May 31, 2014
Watch an exclusive video of Dr. Hudis delivering his Presidential Address at the 50th Meeting of the American Society of Clinical Oncology. The complete transcript is also included.
Thank you, Dr. Lichter. And thanks to all of you.
My name is Clifford Hudis, and I am a medical oncologist at Memorial Sloan Kettering Cancer Center where I am Chief of the Breast Medicine Service. I am also Professor of Medicine at the Weill Cornell Medical College and President of ASCO. I have had an amazing year serving as the President of ASCO, and today I am delighted to welcome you to our Society’s 50th Annual Meeting commemorated in recent weeks by both the Congress of the United States and also by our host city, Chicago, and its Mayor, Mr. Rahm Emanuel.
This may be the only meeting in Chicago where neither he nor Ari are the most famous of the Emanuel brothers!
Our Society continues to grow, making this a record-setting year with more than 5,100 submitted abstracts and 33,000 attendees.
Now, you may have noticed my Twitter handle, @CliffordHudis circled in red, and ASCO's hashtag above [#ASCO14]. We will be tweeting this talk under my handle. This is programmed, I can assure you—and the entire Social Media group—that I am not tweeting from the stage!
As you know by now, the theme for this year’s meeting is “Science and Society.” I chose this theme for ASCO this year to emphasize my intention to bring our scientific community and the society we serve closer together so that we can more quickly make our world free from the fear of cancer.
I chose to begin today's talk with the word “intention” because I believe that this word can sharpen our focus, clarify our vision, and help us marshal the resources we need to achieve our goal. The power of intention is as relevant to us as it was to our founders 50 years ago.
Indeed, reflecting on societal events leading up to ASCO’s founding, I was quickly drawn to this clip of President John F. Kennedy speaking at Rice University in 1962: “One which we intend to win.”
His emphasis on “intention” resonates for me because it is both optimistic and energizing, but it is also humble. And it was effective. Indeed, it was JFK’s clarity of intention that galvanized our successful efforts to reach the moon within seven years in 1969.
Now, since you are here, today, I can only assume that you share ASCO’s mission, vision, and, yes, intention to conquer cancer and to rid the world of the fear it brings. The question of course, is how best to accomplish this.
To address this, I want to go back to April 9th, 1964, at the Edgewater Beach Hotel—right here in Chicago during an AACR meeting, where our founders met, motivated by “their common concern for the patient with cancer.”
Who were these seven? Drs. Fred J. Ansfield, Harry F. Bisel, Herman H. Freckman, Arnoldus Goudsmit, Robert Talley, William Wilson, and Jane C. Wright. All were visionary leaders. And you can learn more about their remarkable lives at ASCO’s website.
Today, however, I want to focus especially on Jane C. Wright who died in February 2013 at the age of 93. She was our last living founder, the only woman—and the only African-American—at ASCO's founding in 1964. I was profoundly honored to represent ASCO at a celebration of her life this past November. During and after her memorial, I tried to imagine what society and our world looked like in 1964, and what she and so many others had to overcome.
It was the era of the Beatles and the Ford Mustang to be sure. But, despite our wistfulness for a seemingly simple time, it was also the year that in South Africa, Nelson Mandela and colleagues were imprisoned for life at Robben Island. And here in the U.S., civil rights workers were murdered while attempting to register African-American voters.
But it was also in 1964 that the Civil Rights Bill became law, marking the formal—but not practical—end to racial segregation and discrimination in the U.S. And it was in October that the Reverend Martin Luther King, Jr., became the youngest recipient of the Nobel Peace Prize.
It was against the backdrop of those events that our founders first met. Here is what Jane Wright said about that era: “Sure, a woman has to try twice as hard, but racial prejudice? I’ve met very little of it.” And then she added, “It could be I met it—and wasn’t intelligent enough to recognize it.” I am especially impressed by her choice to ignore racial and gender prejudice. She knew her situation but chose to see past it and make a better reality. The reality she intended.
This is both instructional and inspirational, and I hope you agree that her story—our story—is one more reason to be a proud ASCO member and to support the Young Investigator Award that the Conquer Cancer Foundation has established in her memory.
On November 5th, 1964, ASCO held its first scientific meeting with 51 attendees, again here in Chicago, and planned our first Annual Meeting for early 1965. Do you think the founding members envisioned, imagined, or intended to develop a Society of, at last count, more than 35,000 members or an Annual Meeting like we are holding today with more than 30,000 attendees representing more than 100 countries?
I would bet they did not.
We know that they intended to improve patient care by convening cancer physicians to share knowledge. But the size and scale of ASCO today was not their actual goal for sure. Instead, it is a consequence of their intention and an indicator of their success.
Shaping and honing that tool – ASCO itself – over 50 years have been all of our volunteers, staff, and past Presidents, so many of whom join us here today.
This entire room owes and thanks each of you for your leadership, guidance, creativity—and your collective inspiration.
And I am truly amazed that I get to join your ranks on Monday at noon, after Peter Yu assumes the Presidency. I am, however, confident that under his leadership, and then Julie Vose’s to follow, ASCO will be guided by dedicated and talented volunteers.
But as we collectively face the next decades, I believe we need to ask, how can we best leverage the hard work of our predecessors to even more fully satisfy society’s rightful expectation of progress against cancer? How can we best develop and utilize this tool called ASCO? Specifically, what is our intention for ASCO now that we are 50?
Our intention is social justice in cancer care.
I believe that our intention should be the translation of scientific progress into maximal societal benefit by assuring that every patient can have access to the highest quality cancer care. In the end, through research and application, our intention should be the achievement of social justice in cancer care.
Everything we do can fit under this broad goal, but this intention provides a unifying purpose that we can use to mobilize the society
If we intend to achieve social justice in cancer care, we simply need more public and private resources.
In 2013, the U.S. federal budget was almost $4 trillion. That is 4 thousand billion. The NIH budget was $32 billion. The NCI component of the NIH budget was just over $5 billion.
I do not want to overwhelm you with frustrating information or bad news, but it is a sad fact that our nation’s investment in science at the federal level has failed to keep pace either with inflation or with the growth in opportunities brought by new discoveries, such as those highlighted by Lee Hood moments ago.
To a first approximation, that makes federal spending on cancer research about 0.1% of the federal budget. Research on a disease that affects one-third to one-half of all Americans garners less than one dollar of every thousand spent federally. Meanwhile, the purchasing power of federal funding to the NCI is now 23% less than it was in 2003.
NIH Director Francis Collins has said that the one thing that keeps him up at night is our inability to fund deserving investigators. And NCI Director Harold Varmus has clearly had to make painful funding choices.
The practical impact of these cuts is felt directly or indirectly every day, by those of you here—and by our patients and colleagues around the world.
Indeed, it is no better—and generally far worse— globally, as this graph of R&D related to GDP around the world demonstrates [see video]. It is clear that the financial resources that society commits to the problem of cancer are not commensurate to the challenges we face.
I hope that everyone here commits these numbers to memory and repeats them—often and loudly. We need societal awareness of the fact that an investment of 0.1% of our federal budget cannot begin to address the problem we face. To help draw attention to the importance of federally funded clinical research, we are highlighting those studies with this symbol throughout our meeting [see video].
We must raise awareness of the remarkable return all of society receives on its investment in federal research so that it can be increased. This entire meeting showcases that return.
If we intend to achieve social justice in cancer care, we must address disparities in access to high-quality care.
The most troubling consequence of dwindling support for research is slower progress against cancer. This is where our patients bear the burden and feel the impact. But there are additional obstacles to care that prevent many from benefiting from what is already known.
To delineate the challenges we face in providing quality care and to develop solutions to uneven access now and in the foreseeable future, in April of 2014, ASCO issued its first annual assessment of the State of Cancer Care in America. This landmark report was made possible by everyone's participation in a comprehensive survey and census effort. We highlighted in a Capitol Hill briefing with Blaise Polite, the incoming Chair of our Government Relations Committee and Immediate Past-Chair of our Health Disparities Committee, along with Carolyn Hendricks, the Chair of our Quality of Care Committee.
In addition to demonstrating the progress we have made against cancer—such as the reduced death rate we now see—the report described ways we are trying to adapt to growing demand for services, the rapidly evolving health care environment, and the tremendous economic pressures associated with maintaining access to care across our country.
Your responses, combined with ASCO’s workforce analysis and new data about projected cancer cases and survivors—expected to increase by more than 40% over the next 15 years--suggest that we need to expand our clinical resources if we are to achieve our goal of assuring that every patient has access to high quality cancer care.
So, in addition to our call to sustain innovation through a robust national cancer research program, what other specific investments are needed? Development and testing of new health care delivery and payment models designed to preserve access to high-quality care in local communities where the majority of cancer care is actually delivered.
Our goal with these models is to reward value, as opposed to volume. Together, we will have to be bold and brave in testing these alternatives, but, as this article points out, we need to control payment reform and our focus on the quality of care we deliver, or others will quickly step in and define all of this for us.
We must end persistent financial threats to clinical practice, especially in vulnerable communities, that are caused by sequester-related cuts and the flawed sustainable growth rate formula that drives physician payment.
Our legislators must understand the price our patients pay for inaction and gridlock on this issue.
Finally, we need strong support for physician-led quality initiatives such as ASCO’s established Quality Oncology Practice Initiative (QOPI®) which, by the way, was recently granted “deemed” status by the Center for Medicare and Medicaid Services.
With regard to QOPI, we clearly have the tools, skills, experience—as shown by the rapid uptake of QOPI by our members since its launch in 2006—and we have the best ability to assess and judge the quality of care we render.
We do not want to yield this to others.
Now, as you know, we cannot avoid the issue of the cost of care. Here is a quote attributed to Warren Buffett: “Price is what you pay. Value is what you get.”
If we intend to achieve social justice in cancer care, we must define “Value in Cancer Care” so that we are best able to optimally use society’s precious resources.
First, we should begin by acknowledging that in some parts of the world, the great breakthroughs presented at this Meeting are little more than science fiction.
Second, even when these breakthroughs are available, such as in the U.S., the cost of care is rising rapidly, faster than the rate of medical inflation.
Patients are bearing more of the costs, with predictable negative effects—such as decreased compliance—as was reported in the JCO this winter.
Ask yourselves where it could ever make sense to have a co-pay for an oral cancer treatment that saves and extends life, and avoids more toxic and expensive alternatives? A financial disincentive for compliance is irrational no matter how you look at it!
The lay press has taken notice and is increasingly focusing on high prices. And while there are many components to the cost of cancer care, one unsolved problem is the lack of a rational or linear relationship between pricing and value. Indeed, you can see that the price of most of the recently approved new agents for cancer has risen dramatically.
The question is not, who is at fault? The question is, how can we work together to preserve innovation and improve access and affordability?
Now, I have a question for you: Who do you believe made this statement in Forbes magazine in May 2014? “The whole oncology pricing structure needs to be rethought because it’s reached the level that is not going to be sustainable for the long term.”
Is your answer:
A) a regulator,
B) an insurance executive,
C) a patient advocate,
D) a hospital formulary member, or
E) the CEO of a large pharmaceutical company?
It may surprise some of you to learn that the answer is E.
I suggest that if our partners in industry can see the problem as clearly as we do, then there is great potential and opportunity for us to work together to identify a productive way forward. One that preserves capital flow and reward for innovators, but that provides even more access to care. We must be creative and innovative, and we can if we work together.
At ASCO, we have begun to do exactly this by organizing a Summit on Value in Cancer Care involving all stakeholders. I want to thank Neal Meropol and Hagop Kantarjian for helping ASCO approach this. We know that the assessment of value is far more complex than simply adding up the price of drugs.
Our aim is, therefore, to provide what we call a “value framework” to help clinicians and patients more fully understand the likely benefits of specific treatment plans for their cancers. By understanding the full range of choices—their expected benefit, toxicities, as well as cost—patients can make choices that best suit their personal circumstances.
We believe that this effort is ASCO’s responsibility to our patients and to society. We are clearly the best positioned to serve as honest brokers because we are the best informed to lead this difficult, but rewarding discussion. This is key to fulfilling our intention of providing access to the best possible cancer care as broadly as we can.
To emphasize our commitment, throughout this year’s meeting you will hear discussions that incorporate value. Lowell Schnipper, as Chair of our Value Task Force, has worked with Jedd Wolchok, our Scientific Program Chair, and Gini Fleming, our Education Program Chair, to provide knowledgeable discussants at many sessions including the post-Plenary ones tomorrow afternoon.
As clear evidence that we can work together, I draw your attention to this piece published yesterday by our own Hagop, and Drs. Crenshaw and Newcomer from industry and the insurance industry.
If we intend to achieve social justice in cancer care, we must address disparities in risk for cancer.
Fifty years ago—in January of 1964—United States Surgeon General Luther Terry publicly declared cigarette smoking was hazardous to health. Since then, the scientific and medical community has galvanized society to raise awareness, reduce usage, and address its health consequences. The link between tobacco use and socioeconomic status meant that related health issues would fall disproportionately on those least able to bear them.
That made society’s commitment, intention, and investment in prevention that much more important. If you stop by the display located in Oncology Professionals Hall, Booth 2111, you can see the story of those efforts and the impact they have had.
Fifty years later, we are confronted by a global rise in obesity, and it is time once again for Science and Society to join forces against this newly emerging public health challenge, highlighted just this week again in the Lancet by Ng et al. A growing body of research is pointing to energy balance including exercise and weight as important risk factors in cancer. In some ways, obesity appears to be the new tobacco for our generation.
My personal interest in this started more than a decade ago when I was introduced by my mentor, friend, and colleague, Larry Norton to Andrew Dannenberg, a gastroenterologist working at MSKCC’s partner institution, Weill Cornell Medical College. His focus was inflammatory bowel disease and specifically the role of the COX enzymes. We studied COX2 inhibition in HER2-positive metastatic breast cancer and preoperatively in ER-positive post-menopausal disease with early collaborators, Chau Dang and Elisa Port.
Perhaps our team’s key experiment—informed by the insights that a true multidisciplinary laboratory and clinical translational team can obtain—was this study of 40 mice. Our initial plan was to determine the impact of a high-fat versus low-fat diet.
Because most hormone receptor-positive breast cancer occurs, somewhat paradoxically, after the cessation of menses, we randomized the mice to undergo oophorectomy or not, so as to model human menopause. The results shown here were fascinating [see video].
While the high-fat (and high-calorie) diet was associated with significant weight gain, this was even greater in the oophorectomized animals. This, of course, matches the common clinical experience whereby menopause is associated with greater challenges in weight control for many women.
Our mouse model recapitulates the human experience.
But, offering the possibility of intervention, we discovered chemical inflammation, evidenced by elevated IL6, TGF-beta, and prostaglandins, in association with these “crown-like structures” consisting of dead or dying adipocytes surrounded by scavenging macrophages. These were found in both breast and visceral fat and were more frequent with increased weight.
In a project led by Patrick Morris, our team then confirmed the existence of these same lesions, for the first time, in the breast white adipose tissue of women (not mice), associated with increased body mass index and correlated with inflammatory mediators.
I encourage you to attend presentations by Andy Dannenberg—this afternoon at the Joint AACR/ASCO Symposium at 3:00 PM, as well as posters by Ayca Gucalp and Neil Iyengar on Sunday morning on this ongoing work.
But I want to return to the societal aspect of this scientific effort. Not only are our patients growing more obese and overweight, as this data from the CDC makes clear, but the trends are predicted to worsen. Hence, the health consequences of overweight and obesity are going to confront us for decades to come, and our team’s intention is to complete meaningful research that provides solutions for this societal challenge.
For the same reasons, ASCO is rising to this challenge. I draw your attention to the Energy Balance Working Group, led by Jennifer Ligibel, which this year produced ASCO’s Obesity and Cancer Guide for Oncology Providers and, for patients, Managing Your Weight After a Diagnosis of Cancer, both of which are available at this website.
We hope you will download and use these resources in your practices as we pursue even more effective interventions. Our concern is that this issue could reverse the gains we have made fighting cancer over the past 50 years, and we do not intend to allow this to happen. I am proud that ASCO has the unique resources and skills to lead the world in developing approaches to manage this challenge and is partnering with sister organizations with expertise.
If we intend to achieve social justice in cancer care, we must harness the new power of information technology
It was the spring of 1964, when IBM announced “System/360”—the first so-called “mainframe” computer with broad scientific utility and commercial success. Along with the first appearance of a computer program written in Beginners' All-purpose Symbolic Instruction Code, (BASIC), these events provided the building blocks for the information systems we use today and that we now seek to exploit to make a world free from the fear of cancer.
The medical science at our disposal today is unprecedented—and remarkable. From Watson, Crick, Wilkins, and Franklin’s proposal of the double-helix three-dimensional structure of DNA to affordable high-throughput sequencing described so beautifully this morning by one of its founding leaders, Professor Lee Hood, we are unlocking the inner workings of cells leading to precision medicine and its promise of better, safer, more effective treatments for all.
But the move to precision medicine adds daunting complexity and challenges that were unimaginable just a few years ago, as Mark Robson highlighted in an editorial accompanying a paper by Kurian et al. this week in the JCO.
Given our commitment to provide access to the best possible patient care across the globe, what is ASCO’s vision of how we can accelerate the practical use of these approaches? How will ASCO lead our community in understanding and applying this rapidly expanding area of clinical science?
One way is by addressing both societal and individual concerns about autonomy and privacy raised by the more frequent sequencing of tumor-normal pairs. The concern is understandable, as this technology can provide insight into an individual’s entire inherited genome.
ASCO has begun to address this in many ways, including a 10-module ASCO University® genetics course organized by Ken Offit and Laney Lindor and a two-day pre-meeting seminar (just concluded) on Genetics and Genomics for the Practicing Clinician, which was organized by William Pao and Judy Garber.
These tools are meant to educate our members—and to provide support for all of us as we seek to navigate this brave new world.
The second way is through the use of advanced information technology to learn from the detailed information now stored in electronic medical records. This, of course, is our plan for CancerLinQ™ as you have heard from this stage and elsewhere since 2012. Boldly, our Society has built a working prototype of CancerLinQ.
We have acquired the records of more than 170,000 patients with breast cancer, benchmarked their care against agreed-upon quality measures from our QOPI program, and recapitulated the results of prospective randomized clinical trials.
CancerLinQ will never replace conventional drug development and testing, but it can be a powerful complement that may save time and money for society as we develop new and better treatments. For example, what if a single randomized trial, instead of several, could be planned and then the real-world results from CancerLinQ be obtained to confirm what was seen in the study? What if accelerated approval could be provided to a new drug in a new and rare subtype of disease, defined genomically perhaps, but confirmation of this positive signal and of its safety could then be provided using our “big data” generated outside of studies in the real world? What if post-marketing surveillance could be converted from expensive, voluntary, and selective into ubiquitous, uniform, complete, and inexpensive? How could this help our colleagues at the FDA think even more liberally about lowering some barriers to drug approval?
These simple examples demonstrate the potential for CancerLinQ to simultaneously increase medical knowledge, accelerate drug development, and deliver meaningful advances more quickly to our waiting patients.
With your support, ASCO can lead the development of these tools—we can galvanize both the scientific community and society to invest in and support this groundbreaking effort and achieve greater social justice.
The third way is by sharing and collaborating. Invited by then AACR President Charles Sawyers, we were early signers to the Global Alliance and plan to help make all somatic genomic information available in uniform fashion to the scientific community around the world so we can accelerate learning and the development of better treatments.
I have set out today to highlight five critical opportunities for our Society, for ASCO, as we turn from our first five decades towards the next one and beyond. My intention is for us to achieve social justice in cancer care by providing meaningful resources for research, by assuring access to high-quality care, by collaboratively defining value and working towards it, by confronting new risks, like energy balance, and by harnessing the power of information technology, as we have in most other industries. Some will say we can't afford this.
Returning to 1964, consider President Lyndon B. Johnson’s Great Society speech, delivered within a month of ASCO’s founding, in May 1964, at the University of Michigan. There he described his intention to do whatever was necessary to eliminate poverty and racial injustice. He opened this push, in his January 1964 State of the Union speech with this challenge: “We can afford to win it,” he says, and “we cannot afford to lose it.” Within the year, he signed the Great Society legislation, as he intended.
For us, don’t these two sentences ring true as we strive to free the world from the fear of cancer? How can we afford not to make the necessary investments in the future of our patients, our friends, our families, and our children, worldwide?
It is my intention to see us do everything possible to enable science to allow us to achieve a world free from the fear of cancer.
I have many people to thank.
First, with this slide [see video], I remind us that ASCO stands on the shoulders of giants who shaped our organization over the past 50 years. In addition to Jane C. Wright, we lost a number of great leaders, pioneers, and researchers in 2013-14. We will miss all of these friends.
At MSKCC my career and my time at ASCO has been supported by some of the most inspiring and driven colleagues imaginable, and I have benefited in particular during Sunday morning spin class from the wise counsel of Charles Sawyers, the Immediate Past President of AACR, and Jose Baselga, AACR’s President-Elect. I do believe I look the least sweaty [see video].
Like all of you I am part of a complex, interconnected network of mentors, allies, patients, friends, and family. I can’t name every single person to whom I am indebted, but wish I could.
Craig Thompson described me as “on loan to ASCO this year.” Maura Dickler, Sarat Chandarlapaty, Andy Seidman, Ayca Gucalp, Elizabeth Comen, Neil Iyengar, and Larry Norton were the unknowing co-signers of that loan, but everyone in this photograph [see video], and many, many more made great personal sacrifices this year so that I could focus on ASCO, and I am forever indebted to them all.
One of the key opportunities I have enjoyed in my career has been my participation in the federally funded cooperative groups. These are under real threat, and I have tried to help by highlighting their challenges this year.
I want to thank my great friends at the Alliance (formerly CALGB) and NCI, as well for working so hard and so productively under duress—as you will see at tomorrow’s Plenary Session where all four abstracts were federally supported.
Augmenting that work has been the Translational Breast Cancer Research Consortium. Thanks to all of you for tolerating my occasional absence.
As many of you know, I am a breast cancer doctor. This is a key aspect of my professional identity forged under the mentorship of Larry Norton, ASCO’s 38th President. All of you know Larry and indeed many of you also claim him as a mentor. That alone is testimony to his special place in the history and development of modern oncology. I first met Larry at Mount Sinai hospital in 1987 when he worked with James Holland. Larry joined MSKCC in the fall of 1988 when I was about halfway through my first year of fellowship and started what became MSKCC’s Breast and Gynecologic Cancer Medicine Service.
It quickly grew to a patient-centered, academically productive, evidence-based clinical care and research team that I took over in 1998. Under his direction our clinical services were moved to the first Evelyn H. Lauder Breast Center, supported by the late Evelyn Lauder, a 2007 recipient of the Partners in Progress Award, accepted that year on her behalf by Leonard Lauder who, along with the BCRF leadership, have once again chosen to spend a weekend here at ASCO showing their dedication to our shared cause. Thank you, Leonard.
All of us depend on our colleagues at the bedside, and I have been blessed to work with great nurses. These professionals define team care and are a great example of why we have pushed to expand and extend membership opportunities at ASCO to all of the professionals who care for cancer patients.
I thank my office staff, Dina Erwin and Iris Ronda, for everything, including getting me here on time this morning.
Finally, our trainees. They are, of course, our future and they offer the hope that our ongoing work will be translated into benefits for generations to come. I have had the opportunity to mentor wonderful fellows over the decades and many of them are well known to you from their subsequent accomplishments.
ASCO itself is fortunate to have extraordinary leaders, and I have benefited along with you from their guidance and thoughtfulness all year. Allen Lichter, Richard Schilsky, and Jamie Von Roenn are physicians with more than a century of combined experience now put to use guiding ASCO. Our staff is remarkable and we are lucky to have them.
And the insights of our Past President, Sandy Swain, have been critically important to me.
Any of you who know me know that I burst with pride when speaking of my wife, Jane, and her intellect and accomplishments.
In a recent column in the New York Times David Brooks suggested that, when contemplating marriage, we should ask “Is this person admirable enough that I want to live my life as an offering to them?” By his criteria I got it right, except that Jane is far more than admirable than my offering. Being with her makes me believe all things are possible, including the pursuit of a world free from the fear of cancer.
These are our sons, Sam and Isaac, who fill us with pride every day [see video]. We are fortunate to be together here today with their grandparents Mortie, Ellen, and Ellen and also our great friends, Deborah and Peter Krulewitch, the latter of silver-screen fame!
This is a man we miss every day—my father—with me in the summer of 1960, four years before ASCO’s founding [see video]. He died at age 64 from metastatic prostate cancer. My vision, dedicated to his memory and shared with ASCO and the CCF, is a world free from the fear of cancer.
My intention is that we will achieve this soon.