Do We Need More Money for Cancer Research? You Bet We Do!

Money KeyEarlier today Jacoba Urist wrote an article in The Atlantic entitled More Money Won’t Win the War on Cancer. In my mind, she wrote a very compelling piece, with one small exception: I think she got part of the conclusion basically wrong.

First I have to get off my chest that I really don’t like the title and it’s reference to “winning” a “war” on cancer. I never liked the idea of a war on cancer, if only because it implies at its heart that there may come a time when we can plant the flag, declare victory, and go home. I don’t think it will ever be thus. And that means than anything less is like “losing” a war and I don’t think highly of that notion either. I wrote previously about the importance of words in dealing with cancer.

However, that’s just a personal soapbox issue I needed to get out of the way.

My main point in rebuttal of the main tenet of the article can best be framed by looking at the subtitle of the piece: A broken grant structure, turf wars, and an exodus of scientists for other professions are bigger barriers to progress than a lack of funding.

I agree with all the maladies she listed, and I won’t bother trying to expand on them all here. The original article is a good read and I encourage you to look at it. It gets all of the symptoms right. But in the end I think that these barriers are as much CREATED BY insufficient funding rather than stand-alone problems.

There is no doubt that most granting systems are broken – they do create a protracted process, they do tend to be risk averse and they do not often reward innovation and creativity, and above all, risk-taking, upfront. And as I myself wrote just last week, there is also a huge and growing over-attention to the notion of return on investment (ROI) that has seen a recent shying away from basic, fundamental knowledge-gathering kinds of cancer (and other) research).

A lot of the premise of the article is based on the thoughts of Clifton Leaf, who has many provocative, but very thoughtful ideas about what is wrong with the cancer research “system”. For the record, I am NOT attacking Mr. Leaf or his ideas here either.

But take this passage, for example:

Forty-two years after President Nixon signed the National Cancer Act and declared the “war on cancer,” it’s virtually impossible to separate cancer from money—walks, bike rides and pink ribbons entice people to donate more and more. To question the need for more funding to help cancer patients seems almost sacrilege.

But that is what Clifton Leaf, a cancer survivor (diagnosed with Hodgkin’s lymphoma in high school) and an editor at Fortune, asks in his book The Truth In Small Doses: Why We’re Losing The War on Cancer— and How to Win It: What if a lack of research funding isn’t really the problem? One reason we aren’t making faster progress against cancer, according to Leaf, is because the federal grant process often chases the brightest minds from academic labs, and for those who do stay, favors low-risk “little questions” over swinging for the fences.

“More money by itself is not going to solve anything,” Leaf said.

So, let’s just look at this a bit more closely. It is my belief that an awful lot of what is wrong with the research enterprise (i.e. the very things he lists) STEM from the fact that there is not enough money in the system overall.

Why do I say this, and what are my credentials for that observation? I was the head of the National Cancer Institute of Canada for many years and was the first Vice-President of Research for the Canadian Cancer Society. As such I was responsible, in one form or another, for the grant-making and peer review processes/systems of what was Canada’s largest national charitable funder of cancer research. Over 20 years at the helm of the peer review and granting processes, I too came to be frustrated by, and appreciated very much, most of the laments that Ms. Urist and Mr. Leaf make.

Why indeed do we seem to favour lower risk, (often called “incremental”) projects? Why do we want to hit singles instead of home runs? There is no doubt in my mind from personal observation of two decades, that when money for research gets tight, peer reviewers get increasingly risk-averse. That might be exactly the time when you WANT to swing for the fences, but it just never seems to work that way.

Think of it in terms of a personal investment portfolio. Most of us will want to see a balance between blue chip stocks, or dividend-bearing stocks, or even fixed-income vehicles to make sure our capital is safe. But if we have enough money, many would love to have a bit of risk capital or venture capital. Money that you are OK to lose, but money that you hope will win big.

So, if you suddenly fall on hard times and have to reduce your portfolio, where is the average person going to cut? Most likely the risky stuff, not the blue-chips.

And so it is with research. As soon as money gets tight, we become very risk averse –  ironically at the very time when we ought not.

We make the rules tighter to make sure that we are only giving the money to the VERY best qualified, and often that means a protracted and increasingly cumbersome granting process. And we indirectly promote turf wars, as much between the really established scientists with great track records and those earlier in their careers who will move on to other pastures if they can’t get a foot in the funding door.

And then we wonder why our best scientists spend half of their time writing grant applications. And don’t forget the huge time burden of reading and reviewing each other’s grant applications as well!

If we really want to promote innovation and accept more risk in relation to the reward, and if we want to fix the granting system and get our scientists back into the research environment and out of the office where they read and write grants, then I believe we need to adopt a mantra of: Time, Freedom. Money.  But unlike the old business saw of “Do you want it fast, cheap or good? Pick two”, we need to have all three in some balance…

We need to lengthen the time horizons over which we expect meaningful results. We have to give exceptional and creative scientists more rein to follow their noses. And we need more money, which is the glue that makes the other two possible.

So, do I agree that just throwing money at the problem will not solve it? I surely do agree. Will there ever be enough money? Nope.

But I also think that we will not achieve the cultural shifts we seek unless there is more freedom in the research system, and that freedom can only come with a more relaxed approach to funding and more dollars.

Mr. Leaf and Ms. Urist are unquestionably right in the assertion that money alone will NOT fix all these things. I could not agree more. But the things that CAN and DO need to be fixed are not going to fall easily unless there is more money to enable that cultural and system transition.

What I fear most from an article with a title like “More Money Won’t Win the War on Cancer” is that a critical nuance gets lost.

It is true that money alone cannot fix things, but for the public (whether as taxpayers or donors) to infer the opposite, namely that this means there is ENOUGH money in the research enterprise would be wrong, and would do us all a grievous disservice.

     
 
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Comments

Do We Need More Money for Cancer Research? You Bet We Do! — 8 Comments

  1. While I agree with a lot of your points Michael, I think there is room for debate as to whether the amount of funding is the most critical factor, especially in cancer research. Over the last 20 years or so Western societies have developed fund-raising machines for cancer research in particular which have become so successful that many have become means to their own ends. As someone who does cancer research (among other diseases) and who reviews cancer research programs around the world, I know that more money can do more work, generate more results. However, the fund-raising machines are so efficient that I am beginning to seriously question whether the money raised is truly all being well spent. As you know, there is fragmentation in the funding agencies, who, despite a common, laudable goal, essentially compete with one another, both for dollars and for researchers. There has been an emergence of powerful funding strategies that largely focus on cancer research as a heart-string puller. We all know someone who has suffered and/or died from cancer. We naturally want to stop this. As researchers, we make ever more ambitious promises that are, of course, well intentioned. But good intentions do not make for good research and much money is being poorly directed (and I am not talking about the astronomical overheads associated with some fund-raising efforts). Research is, by nature, wasteful because we don’t know what will work, which experiments will bear fruit and which ideas will fail at the last hurdle. But that is not the waste I am talking about.

    As a researcher, it may seem weird that I do not put $$ at the top of the list of needs. It is certainly important and I work hard to raise money. But I see dangers with the argument that funding is holding us back, including:

    A. More money won’t help solve the problems of most cancer researchers. It will largely flow to those who already have it. Research is insatiable when it comes to funding, but it’s often a case of “to him that hath, it shall be given”. This, ironically, often makes these well-funded investigators less efficient. Their labs grow. They look as though they are producing, but you don’t see the contingent of people in their labs who are not so productive. There are exceptions, but they are relatively few – and those scientists tend not to call for ever more funding as they know it will not make a major difference to them (and could stifle them through dilution/distraction). Put another way, there is an optimal level of funding for research teams and more is not always better and can be a burden(1).

    B. The biggest increase in funding has been in non-competitive funding to institutions. This is excellent in many ways but makes the rather idealistic assumption that the best science/scientists are within those institutions. This is not the case(2).

    C. With more money comes more ambition – especially when ideas start to dry up. Large scale projects are devised to consume large budgets. These are often technical and high profile but their true impact is often much less than anticipated. This is also driven by the higher expectations and promises made to attract the money.

    D. The type of research being funded is often influenced by how the funding is raised. You are well aware of the dearth of funding for lung and pancreatic cancer research, for example, compared by their relative burden and outcomes. If more money was the answer, we should have breast cancer beaten (or be much closer to it).

    E. There is also a bigger world than cancer and I worry that the cancer research machine is drawing dollars away from other diseases with equal or greater impact on health. Of course, that’s a problem of the charities and institutions trying to raise money for HIV, diabetes, inflammatory bowel disease, arthritis, heart disease, mental health, etc. But cancer is well ahead of these in dollar amounts. Cancer Research UK raises more money than any other disease charity in the UK, by far. Does this mean cancer is over funded? No, but it does distort the activity and impact on other diseases.

    F. If money was the true limiter, the private sector would have been far further along the road to solving cancer. Instead, pharmas are reducing their in-house research and out-sourcing to academic institutions. Their financial and organizational resources greatly outmatch academia. What they lack are the environment and means to generate and pursue sufficient new ideas where only 0.1% ever work out – access to money doesn’t make up for diversity of thought.

    G. Lastly, and most importantly, I fear that the public will, at some point, grow cynical and weary of the lavish but empty annual promises. This will inevitably reduce confidence in health research as a whole – accelerated by the ever-increasing hyperbole espoused by fund-raising organizations, trying to one-up each other. That will impact all research.

    Of course more money would help but it needs to be spent smartly and be subject to conditions. Rather than asking for more money, we and the public need to re-evaluate how we are spending current funds. There needs to be greater accountability, less hyperbole and support of more ideas – no matter where they arise. Our society wastes billions of dollars on a variety of things (from F-35s to power plant closures to advertising) but that doesn’t mean research is entitled to one red cent. It has to make the case, and to deliver on it.

    To you, as someone who dedicated a good chunk of his life to fund-raising for cancer and carefully administering those funds in as fair and competitive manner, my response may be dismaying – and I do know that no one in cancer research is intentionally wasting money. But times have changed. Worldwide, cancer research funding has become concentrated – and not necessarily in the right hands. Unless our processes are changed, more $ are not the solution. While this may not be the message we should be communicating, I fear the idea that “more money, more research” will backfire as the results will not justify the promises.

    Cancer will never be beaten by money alone. It can only be beaten/controlled by brilliant ideas and hard work. I recognize the danger in even suggesting that more is not better, but we must also be careful not to suggest that more money is the easy answer. It quite simply isn’t.

    Footnotes:
    I. I can name many researchers whose research would greatly benefit from more funding. I just know that they won’t be the ones getting it.

    2. I’ll be honest and say I would love to have unfettered funding to be able to support our own researchers. But I also respect the discipline derived from competitive funding, where the best ideas are assessed against each other. It is the competitive sources that are starved of funding but I cannot see how one can direct the message of more funds to such processes.

  2. Jim,

    Thank you so much. I should just commission you to write my posts for me 🙂

    You may be surprised, but I don’t find your answer dismaying at all. I think we agree on far more than we disagree. In fact, I’m having a hard time seeing where we even *do* disagree 🙂

    Nowhere in my thinking (I hope not implied above either) was I assuming that the “more money” would just be same old, same old. I agree we have to spend more smartly, we have to be more accountable etc. In other words, all the stuff you said.

    But even then I still maintain there are not enough dollars to fuel the amount of creative, innovative and risk-taking (and therefore much more highly prone to fail) research, especially now in the genomics era. I would dearly love to see a LOT more highly qualified researchers get far more adequately funded than we seem to be able to do now.

    Unless of course you are implying that we have a dearth of younger i.e. not as well established researchers to spend the money wisely. I know you don’t believe that. We both know way too many of them!

    Now as for your point on the “fund-raising machinery” I think we have to be very careful not to confuse the raising of funds with the investment of funds. I agree that there are many foundations and charities that are now into raising money it seems just to raise money. Let’s look at some of the larger hospital foundations (not necessarily yours) and we see for example in PMHF one of the most successful fundraising operations in Canada. But how much of that money actually goes into the direct costs of research? I don’t think it is fair to imply that if they spent more of the stockpile money on research that somehow it would not be well spent. On the contrary I think they need to put a lot MORE of the money they raise into a legitimate peer-reviewed system to more adequately fund real research.

    And at the risk of biting the hand that used to feed me (well, still does) I think that even cancer charities like the Canadian Cancer Society need to really assess where their priorities are. I stand by the CCS in knowing that the money is not wasted in the slightest, but I do not necessary agree with the priority of the allocation. I think that more of the pie should go to research and always have said that.

    So, I think you and I are pretty much on the same page. I am all for competition, I am a die hard when it comes to peer review, I want to see a broader funding base and not just “those that hath” as you put it. But I want to see “success” rates at a much more reasonable level than we are choosing to afford right now. Notice I said “choosing to afford” as opposed to “able to afford”.

    As you know when I started at the NCIC in the early 90’s, peer review was able to distinguish excellent applications from good applications, and we funded all the excellent ones.

    Today the discriminator is not on excellence or quality; it is strictly on dollars available. We draw our cut lines in any established competition where the money runs out, not where the science does. We make our distinctions now between excellent research and OTHER excellent research.

    I always believed, and still do, that the grants that get funded in our increasingly difficult competitions all deserve to be funded. These are not wasted dollars.

    But I cannot and do not believe the reverse, namely that all those that are not funded didn’t also deserve, even equally deserve, or even better deserve to be funded.

    I just wish that were not so.

  3. All funding is not equivalent in its impact. I totally agree that there are many scientists who are not being supported who should be. My argument is that raising more money without changing how it is invested is unlikely to move the needle and those same researchers are highly unlikely to see the benefit.

    • I totally agree.

      And as a corollary to that, I am saying that if you really want to change how it is invested so that it moves that needle and gives us the impacts and the benefits, then I believe we have to have more money in the system.

      I don’t think this is a vicious circle is it?

  4. I don’t see why we need more money in order to change the “system” for the better. Shouldn’t we be working on improving how money is invested before lobbying for more money? Indeed, while funding rates are at their lowest in recent memory, there has also never been more funding available.

  5. So if there is more funding than ever, why are funding rates so low? It’s because of what you already alluded to – there is fragmentation, competition among funders etc. Just because there are more “dollars” available in the system, doesn’t mean the system is working effectively or efficiently. That means more grant applications, more reviews etc. And yet few will get really adequate funding even then. That was the point of the original Atlantic article, and I think we all agree there.

    To me, to use a local analogy, the idea of throwing money at the problem (NOT what I am advocating)it’s like saying: if you raise taxes, we will have a much better transit system.

    What I’m saying is the reverse of a sort: If you want a better transit system with both subways AND LRTs etc, you will need to invest more money (raise taxes or re-allocate).

    None of that means that City Hall can’t do a better job than they do now on existing transit with the money they have.

    Anyway, I think I’m done – my little noggin is getting fried. Always love “debating with you – I learn a lot.

    And I’m pretty sure you will want to get in the last word on this thread so I will let you 🙂

  6. We should not obsess on funding rates. Scientists are insatiable. Funding rates are important because below 16-20% the selection of the very best science becomes stochastic. Scoring scientific merit is imprecise and different people judge different aspects. Attempts to normalize adjudication typically make things worse by imposing unnatural structure and order that limit reviewing to specific ingredients (often resulting in cookie-cutter proposals).

    Throwing more money at science will not increase funding rates in the same way that throwing food at a gaggle of ducks will not satisfy them. They’ll get bigger and breed and present more mouths/beaks. So it is with scientists (aside from the breeding part). The question is what number of scientists is optimal for a given country? This is a difficult question to answer but it is not directly linked to funding. We could quadruple the number of cancer researchers simply by canning lab based researchers and focussing on population studies. Likewise, we could fire 90% of cancer researchers and fund double the number of clinical trials. In other words, there is a portfolio balance and while more money raises all boats, it does it in an unpredictable manner.

    We aren’t managing our existing funding well and until we do, more does not mean better and we’re approaching the point that Jacoba Urist suggests where the dearth of apparent funding is perhaps better solved by re-engineering how we fund instead of pouring it into ever more leaky plumbing.

  7. Jim: Couldn’t agree with you more; am particularly connected with sub para ‘f’ in your initial reply

    My Dad and I are in the independent researcher domain who are in it simply because the vision of mainstream science is myopic at best, and anything that hypes magic bullets has for some time eroded society faith in present plan…so your para ‘g’ resonates well too

    The world has so many great precise scientists who can conduct the basic science…we need many less of them. We need more of those seemingly eccentric and convincing simply brilliant minds with science based approaches that have assimilated both the successes and failures experienced to date…yet most of all we need a cancer general to lead them.

    Dr Wosnick – Nice perspective. However, I differ markedly in the view about the war on cancer…it should be a war (not a job), and we’d do better on finding a paradox free hypothesis/model; the defence of the pedestal placing of the somatic mutation theory most troubling