American Association for Cancer Research Asia Centennial Conference

04 Nov 2007

By Mr Khaw Boon Wan
Venue: Suntec International Convention and Exhibition Centre

Dr William Hait, President, American Association for Cancer Research
Distinguished guests
Ladies and Gentlemen

We are honoured that the American Association for Cancer Research has picked Singapore to hold its Asia Centennial Conference, as part of its celebration of 100 years of cancer research.

LOOKING BACK: 100 YEARS OF CANCER RESEARCH

The last hundred years has seen a sea-change in cancer research.  In 1907, only a few countries were active in cancer research.  Today, it is a multinational effort, with AACR’s membership standing at nearly 26,000 across 70 countries.  That the AACR is holding its Centennial Conference not only in North America, its birthplace, but also in Europe and Asia is a reflection of its global reach.

The amount of financial resources poured into cancer research has also grown dramatically.  When Nixon pledged US$100 million to fight cancer in 1971, the amount seemed mind-boggling.  But this has been dwarfed as governments plough huge sums into this area.  Annual spending on cancer research in the US exceeds US$7 billion.

Singapore is a relative late-comer.  Nevertheless, we are making significant investments and progress.  At the broader level, we have invested heavily to build up our biomedical sciences infrastructure and capabilities.  We have developed Biopolis as a key, focal infrastructure that is now the leading biomedical research hub in this part of the world.  We have attracted world renowned scientists who have brought with them critical expertise, leadership and inspiration to jump-start our efforts.

In the area of cancer, we have gained tremendously from the presence of people like David Lane, Axel Ullrich, Edison Liu, Neal Copeland, Nancy Jenkins, Yoshiaki Ito and many others.  They have helped build up our basic sciences research capabilities in cancer and put our institutes like the Institute of Molecular and Cell Biology and the Genome Institute of Singapore on the world map.

As a logical extension of our work thus far, we are moving into translational and clinical research, with US$1b of government funding committed.  Indeed, our inaugural TCR flagship award was given to the Singapore Gastric Cancer Consortium led by Professor Yeoh Khay Guan.  We are working with industry to support early-phase clinical trials, and will be setting up a national Academic Clinical Research Organization to provide core services and infrastructure as well as intellectual leadership for later phases of clinical research in Singapore.

In short, cancer research in the past century has seen exciting growth.  It is perhaps worthwhile to pause and take stock of where we are today.

To be sure, we have improved our knowledge and understanding of cancer – whether in prevention, early detection or treatment therapies.  Smoking declined in developed countries thanks to smoking cessation programmes and public education.  Similarly, Hepatitis B vaccination programmes have led to better prevention of liver cancer here.

Major strides have also been made in detecting cancer earlier.  Improved mammograms and tests to detect prostate cancer have helped us find these cancers at earlier stages, when they are more curable.

In addition, developments in molecular biology and chemistry have led to the discovery of effective therapies.  Many cancers are now curable.

On the other hand, critics point out that the outcome of the war on cancer is far from clear.  Despite a century’s worth of effort, cancer remains a major cause of death, with cancer survival rates remaining modest. 30 years ago, for example, about 50 percent of those diagnosed with the disease in the US survived more than five years beyond their initial treatment. Today, the number has risen to 64 percent.

Perhaps the most controversial and politically sensitive criticism about cancer research and resulting new treatments is the high costs involved.  Avastin, for example, is priced at US$50,000 a year for colon cancer and twice that for lung cancer.  Erbitux for colorectal cancer comes in at US$120,000 per year, while Nexavar for kidney cancer and Herceptin for breast cancer at US$50,000.

It is thus not surprising that ever so often, we read heart-wrenching stories of how cancer patients, fighting for their lives, fret about how they are going to pay their medical bills if they do indeed win their battle against the disease.   
Policy makers know that the entire healthcare system is under strain.  The National Institutes of Health estimates that the bill for treating the disease in the US exceeds US$190 billion. American insurers are feeling the pinch.  Aetna Specialty Pharmacy, which manages health care claims for many large self-insured employers, spent an estimated US$900 million—about 45% of its total specialty pharmacy expenditures—on cancer therapies in 2005.

The result: huge premium increases, fewer choices and less access to any kind of care.  Citing uncontrollable costs, smaller employers in the US are bailing out of the health insurance market entirely.  Larger employers have shifted costs to their workers, dropping retiree coverage and forcing very difficult conversations about the costs and benefits of expensive treatments.

LOOKING AHEAD

These debates will rage on, even as cancer continues to extend its deadly hand and claim the lives of many more.  Clearly, there can be no let up in our efforts to battle cancer.  Efforts to spread the message of prevention must continue, just as research to understand and defeat the enemy must proceed.  But beyond that, what else can we do moving forward?

Global International Cooperation

One thing is clear: we not only need more investment in basic, translational and clinical research, we need greater international collaboration to maximize synergies and our chances of success. Based on Singapore’s own experience, I am optimistic that greater international collaboration is possible.  Singapore institutes have successfully established collaboration initiatives with various foreign groups.  These include the Karolinska Institute of Sweden, the Max Planck Society of Germany, the Australian National University’s Australian Phenomics Facility, RIKEN of Japan and the International Cancer Biomarker Consortium (ICBC) of the Fred Hutchinson Cancer Research Centre in Seattle.  We also have a Cancer Consortium comprising experts from around the world to share their experiences about cancer research globally. These networks have proved to be invaluable in helping us improve our capabilities.

We will continue to seek more international partners.  In this regard, I am happy to announce that the AACR will open its Asia office in Singapore in 2009.  This will be the AACR’s first facility outside the US.  AACR intends for this Asia office to become a hub for cancer research information, networking and collaborations. It will seek, among other things, to increase cancer research collaborations between the East and West, provide educational opportunities for young scientists in the Asian Pan-Pacific region and serve as an expert resource in the region.

I am also very happy that the Ludwig Institute for Cancer Research (LICR) has signed an MOU with A*Star, the Yong Loo Lin School of Medicine and the Duke-NUS Graduate Medical School to set up a research branch in Singapore for translational and clinical research. Founded in 1971, the Ludwig Institute is the largest international, non-profit cancer institute with 800 leading scientists, clinicians and support staff.  LICR -Singapore, the first in Asia, will be the latest addition to Ludwig’s 10 research branches across the globe.

We in Singapore are thrilled.  The decisions of AACR and Ludwig to locate here will bring to Singapore and Asia valuable resources and networking opportunities that complement the strengths of local healthcare and research institutions.  It is also a strong validation of Singapore’s growing importance as a global node in cancer research. These developments will boost our bio-medical science efforts, and strengthen our capability in cancer research to bring new and novel therapeutics to cancer patients.  

I would like to take this opportunity to wish the AACR Asia Office and LICR -Singapore success, with fruitful collaborations with Singapore and the region.

Getting the Economics Right

Beyond science, we need to put more effort into getting the economics right for the whole system to be sustainable.  
At the macro level, getting the economics of healthcare right is an urgent task.  Countries all over the world have taken different approaches.  Their experiences show that more resources do not necessarily improve healthcare outcomes.  The reality is that demand for healthcare is unlimited and has to be rationed.  Hard to say politically but that is true. Some countries have gone for free healthcare at point of use, only to face the intractable challenges of meeting insatiable demand and curbing abuse while keeping high standards of healthcare.  But this is a separate debate for another forum.

At the micro level, however, we also need to address the economics of cancer treatment.  Drug pricing, for example, involves a complex inter-play of economic forces which need to be understood, and managed. The often stated argument that drug companies need to recoup their heavy investments in R&D and therefore charge high prices, over-simplifies the issue.  It cuts little ice with the average citizen, especially cancer patients.  They cannot understand or accept why, notwithstanding the billions of dollars of their tax money being ploughed as government grants into cancer research, the pharmaceutical companies still justify their high prices on the basis of earning decent returns for their R&D investments.  Healthy profit-and-loss statements and the fact that drug-makers see profits and stocks soar when new biotechnology drugs hit the market add to the soreness felt by those who have to pay up.

In reality, various factors are at play in price determination.  Market size is one.  Herceptin, for example, costs so much partly because the market for it is not huge. And because of the potential for heart damage, it is generally prescribed for only one year. Some cancer drugs, like those for late-stage lung cancer, are used even less, as sadly, patients often do not live very long. And drug companies have limited time to profit from new drugs; after their patents expire, other companies can undercut them with generics.

In addition, some drugmakers will acknowledge, in private, another key reason for the eye-popping price tags: the drugs cost a lot because patients are willing to pay a lot for something that works so well. I am not passing any value judgments here.  In the world of economics, there are no absolute rights and wrongs.  Each market player behaves in the way which is rational from their respective perspectives.  To the drug company, they will charge what they think the market will bear.  To the individual faced with a life or death situation, price is no longer a consideration as each grasps at every straw in sight in order to live.  However, there is no free lunch, as economists always point out, and ultimately, society as a whole will have to bear the costs of these decisions.There are no ready solutions for these issues.  But the journey to find the solutions must start with better understanding of the issues, asking sometimes difficult questions and finding candid answers.  Why, for example, do other industries like electronics and IT manage to bring down prices of new innovations so quickly?  Is it competition which drives equally innovative manufacturing processes to shave costs to the bone?  Can greater transparency be brought to bear on the determination of drug prices, so that the markets function better?

Accepting the Limitations of Man and Medicine

We must not forget that doctors play a pivotal role.  A patient is almost entirely dependent on his doctor.  They look to their doctors for care and compassion, for relief of their pain and suffering. With this, people accord doctors the respect that the medical profession has enjoyed since time immemorial.  On their part, doctors are guided by a deep sense of duty and commitment to their patients.

Indeed, researchers who surveyed oncologists found that the prevailing mindset among the majority of respondents was, “as a doctor, my responsibility is to my patient sitting in front of me, whose life I am helping to protect with the best medical care possible”.  Cost did not influence their clinical practice.

The fundamental motivation of such sentiments is laudable. The practice of medicine is about serving mankind and humanity. That is the passion of members of the medical profession.But these noble values have to be reconciled with the realities of life.  Whether we should marshal vast amounts of high-tech resources to manage the last few weeks of the terminally ill, delivering poor quality of life to the patients sometimes at very high cost to society, is an issue which we must all confront in the healthcare industry.  Heedless pursuit of “pure” medicine to prolong life cannot be sustained. At the end of the day, we need to accept that man has his limits, and the practice of medicine, too, has its limits.  It takes wisdom to know these limits and the true needs of the dying. Not too long ago, the American College of Physicians released their Charter on Medical Professionalism. It had, among other things, 3 principles:

a. The principle of patient welfare - holding the patients’ interest uppermost;
b. The principle of patient autonomy - enabling our patients to make an informed decision; and
c. The principle of social justice - to serve regardless of social status and to remove discrimination.

All of us intuitively accept these principles.  But “living” these principles will require doctors to strike delicate, difficult balances.  What exactly does “holding patients’ interest uppermost” mean in practice?  How do we help patients make informed decisions when their lives are at stake?  How do we balance these with societal considerations?  Given that net social good and health outcomes are the key deliverables of any healthcare system, sustainability involves managing and maximizing these two objectives at an affordable cost. Cost or outcomes - optimizing one at the expense of the other, or optimizing one alone – will bring down the whole system.

CONCLUSION

In summary, the agenda for all parties involved in fighting the war on cancer is full and challenging.  Much work needs to be done, not only in scientific research, but beyond.  And the work cannot be done in isolation. There is a need for cross fertilization of ideas and exchange of views. Hence, the need for conferences like the AACR’s Asia Centennial Conference, which brings together many leading experts to discuss the many challenges posed by cancer. 

I wish you an interesting and fruitful conference.