story is the patients are no longer comfortable sitting back and waiting for someone else to make decisions about their care. We are in the era of the empowered patient and the internet has made that possible even for individuals who have no medical background to find information and ask pointed questions about how come you are doing this when you could be doing that. That alone motivates physicians to get up to speed. No physician wants to be embarrassed by their lack of understanding a patient brought to their attention. We are seeing improvement. ,he Electronic Health record michigan opportunity there and provide an opportunity for more patients to have access to Clinical Trials. In childhood cancer, it is the case for most hits with cancers. Is a missedlts, it opportunity both for the Research Community and especially for patients who would benefit by enrolling and maybe giving them access to something that couldve been much work targeted for their needs. We have to work hard on this. The other point is reimbursement. If we are going to see these types of events is finding their way into the standard of care, who his handclear and as a challenge with