Approaching a Critical Juncture to Preserve the Oncology Enterprise

Throughout my 25-year career in clinical oncology and translational cancer research, I have frequently encountered financial pressures, whether from fluctuations in National Institutes of Health/National Cancer Institute (NCI) budgets or federal Medicare physician reimbursement cuts. Such challenges have historically posed theoretical risks to the remarkable progress made in the United States in advancing fundamental discoveries in cancer biology and immunology. This progress has been pivotal in developing targeted therapies and cancer immunotherapies, which now significantly extend and improve the lives of countless cancer patients globally. The oncology care delivery system in the US has evolved into one of the highest quality systems worldwide.

However, I cannot recall a period during which this immensely productive clinical oncology and research enterprise faced simultaneous threats to its foundation, as we have observed in the past 4 months. Concerns regarding Medicare, Medicaid, and various hospital-based reimbursement mechanisms are escalating. Although identifying and addressing fraud and abuse are essential, and the system's financial sustainability is paramount, hasty implementation of changes risks unintended detrimental effects. These could include reduced cancer screening and treatment, leading to delays in care or even the substitution of consistent clinical management with haphazard emergency services, ultimately increasing overall costs. As a physician-scientist, witnessing potential risks to the future talent pipeline in academic oncology is deeply concerning. The dramatic and sudden alterations to the NCI Cancer Centers program and its peer review process for NCI designation—effectively changing the rules midgame at the very institutions responsible for deploying 75% or more of the national cancer research and NCI budget—have triggered widespread alarm. It raises a critical question: Does Congress truly grasp the magnitude of what is at stake, and will it act in time to safeguard it?

Encouragingly, some leaders within the US Senate and House of Representatives do recognize the immense value that a productive workforce, coupled with exceptional cancer prevention and timely care, holds for both the health and economic competitiveness of our nation. Although a few billion dollars represent a substantial sum, within the context of the overall federal budget, it is a relatively minor adjustment that nonetheless imperils the future of cancer research. When Ned Sharpless, MD, then the NCI director, aimed to increase the funding payline for R01 grants to the 15th percentile, but budgetary constraints limited it to the 10th percentile, we were disappointed, but we understood and adapted. However, the current proposed NCI budget cuts suggest a fundable threshold of merely the fourth to fifth percentile at best, which would have devastating consequences for the return on investment in discovery, translation, clinical trials, and biotech and pharmaceutical commercialization.

In the clinical realm, proposed reimbursement changes affecting the 340B Drug Discount Program, a cornerstone for subsidizing and supporting high-quality care in eligible disproportionate share hospitals when direct professional billing is insufficient, are equally troubling. Many of us in cancer research and oncology treatment chose these careers despite opportunities for higher salaries, lower tuition costs, or more immediate permanent employment. We have been fortunate to attract the brightest minds to these fields. The question remains whether the Trump Administration and Congress will recognize the favorable cost-benefit model of investing in the biomedical research enterprise. We can only hope for this realization and continue to pursue alternative revenue streams, such as commercialization opportunities, and increasingly rely on our philanthropic supporters and foundations. Our reliance rests on the ongoing deliberations of Congress, particularly the leaders of the appropriations committees in both the Senate and the House. Let us hope they perceive the profound value of this tremendous enterprise, built upon more than 50 years of national investment, which should not be disregarded or deconstructed in a mere year or two. Our system has fostered some of the most effective efforts in cancer prevention, delivered successful cancer treatments, and established robust educational pipelines to replenish the ranks of oncologists and researchers for humanity.