Frontiers

Gregory A. Otterson, MD Medical Director, Thoracic Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute.

Despite the overwhelming statistical data, however, this disease has received relatively poor research funding on the national and international levels.

The National Cancer Institute’s (NCI) Financial Management Branch estimates that in 1993, $173 million dollars was spent on AIDS research. That same year, $211.5 million was spent on breast-cancer research and $92.6 million on lung cancer by the NCI.

Today, this inequity has improved, but by no means completely. In 2003, the NCI spent $263.4 million on AIDS, $548.7 million on breast cancer and $273.5 million on lung cancer1. The American Cancer Society (ACS) estimates that 40,200 people (mostly women) died of breast cancer in 2003. Roughly, this means that NCI spent $13,650 per breast cancer death. Similarly, the ACS estimated 157,200 deaths due to lung cancer in 2003, and the same rough calculation reveals that the NCI spent $1,739 per lung cancer death.

These simplistic calculations are not meant to estimate the worth of a human being or to cry that “my disease” deserves more than “your disease.” But they do raise an important question: Why is lung cancer research so poorly funded?

Other evidence illustrates the problem, too. Consider how many 1 Mile “fun runs” and 5K and 10K runs are held for breast cancer, ovarian cancer and Alzheimer’s disease each year. Few fund-raisers are held for lung cancer. Compare the number of red, pink or yellow ribbons worn by celebrities attending the Academy Awards and other ceremonies with the number of clear ribbons, which symbolize lung cancer.

Why do these disparities exist? I propose four reasons:

Stubbornly poor cure rates. The cure rate—translated as 5-year survival—for lung cancer has changed little in 30 years. From the mid-1970s to the mid- 1990s, the 5-year survival rates for the second, third and fourth leading causes of cancer death— colorectal, breast and prostate— improved from 50 percent to 61 percent, 75 percent to 86 percent, and 67 percent to 96 percent respectively. Lung cancer, on the other hand, went from 12 percent in the 1970s to a mere 15 percent in the 1990s.

True, we have made gains in lung cancer treatment. Today, nearly 40 percent of patients with metastatic lung cancer are alive after one year compared to only 10 percent in the 1970s. And two-year survival is now nearly 15 percent, better than the one-year survival 20 to 30 years ago. In addition, chemotherapy is better tolerated, its side effects are much better controlled, and in general, the quality of life even for those with a terminal diagnosis is demonstrably better than in the past. But improvements in the cure rate have been slow in coming for lung cancer.

Lack of a charismatic spokesperson. Someone such as John Wayne, Rosemary Clooney, or George Harrison could fill this role, but then they died from their disease. Interestingly, even death does not necessarily stop some charismatic spokespeople. Think of Gilda Radner (and her husband Gene Wilder), whose name continues to increase awareness of ovarian cancer, another silent killer.

Embarrassment related to smoking. The lack of a spokesperson is due largely to the third factor, embarrassment related to smoking. There is a sense that, “I brought this on myself.” These notions of guilt, shame and responsibility because a person has smoked are a heavy burden for some patients and families. Patients often feel that there is a moral stain upon their character since they were unable to quit the instrument of their death. The reality, of course, is much more complicated. In 2004, only 40-45 percent of lung cancer patients are current smokers and about 15 percent have never smoked. The remainder have successfully “kicked the habit,” often many decades before their diagnosis.

Low socio-economic status of smokers. This factor is well documented but rarely acknowledged: Smoking is much more prevalent among those with lower socio-economic status. Does this explain why there is less recognition, less media attention, and ultimately less concern by society for those addicted to cigarettes and those who ultimately develop cancer? No clear arrows can be drawn, but the association remains.

What can be done? I believe it’s time to politicize lung cancer. Questions need to be asked and answered. Does the lack of improvement in lung cancer survival from the 1970s to the 1990s reflect a stubborn and deadly disease, or does it reflect a lack of commitment and focus on the part of our funding agencies, academic cancer researchers and politicians?

I believe both are true. It is time to refocus and recommit to this disease and, more importantly, to the patients with this disease. The addictive nature of tobacco and the harm caused by its use calls for stringent regulation of tobacco, but that still has not happened. Here at home, the OSU CCC’s commitment to lung cancer ranges from the concrete— studies are under way of new therapies, delivery methods and chemopreventive agents—to the philosophical. For example, OSU CCC members cannot accept direct research funding from the tobacco industry.

Embarrassment, guilt, shame and blame have no role in medicine. The AIDS community quickly learned this and has effectively communicated it to politicians and decision makers. The lung cancer community— patients, families, health-care workers and researchers—need to take to heart the lessons of the AIDS and breast cancer communities and effect change.

For more about lung cancer, see "The Invisible Cancer."