in an essay about unfairly convicted elizabeth holmes, she wrote, for those who believe she is guilty of a great crime, it's a disappointing verdict, end quote. >> journalist and author bethany mclean on this week's booknotes+. it's available wherever you get your podcasts. more now from the richard nixon presidential library museums event noting the national cancer act of 1971. this is done by notable doctors in hospitals around the country.

welcome back, welcome back. if you can please take your seats. i'm looking forward to the next panel around some of the clinical advances that have been made over the past 50 years by the national cancer act. as a former nci director, you know that some of your greatest assets and best friends are those heroes that agree to become cancer center directors because they have to deal with the complexity of everything from supporting basic research on one hand of the spectrum to all the way to the other end of the spectrum with regard to

training, clinical research, cancer prevention, et cetera. so being a director is a challenge. we're very fortunate today to have with us to chair this next panel, dr. steve rosen, who was, for 24 years, the director of the robert e. slurry comprehensive center at northwestern and now is serving as the head of the cancer center and research. he has a prestigious career as a medical oncologist and dedicating himself now to the academic progress being made, having published over 400 articles himself, and is currently the editor in chief of the textbook series, cancer treatment and research. so we're very fortunate to have him lead this conversation as it

relates to the progress that's occurred in the clinical care of patients, and he'll introduce his distinguished panel. steve, thank you for being willing to do this. >> thank you, andy. good morning, everyone. welcome. we have three renowned panel panelists who are all experts in the field. i'm going to introduce them briefly and then i'll ask them to answer a series of questions and we'll open it to the audience and hopefully have a thoughtful period of communication about all the issues we're dealing with. first i'll introduce dr. peter seuss. else an oncologist of gastrointestinalal cancers and he's received numerous awards at the institution.

thank you, peter. lori pierce is the director of faculty affairs. she is a distinguished officer of breast cancer research, a member of the academy of medicine and the 57th president of the american society of oncology. welcome. and the director of the cancer and therapy program, medical director of the therapy laboratory at children's hospital in philadelphia. phil is a pediatric oncologist and leading figure in cancer and therapeutics. please join me in welcoming this very distinguished group. so the first question for you. what do you feel is the most profound piece of the national cancer act. >> that's a topic of

conversation in many ways. i think probably among the many contributions that we all see now and are discussing is the ability to bring clinicians and researchers together in synergistic ways that nobody even imagined at the time that have created opportunities for discovery, brought conditions to understand common problems and to create solutions we're now seeing and to save lives. i think it really took cancer research from an obscure area to a coordinated national effort, and we're really seeing 50 years of progress as a result. >> do you have one example in your mind that lends to this teamwork? >> i think a lot of the work we've seen in targeted therapies where you're understanding the basis for cancer, you're understanding potential targets and you're making gains against those targets. and then moving forward with

what we now know as target therapy is an excellent example. >> i can answer this in a very gentle way and very specific. i'll do the general. i think about what i do every day when i see patients with breast cancer, so i see smith and i can take the imaging information, i can take the genomic information, i can take the clinical information and then derive a treatment recommendation, individualized, and that is all possible because of the national cancer act. everything we do is so different because of the national cancer act. you think about 50 years ago, it was a one size fits all. and now with the individualized we do based upon the specifics of individual cancer. and then from a specific perspective, i think it would be the creation of the national clinical trials network.

clinical trials change everything. that's how we move the needle. that's how we improve what we do for patients. taking care of patients, offering them the best therapy. that is what we aspire to be able to offer patients with the best possible treatment. with clinical trials, you can take a therapy, similar to what we heard in the first panel, and process that through phase 1 trial to find the best dose, phase 2 and phase 3 and be able to compare these therapies to whatever the standard of care is. that's how we move the needle and that's how we improve treatment. i think this is all absolutely possible because of the advancement of the national cancer act. >> yeah, i think the first session was so fascinating for me, and what i see, again, is the theme of bringing everything together. often nasa tries to justify some of what it does by saying look

at all this cool technology falling out of the space program, which as a space geek, i think is the greatest thing in the world. multiply that by 10,000 for the national cancer act. i think bringing all these folks together, all this basic science. looking at dr. goffmore talking about reverse transcriptates, which i need to make things actually work, thinking you can understand the virology of hiv, cripple hiv, then make t-cells do what you want. we talked about waking up t-cells and then we reprogram t-cells to force them to kill tumor cells. all of these are completely unexpected technologies that came out of basic science research, handed off to the clinical programs, and then the think that excites me most at

this moment, in addition to being able to provide transformational therapies to patients, we talked about the bedside. now we have bedside to bench. you have children in the hospital who have this brand new medicine, with cartee and many other therapies, and then you can take their cells right back to the lab with incredible techniques done by all the scientists and you can look at this in a rapid fashion, none of which would not have been possible without this infrastructure and focus on cancer. >> i also think the speed of development now is just astounding. a colleague renowned clinical investigator would always say cancer is a four-letter word,

and now we're at the point where we find we can bring therapies to patients in a reasonable period of time that didn't exist in the past, with therapy is going to work. what do you feel are the most significant advances over the last 50 years? we'll start with you, steve, on this one. >> given a certain level of bias, i think that immunotherapy is incredible. of course, it's new, relatively new within the context of 50 years of development, but just the idea that we may actually -- and dr. ellison touched on this briefly -- may actually be able to go chemo free for so many more of our patients and spare them the experience with chemotherapy. i would like to avoid chemotherapy, and in the future that we could possibly do that

for our patients is extremely exciting. i think both sides of the axis provide that potential. i remember hearing early on from mentors, why are you thinking about immunotherapy for cancer? they have nothing to do with each other. that recognition of t-cells but other immune cells can also have an impact, i think, is one of the more important discoveries. >> lori? >> wearing my radiation and oncology hat. 50 years ago, everything was cobalt. fast-forward to now how we have accelerators, we can vary the beam arrangements, we can vary the intensity of the arrangements, we can do modified radiation. we can target specifically to a tumor and give radiation to that

tumor. looking at the biology side of things, being able to understand the biology of the tumors, assessing what genes make them radio resistant and then combining the therapies which address that radiation resistance. it's explosion of what we can do now with radiation compared to 50 years ago. and then wearing my breast cancer hat, 50 years ago, where i think the majority of women probably still would have been cheated with a radical mastectomy, then a modified radical mastectomy, and now we have mastectomy with radiation, which we know gives the same results as mastectomy, which we learned this is all with clinical trials that radiation reduces the risk of global occurrence but transfers to a mono survival advantage. knowing from a systemic point of

view looking to how trastusemite therapies have now changed the natural history of a disease from an untreatable cancer to a highly treatable cancer. other aspects, also radiation where we're learning that sometimes less is more. that if we can assess the potential outcome from a certain cancer that perhaps some of them don't need to have radiation. we can spare radiation for those and for those that have breast disease, perhaps they need more radiation. we're learning to be able to look at molecular profiles that help us select those. so it's changed significantly both from a radiation perspective and from a breast cancer perspective. >> actually, if i could jump in

very briefly on that, what i'm hearing between both of those are hurt people less and get better outcomes. as a pediatrician, we have kids with their whole lives ahead of them, and we want to make sure those are healthy lives, and we see sometimes they're not. they're survivors, which is fantastic, but they pay a price. >> also combining the technology with the biology is fascinating how that all comes together. >> it comes together beautifully in radiation where you have the cancer biology, you have the visits and then you have the clinic. it all comes together. >> i think what you're hearing is part of the fusion of the forces of physics, engineering and medicine, and that that has created proton therapy in the radiation and oncology world and has led to innovative biologically surgery where less is more. invasive surgeries have been

applied to people with cancer in many ways. it's an invasive approach that takes into account biology and spread of disease. these are advances that have a huge impact on patients over time and that we see every day today. as we see in the past, chemotherapeutic treatment has been largely pills, and now we're moving into what's been reinfused into patients. that i think will be game-changing in many ways. it is now a pill, it's not a compound in an iv fluid and infused into a patient, but it opens up a brand new pathway for a cancer patient. >> and we're blessed that we're

leading that activity with about 300 active patients and a single death in three years with a hand handful of chemotherapy. it is quite profound and it's been a game changer in terms of what we can accomplish for our patients. >> there is a national cancer survivorship. it seems like there is a period of passion and then we sort of start and stop. so maybe, lori, you can have this one. >> so when you are president, you have a president-elect and you're asked what your theme

will be. i chose a theme of equity. i did it before george floyd, before the pandemic. and i wondered if this was going to be welcomed by the oncology community. oh, my gosh, this was the time for a theme of equity. i chose it at the time because we all are cancer people and certainly as a minority oncologist, we're all aware of the disparate outcomes for certain populations of cancer. you think of black males and prostate cancer and over 100% increase in mortality rates compared to white male prostate cancer. you think about black women with breast cancer, a 40% mortality compared to white women with breast cancer. you think of asians and pacific islanders having gastrointestinal cancer compared to white people. you think of kids with a higher

risk of leukemia. you think of native americans and the higher incidence of g.i. cancers and liver cancers. the list just goes on. i thought equity would be the right decision. during the year, we were able to put together a lot of initiatives. we increase this as well. one of the things we focused on was increasing -- needing to increase a diverse work force. we all know that the number of minorities in oncology is woefully low, much less than the majority of patients that we serve. so we are working on a way to increase the pipeline by having more minority oncologists. we are working on an initiative with the association of cancer

centers to increase minorities in spatial clinical trials. we already talked about how important clinical trials, and if you look at the percent of minorities in clinical trials, it's roughly 3.4%. it's higher for pharmaceutical clinical trials. we know that is the way to move the needle. so many times i've heard people say, we just can't get patients to go on clinical trials. the problem is not the patient. the problem is us. we need to create an infrastructure to remove the barriers that patients have and that institutions have so that patients can go on clinical trials. so this initiative i mentioned is to develop -- we have a pilot looking at a tool that institutions can do a self-assessment and look at various stages for enrolling patients and see where the barriers are. you see how many patients come

into your cancer center, yet you see how few are actually offered a clinical trial. what are the barriers preventing those patients from coming on board? because the bottom line is if you look at many studies, including a very recent one published in jnci last year, once you ask a cancer patient to go on study, whether they are white or black, the same people go on study around 55%. it makes no difference what race they are. we have to get things to the point where they are offered a clinical trial, so that self-assessment study hopefully will open some eyes, because every institution has different barriers, and be able to see where the barriers are. then another issue i've been working on is increasing awareness socially in terms of health. we know a lot of barriers patients face is from the social terms of health. these factors are so important in terms of not only treatment for cancer but also prevention.

we need things along the full continuum. prevention, screening, treatment and survivorship. if we can prevent a cancer, that's better than having to treat a cancer. and so we're working on increasing risks in social terms of health, and i apply all the work that the nci is doing and we need all hands on deck for that. i could talk about this much longer. >> i think it's symbolic we're talking about this and the fact that america is at a crossroads, driven by george floyd and so many things happening in our society. you see institutions embracing dei in their strategic plans, and you see a massive sea change occurring right in front of us. so i couldn't personally be more excited about what we're seeing.

it creates real opportunities for us to come together as a community, to have impact, and to think about the importance of the policy issues that lori was alluding to. when you look at the important aspects of the social determinants and how they're largely ignored over time, or the structural issues in american medicine and how policy, for whatever set of reasons and circumstances, insurance is linked to employment. that is a fundamental flaw that underpins many of the access challenges that we see in america right now that is not a mistake that other countries have made, and that's the reason why health outcomes large in america do not rank anywhere in the top ten in the world. while we have unbelievable outcomes that we're discussing now in oncology, when we look at other aspects of public health,

longevity, so many aspects of things such as infant mortality rate or maternal mortality during childbirth, we have a long way to go. in addressing these allows us to come together and focus on important policy issues in washington that would really help to change the landscape for americans. >> you know, you talk about policy issues. i think a great example is the clinical treatment act. the clinical treatment act, to give you a little background, for medicare patients and patients with private insurance, if they enrolled in a clinical trial, their routine care cost would be covered by insurance. seeing the doctor, getting meds, x-rays, those types of things were covered by the insurer. medicaid were the only patients who didn't have routine core costs. these are poor patients.

these are the patients who need that covered. a lot of work by asco, by cancer research, by many groups said this has to change. i'm very happy to say that as of january of 2022, it will change. this was a classic example of disadvantaging a population needed the most. and the irony was that those particular charges were covered by medicaid and people were not in the clinical trial. so it was a discommunication for those who probably kneeled it the most. so taking the time to actually scrutinize policies in place for a while that probably need to be reassessed and changed is so very important. >> i just want to build on something lori said that i think is very important. those of us who are in the field and work in centers like md

anderson have access around this cognizance issue, and the institutions who are well aware of these gaps can't do anything about it and need to institute policy change in washington about it. when i talk to our faculty about our commitment to harris county safety net hospitals and a clinic we have in the lbj hospital, they are wildly enthusiastic about what we're doing for the underserved in our own county. they were raising their hands, and this is a reflection of the moral distress caused right now. >> steve, from your perspective, as a pediatric oncologist? >> i think what i find myself thinking about over the last five years, as we were developing this whole new field of medicine was access. access and equity goes so much hand in hand. you know, you look at these therapies that we're talking

about, the genetically engineered therapies are really being delivered, and quite appropriately, at complex, tertiary and other forms of therapy. as an example, at our center we treated our first cartee patient in 2012, and almost immediately we were able to secure dollars that allowed us to pay for travel and hotel rooms for patients who were coming to us. that doesn't alleviate a lot of the problems, but at least it prevents it from being a filter only for people in the upper income strata. this is going to be more and more of a problem, because on the one hand i'm incredibly excited to be part of the cartee process. but at that moment it became one of the highest single costs of therapeutics in american history, and even though we see the same pricing across the field, we're talking about

three, four, five hundred thousand dollars for these genetically engineered products. how do people access that? is that an appropriate price? i can't say, i'm not an economist, i can't speak to that. you can talk about value and say that's value delivered, but is it actually something we'll be able to do for a number of patients? you made the key point that this is only in blood cancer. forgive me for saying it this way, but god forbid it's a more solid cancer tumor, because how would we handle the costs? are we set up for it? can we imagine what that's going to cost? we know that cancer therapeutics in general is expensive and health care in the united states is expensive, but this issue of equity and access is really something we're thinking about a lot. i will end with something we were talking about last night, which is a non-cancer example, which is sickle cell disease. and so right now, there are at

least two approaches to gene-engineering stem cells to cure sickle cell disease. we don't know, we may be following these patients long longer, that these are potentially curable therapies. they're much more than things i do as a clinician most frequently. we want to move to this safer therapy. those products are going to cost over a million dollars apiece. in a medically underserved population, how can we possibly serve the population? this really goes to equity and access for us for high cost of these extraordinarily transformational therapeutics. >> steve, this is such a good point if you don't mind me jumping in for a second. part of the future has to be a push in science, a push in access and a focus on cost. if we don't focus on cost, we're

going to be developing therapies for 1%, and that is something we can't let go of. one of the most compelling pieces of data we talk about internally is the risk for personal bankruptcy associated with a diagnosis of cancer, and what we know from large medicare data is that 43% of americans will be personally bankrupt within two years of cancer diagnosis. and that is an absolute disaster, and it really needs -- if we're not focused on the cost of care, we're not going to be able to make advancements at a societal level. >> i need to make one more comment talking about the cost. again, if we can prevent cancer, that's the most cost-effective way forward. if you think about all the advances, a lot of them had to do with tobacco control. while it was so important to

biology, we need a panel in terms of social sciences and prevention so that we can be focusing on biology at the same time we folk on us prevention. that's really a way forward in terms of cost effectiveness. >> one of the pioneers in tobacco, his main thing was smoking cigarettes, but he was looking at the impact of tobacco, and he went to his thoracic surgeon and he showed this profound data, and he says, we have it presentable, but we'll get through it. he says, how will you get through it? he says, because we're right. i'll never forget that. it's hard to believe it took so long to appreciate the devastating aspects of tobacco use. >> before we leave this compelling issue, because it maybe is the most important at this moment, it's disheartening

to think that ten years from now we may be discussing the same issue of health equity. in the audience we have one of the leagues figures, barbara nguyen, who has made contributions to this in passionate ways. rob, do you have anything else or has this been covered? >> i think first of all one of the things i say -- [ inaudible ] >> so our next question that is

almost an antithesis is we're dealing with the pandemic, which nobody was anticipating, and what valuable lessons we've learned that are relevant to cancer care, and one of the positive things in addition to recognizing the terrible surge of the disease and you change the way you provide care for your patients. peter, let's start with you. >> first is the pivot to virtual care which is unbelievable and hopefully permanent in many ways, presuming some of the issues are addressed definitively. this is cost effective, patients love it and it's integrated into our work flow. we've done approximately 3,000 visits. it's been a fantastic, successful silver lining to the pandemic without question.

the second area that i think is impactful is the work transformation associated with bloodwork. i think, as we look at our own organization, we believe this is going to be permanent. we have a work transformation team working on this that we believe can be a competitive advantage to us. we have wfa, which is work from anywhere. scientists can be in cambridge, in oxford and md anderson. we're working on this very aggressively and we believe it will work for us. >> lori? >> there is a lot we need to learn for how best to optimize telehealth. there are certain patient interactions that are very appropriate for telehealth and some are not. i think over the next few

months, we are looking at this very carefully and other groups as well to try and optimize it. but we have to know that it will be sustained and the option will continue. that will be very important. esco published a paper of recovery that looked at this very thing. as we potentially emerge from the pandemic, what can we use that we learned? we need to make clinical trials more pragmatic. we should have these trials that everyone has to come into the main institution, which is usually in the city, to be able to get those trials, for patients to go on those trials. we should make them more pragmatic so that patients can be involved in trials in the community, because a majority of cancer patients are in the community. another point is that we need to somehow lessen the regulatory burdens. there is a law that was during

the pandemic, because working with patients and not filling out forms for regulatory. i'll stop there, but there is a lot -- >> i'm old enough to remember the one-page informed consent where you could actually talk to the patient about it rather than the book that nobody goes through. >> it's very different. >> i would say the issue of the regulatory burden is an extraordinary one. i know patient protection is incredibly important, and much of what we are as clinical physicians dealing with in terms of what we have to do in terms of relations brought on by ourselves and our prior poor behavior, but the reality is that it's so much harder. it took me a year to get my first cartee study open. we wanted to do two things with that. we wanted to learn how to use that. we could have done that in 22 patients, but we also wanted to

give it to patients where we're seeing this transformational effect of cr effects in 90% of leukemia. it's the only way we can actually deliver the therapy. getting back to the pandemic very briefly, and i know there is not a lot of time, two points. one is back to mrna. these mrna vaccines, knowing there was basically at design of a current mrna vaccine a month into the pandemic and that they got it up and going in the previous administration in the time frame that they did, which was an extraordinary success. so on one hand you have these amazing successes and also same thing in terms of these new dedication to issues of equity. on the other hand we have counterveiling forces. 80% of our patients come out of

a kid with leukemia, they have no immune system. we have changed their child's life, and it's like, great, here's what we need to do. at the end of the conversation i say, is every member of the family vaccinated? a third of the time, no. having that conversation without bringing anger and judgment is challenging. it's possible but it's challenging. what do we do about that aspect? we're talking about access but we're also talking about the lack of a shared understanding of what's the appropriate thing under these circumstances, and that's a challenge, i think, as well, that the pandemic has made completely clear. >> i just have one thing, is that when we look at what's happened during the pandemic, it is a great advertisement for team-based science where you can go from sequencing on january 6 to introduction of vaccine trials in the summer and approve vaccines being in arms in december. that is a result of team-based science. while we want to respect and support curiosity-based basic

science exemplified by this morning's session of nobel laureates, we also want to highlight the benefits created when teams focus on the benefit to society. >> steve, do you have anything you want to add to that? >> just the outcomes of team-based scientists, this is such a great point, are extraordinary, and it requires multiple people to be very good at the one thing they do. but universities haven't quite figured that out yet. and i think that if we want to propose big science and team-based science, we need to get our universities to value that. >> can i say just this last week we made a proposal to have team science awarded, so your point is well taken. >> the provost, we take that into account now. >> we can get down another path very quickly, but as you're talking about, steve, the

promotion of tenure criteria in university cancer environments. to the extent they're oriented towards individual outputs, as soon as we understand what criteria should be really awarded and enhanced, we're going to see teams come together in unbelievable ways. >> so the final question was, moving forward, what do you feel is the most important issues related to cancer prevention, early detection and/or clinical care in your mind? if you had control of the resources the way you would like, where would you put them? >> well, this was alluded to earlier today. i believe the biggest advances can be made by the fusion of data science and medicine right now. it's an untapped area. it's an area that we and others are really deeply investing in

for really important reasons. we have terabytes of data, and i say this all the time to people at md anderson, the secrets to cancer are hiding in our freezers, and it's our job find ways to unlock that, and that means bringing people to our teams that come from organizations such as facebook and google who are fed up with, really, finding ways to sell more socks and get more likes and putting those people onto the cancer problem. that, i think, is the next frontier as we see the fusion of mathematics and biology. >> lori? >> i'm going to say a similar thing. taking the biology, taking the social sciences and putting them into clinical trials. having a greater pipeline of patients in the clinical trials thanks to a lot of work that my friend here and my friends at cancer research have done at

esco, it can put more patients in clinical trials. clearly that is a future collaboration. i tell my residents we're seeing more dropping moments. it's because we're seeing more clinical trials, more advancements and more changes, and i think it's all coming together extremely well. >> i'm going to touch on two things. one is the clinical aspect trial. somewhere 3% to 5% of adult patients going on clinical trials more than half, and i understand the differences but i think there is a way to have more access to clinical trials. that may actually provide more opportunity for folks who may not have the means to necessarily get some of the most cutting edge therapeutics. the other aspect that i worry about, and i don't want to end on this because it's the worst

thing to end on, but cost is out of control. you know, we're 18% to 19% of the u.s. economy. are we going to be 20, are we going to be 25? it can't go on forever. is there a way, as we learn how to live with these therapies that are transformational and safer and have fewer side effects, can we also have a way to leach a little bit of the cost out of the system? because we're heading toward a circumstance of not two, but three, americas. we have the red america and the blue america and then the poor america. this is -- the access in those circumstances are so different. if we can address cost issues. i'm in a high cost institution, i'm not going to say different, but this is something i do worry about. someone has to go a different direction because that's not a positive way to look at it. >> actually, ending on a positive note, i would say there's not a single patient i see with the blood cancers i

treat that i don't think i can control the disease. and that's profound because ten years ago i would say there was one or two options, and not knowing whether there will be a plan b. and now there's always a plan b, a plan c, and it's quite remarkable. do we need to end the session? i see you patiently waiting there. >> i would like to open it up to audience q&a. i know we had a discussion about doing that. we're going to do that right now. those of you who have a question, please raise your hand and i will come to you. but i do want to ask the first one. the title of this panel, the national cancer act: saving lives from hopelessness to hope. i'd like to go back to the national cancer act, specifically about therapies. there's been a lot of talk about therapies. can you tell us, sort of touch on what the national cancer act has done to advance therapies? what was available 50 years ago and what's available today?

>> so my little domain i mentioned, now just about every patient i care for is doing well, no deaths. in 1979 the diseases we focused on were lung cancer, myeloma, skin lymphomas, and then the other branches obviously were involved in other disease areas. mine was an inadequate drug and the survival of three years, and now the majority of patients are living for more than a decade. there's so many drugs it's hard to advance the new situation. and it led to all the profound observations now about the novel targets that we're playing biologics to. it took twenty years and now we're here and this profoundly changes the way we treat lung

cancer. >> thank you very much. our next question from this gentleman right here. >> my name is jared rumbler, and in 1963 i was diagnosed with testicular cancer. i went through surgery and uci. i first want to thank the nixon foundation and richard nixon for the cancer act. i think if it wasn't for such an act, i probably wouldn't be here today, and i wouldn't have two beautiful daughters and my wife here. and thank you for the doctors and the nurses and the exhibit here, if you get a chance to see that. something i did want to ask is what have been the advancements in mental health for survivors? is there anything being done to help people that have gone

through and hurt by chemotherapy? i'm so grateful to hear we're not going in the direction of chemotherapy. but what has been done in the past 50 years, and what could be done in the next for mental health for cancer survivors? >> peter, would you like to initiate that discussion? >> i certainly will. i think lori is probably closer to this than i am. i think that in america we're going through a change also related to mental health, and people understand that mental health is part of health. when all of us went to medical school, medical health and physical health were dichotomized. people with mental health issues were in a separate hospital. we did a rotation there for just about everything they taught us. now what we're seeing is mental health issues are being destigmatized in our society, and we're understanding that mental health issues are not a

black box issue anymore, that they have biologic causes and that they can be treated with new targeted therapies, and that they can be approached with science. and i think by destigmatizing mental health issues, we are really going to advance the overall welfare of americans who all struggle at different points of their lives with mental health challenges. this is part of the normal life, and that's something that we have to help people to understand. this is especially acute in cancer patients who have gone through a life-changing, life-threatening experience. as we think about, really, reconfiguring survivorship, we're doing you a disservice by not focusing on the mental health challenges associated with survivorship. >> i don't have much to add. such a great response. other than to say that through the years, the focus on cancer therapies was on therapy and not survivorship. now we're in survivorship, but we need to look at mental health as a very important part of

survivorship. and social sciences and asking the right questions and looking at the biology of it all is a focus of trials ongoing. i also want to comment, like i said before, less is more in certain situations. obviously if you can avoid certain therapies, you will avoid the mental health issues secondary to that therapy. i think that's another way of approaching such a very important issue, and thank you for bringing that up. >> there was a sea of hope advanced by visionavisionaries. at the same time you destroy the salt. >> our next question from a colleague. three to the right in the back, guys. >> i wanted to make a quick comment and then a question.

i talk about progress, progress from 1971 to 2021, and i'm looking at the three of us sitting at this table who are also cancer center directors, dr. rovert, dr. mesa and myself that gets made with the national cancer act. as we're thinking about the science, we also have to take a moment to think about the greatness from that act that allows us to sit as cancer senator directors right now and bringing different focuses to the table and while i believe the best is yet to come. learning from covid, one of the things that i have learned specifically is that technology alone doesn't get the shots in the arm. in fact, the science alone and even the most brilliant science. it's amazing and yet we still have people who mistrust and distrust. so the question that i have for you is, as we are looking at the

benefits of the national cancer act and where we sit, how do we as eric lander and i have been discussing, how do we rebuild and regain trust. because in '71, the magic was not only the science, not only the hope, but the trust of their communities. so how are you looking in these next few years or these -- over the next few years of building that community trust which we find out also was important as things on the cellular level? >> so first, rob, i'm going to address your first question, where now we have such great diversity. when i started close to, what is it, 35 years ago, i was the youngest in america. now i think i may be the oldest. i remember arriving and it was all older white male. it was such an unusual experience. and so the diversity is absolutely wonderful and the necessity, but i think getting to your point of how do you

communicate these issues to different communities, you have to have people within those communities who can dialogue. it's one thing for me to walk into a specific area and say this is what i think should be done when i have no particular relationship with the group versus someone who everyone feels comfortable with, who they'll trust. so i think it's that sort of outreach that we need having our outreach teams. >> back to the mental health issue. so important as we talked about the impact of the national cancer act and the authorities it gave to the nci who was able to put survivorship into the agenda and, fortunately, peter, when i was at m.d. anderson, we were about to start reha ambition and we have programs that including yoga, meditation and a variety of things that are supportive.

and we're grateful that you've been introduced to melanie eisenhower, great-granddaughter of president eisenhower and granddaughter of president nixon who is devoting her career to exactly this same issue. she's at children hospital of philadelphia in the radiology program supporting children in their family to deal with the mental health consequences of cancer. so it is part of the benefits of that national cancer act and an sbregle part of what you're doing at cancer centers as part of the agenda. >> you want to make a statement? >> i just wanted to make one comment to dr. nguyen's incredible question. and that is -- you allied to this. we need a team approach, right? everything can't rest on the attending physician in terms of interacting, being able to answer all the patients' questions, family questions, and going into the community.

all of those things are important. but it's best done by a team. and it may be that it's -- that it's not cost-effective to have these members of the team -- i think we have to make the case to our administrators that everything is not cost-effective. these are things -- at least not readily cost-effective. these are things that will pay off in time and we need to have other members of the teams, nurses, nurse practitioners, other members of the team that can help us to interact with our communities. >> steve, did you have anything to add? >> i want to make a quick comment on the trust question. because what i feel like is, you know, as an older cis head white guy is that distrust is wholesale. there are societal forces that are driving distrust. trust is retail. it is the individual interactions that we have with our patients. and those are the only effective tools that i have seen work in trying to convince folks who have hesitancy of one sort of

another, trust in the physician, trust in the medical team, trust in the nurse practitioner, trust with the nurses, and having a team that looks like the folks who are coming into the hospital, which is also incredibly important. the only way we fix this is on a one-to-one level. i don't know how we fix this on a societal level. that's for other people to figure out. >> this could go on and on and on and i wish it could. but we are running out of time. we have time for one last question and then we're going to take a short break before coming back from lunch. doctor? >> thank you. this is a great panel. we talked a lot about clinical trials and the importance of getting them into the community. we didn't talk about clinical trial transformation and good trials and better trials and trials that are more meaningful to patients. we learned a lot through warp speed, how to really get these things done faster, better. but we still haven't addressed

good trials and the trials that are most meaningful and what we need to do to get these trials so patients want to go on them. >> maybe i could start and others can build on this. i think that there's a dynamic tension that we have right now around clinical trials. on one hand, we want them to be pragmatic. on the other end, we want them to be insightful from a biologic standpoint. when you load the trial, it gets complicated and can only be done in certain centers and is nonpragmatic. if you make it pragmatic, you lose the ability to gain important insights on the underlying biology. that's the first point. we also need to spend time looking at the complexity of phase three designs, how expensive it is to do these trials and look at the opportunity for things like synthetic cohorts to create a single-arm design that can be completely matched to the trial

cohort and reduce the cost and the time for real insights on new therapies. >> anything to add? >> yeah, i think that the clinical trial approach that we're using has created a large part of the success that we have at this moment. and it's kind of breaking down because, you know, if you look at any regulatory packet, doesn't matter what the area is, and you have them in your bookshelf, in paper, they get thicker and thicker and thicker and thicker over time. and at some point we get to the point where we can't do the work. i think that there are -- what we get to is only a care center can have the staff that makes that possible. we need to democratize clinical trials, make it easier to be on clinical trials. the affordable care act says insurance companies are responsible for paying clinical costs on a clinical trial. we need to make that clear. the insurance companies are part of the issue as well.

but in the end, we know over and over again, patients who are on clinical trials get better outcomes and that's the most compelling reason to have them. >> sounds like a great topic to have a group discussion at the nci with physicians, leaders in cancer nationally to really kind of rethink all of the compelling issues around clinical trials and how can we achieve -- probably can't achieve everything. how can we achieve the majority of things? there's certainly work that can be done to improve our clinical trial progress, no question about it. >> i just joined the board of the rising tide foundation which is out of switzerland and they have quite a bit and are investing it in trials that the patients are interested in and the patients want to put their input into and with real-time patient monitoring. we'll see how that goes. but it's different way of thinking about how the trial

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