Beyond the Fight: Why President Biden's Cancer Moonshot Must Include Palliative Care

President Biden recently announced a reboot of the Cancer Moonshot originally launched in 2016 to end cancer as we know it. For clinicians and patients alike, the goals are ambitious: reduce the cancer death rate by at least 50% over the next 25 years and improve the experience of living with and surviving cancer.¹ The initiative proposes to achieve this vision through enhancing prevention and treatment efforts while controlling costs, expanding insurer coverage, and addressing long-standing inequalities. Although many researchers, clinicians, and those affected by cancer welcomed the announcement, an essential element remains lacking. Palliative care is a crucial component of improving the experience of living with and surviving cancer. It is defined as specialized medical care focused on quality of life for patients and their families living with a serious illness, providing relief from the symptoms and stress of the illness.² High-quality palliative care is provided via interdisciplinary teams (physicians, nurses, social workers, chaplains, psychologists, etc) and attends to eight major domains of care, as seen in Figure 1.

FIG 1.

Domains of high-quality palliative care.^3,4 Discussion of patients' goals and values and shared decision making should be included in each domain.

For President Biden, addressing cancer care is more than good policy, it is personal. Having lost his son, Beau, to glioblastoma at the age of 46 years in 2015, he has experienced how cancer can affect the well-being of loved ones and patients. Supporting Americans affected by cancer involves equal attention to the quality of those added years in addition to saving lives. It also involves addressing uncontrolled symptoms, reducing emotional suffering, ameliorating financial and caregiving burdens, and offering skilled communication about what to expect and how to plan. Improving care for patients like Beau requires bolstering funding for palliative care research and clinical services.

Numerous investigations have shown that palliative care helps patients live better and, in some cases, longer. Early integration of palliative care into cancer care has been found to significantly improve quality of life and mood while increasing survival.^5-9 Palliative care has emerged as an essential element of high-quality cancer care, can be accessed at most National Cancer Institute–designated comprehensive cancer centers,¹⁰ and is required for institutional accreditation by the Commission on Cancer.¹¹ If the Cancer Moonshot focuses on prevention, detection, treatment, and cure to the exclusion of quality of life, many patients will lose out on the promise of living well—a goal of high-quality cancer care.

Research strengthens the evidence base of best supportive care and much more of it is needed. This is an essential arm of how we improve the experience of living with and surviving cancer.¹ For our patients with advanced-stage disease, multiple comorbidities, or older age, cutting-edge cancer therapeutics are not enough—palliative care has been shown to be the key component to support quality of life.^5-9 Increased funding to help address the palliative care workforce shortage¹² and for palliative care research is greatly needed. Research addressing racial and ethnic disparities in the receipt of/quality of palliative care for patients with cancer and addressing both clinicians' and the public's misunderstanding and avoidance of palliative care is especially needed.¹³ Currently, the Palliative Care and Hospice Education and Training Act has been reintroduced in the US Senate. It proposes to expand opportunities for interdisciplinary palliative care training and education, implementing an awareness campaign for both patients and clinicians and directing funding toward palliative care research.¹⁴

As palliative care clinicians who take a comprehensive approach to care quality, we affirm the intention of the Cancer Moonshot to address issues of health care inequity. The initiative acknowledges that there are stark inequities in access to cancer screening, diagnostics, and treatment across race, sex, region, and resources.¹ Those in rural areas and individuals from vulnerable populations know the cancer experience to be marked by failures of access, financial distress, and unmet support needs.^15-22 Similar to all other aspects of our health care system, underserved groups experience disparities in both receipt of cancer-directed therapies and referral to palliative care²³ despite the strong evidence base for its benefits. Barriers contributing to this disparity may include the palliative care specialist shortage which is exacerbated in underserved communities,^24,25 implicit bias affecting clinician-patient communication about serious illness,^26,27 and well-earned distrust of the medical establishment among minority patients.^28,29

The Cancer Moonshot has a major opportunity to transform the cancer care experience of all Americans, not only those who happen to be wealthy or live in the right state or neighborhood or are lucky enough to have an oncologist who chooses to collaborate with palliative care teams. The promise that "we can ensure that every community in America—rural, urban, Tribal, and everywhere else—has access to cutting-edge cancer diagnostics, therapeutics, and clinical trials"¹ will ring hollow if patients in those communities who are disproportionately suffering with cancer continue to lack access to palliative care.

How our society talks about cancer continues to be challenging for patients. Palliative care clinicians are often consulted late in the illness course when oncologists feel there is nothing left to offer or when a patient's goals are seen as giving up the fight.^30-32 Such winning and losing language compounds the injury of a cancer diagnosis, implying that patients with advanced illness are somehow losers. We wonder how it will feel for the millions of Americans with Moonshot-era cancer experiences that lose their fight. What will it mean when so many of our patients do not get their moonshot? The Cancer Moonshot provides an opportunity for our society to move beyond the fight and expand our view of what living well with cancer looks like at any stage. Ambitious claims about the reduction of cancer-specific mortality belie the reality that illness, decline, and death are in the cards for every one of us—patient, politician, and clinician. The revitalized Cancer Moonshot has a powerful opportunity to change the public discourse around cancer and acknowledge the full spectrum of human needs during cancer care, including physical, psychological, social, and spiritual needs through enhanced collaboration with palliative care.

Through the Cancer Moonshot, we believe that change is indeed possible for the more than 1.6 million Americans diagnosed with cancer each year.³³ President Biden is directing much-needed energy, focus, and action toward the needs of patients across the cancer spectrum. However, we must also acknowledge the reality of living with cancer—that many patients and their loved ones suffer unnecessarily from pain and other symptoms, families are turned upside down and bankrupted by the costs of cancer care, and many feel abandoned when they appear to be losing their fight with cancer.^22,34-36 As the Biden-Harris administration calls for all hands on deck, we strongly advocate that palliative care researchers and clinicians should be among those hands working to assure optimal cancer care throughout the experience of oncologic illness for every American.

AUTHOR CONTRIBUTIONS

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Beyond the Fight: Why President Biden's Cancer Moonshot Must Include Palliative Care

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.

Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

No potential conflicts of interest were reported.