Why do the deadliest cancers get the least attention?

Research to understand, diagnose, and manage the deadliest cancers, like lung, colorectal, and pancreatic cancers, receives significantly less funding than that for other cancers, such as breast and pediatric cancers. What’s behind this discrepancy?

Lung cancer, for instance, has the highest mortality of all cancers: an estimated 142,670 US deaths in 2019 alone, according to the National Cancer Institute. But the amount of funding raised for lung cancer was only $92 million in 2015.

At the same time, breast cancer caused an estimated 42,260 deaths—about one-third of the number of those who died from lung cancer. But the amount of money raised for breast cancer—$460 million in 2015 alone—dwarfs the amount raised for lung cancer by five-fold.

Why do deadlier cancers get less funding? Are lung, colorectal, and pancreatic cancers less important or less deserving than breast or pediatric cancers? Do the latter merit more attention or urgency? Does comparing one cancer to another even make sense? Or is there more to this than first meets the eye?

Funding doesn’t match ‘burden’

In a 2019 study published in the Journal of the National Comprehensive Cancer Network, researchers at Northwestern University looked at funds raised by nonprofit cancer organizations and compared these with the incidence, mortality, and years of life lost (YLL) for different cancer types. They found only a weak association between higher incidence of a particular cancer and the funding for that cancer. Furthermore, they found “essentially no correlation” between mortality or YLL and the amount of nonprofit funding for any cancer.

“Many common or highly lethal diseases, including lung, colorectal, pancreatic, ovarian, and endometrial cancers, are underfunded relative to their burdens on society,” the authors wrote. “Underfunding may have negative downstream effects on research, novel drug development, and number of FDA drug approvals for poorly funded cancers.”

Indeed, cancers that have less research funding are less likely to have innovative cures. Likewise, cancers that are highly funded are more likely to spur new treatments.

The authors speculated that stigmatized behaviors that are strongly associated with certain underfunded cancers—like smoking and lung cancer or alcohol and liver cancer—make raising money for those cancers more difficult. On the flip side, some of the most well-funded cancer types (breast cancer, leukemia, lymphoma, and pediatric cancers) have no association with stigmatized behaviors.

“The goal of our study was not to divert funding away from any disease but rather to educate the public and augment charitable funding for diseases that do not receive proportionate support. Well-funded [nonprofit organizations] should be applauded for their successes and could collaborate with other organizations to improve funding,” the authors concluded.

‘A considerable mismatch’

Nonprofits aren’t the only source of funds for cancer research, though. The federal government contributes quite a bit, too. (Your tax dollars at work!) But as with nonprofits, government funding favors some cancers over others when death or other factors are taken into account.

A study that compared amounts of research funding from the National Cancer Institute to different metrics of “cancer burden”—including incidence, mortality, and YLL—also revealed “a considerable mismatch between funding levels and burden,” the authors wrote.

“Some cancers are funded at levels far higher than their relative burden suggests (breast cancer, prostate cancer, and leukemia) while other cancers appear underfunded (bladder, esophageal, liver, oral, pancreatic, stomach, and uterine cancers),” they concluded.

These researchers looked at ratios of cancer funding relative to the different metrics of cancer burden. Looking at mortality alone, brain/CNS, breast, cervical, leukemia, and testicular cancers appeared to be overfunded. At the same time, bladder, esophageal, lung, oral, stomach, and uterine cancers were the most consistently underfunded across the different metrics.

Of course, there are different ways to evaluate cancer burden. When looking at incidence, breast cancer has the greatest burden, with an estimated 271,270 new cases in 2019, according to NCI data. When looking at YLL, lung cancer is far and away the greatest with 2,372,000 YLL (even when compared with the second highest: colorectal cancer with 800,000 YLL). In terms of mortality, lung cancer has the greatest burden with 142,670 deaths last year, as we’ve discussed.

“In absolute terms, lung cancer accounts for 32% of cancer deaths while receiving 10% of cancer research funding,” the researchers noted. But why might this be?

“Funding for lung cancer is quite low given its cost, mainly due to a ‘blame the victim’ attitude in which the personal choice to smoke is seen as the direct cause,” they contended. “The levels of funding for liver cancer (2.6% of funding compared to 3.8% of deaths and 3.8% of YLL) and oral cancer (0.5% of funding compared to 1.6% of deaths and 1.8% of YLL) may also be influenced by this ‘blame the victim’ prejudice (Hepatitis B infection and alcoholism contribute to liver cancer risk and chewing tobacco contributes to oral cancer risk).”

How do we fix these discrepancies? “We recommend redistribution from overfunded cancers to underfunded cancers to improve the effectiveness of cancer research funding,” the researchers stated.

Intuitively, that makes sense. Overfunded cancers could apportion some of their research dollars to the underfunded and more deadly cancers. But, is this really the best way to fairly allocate cancer funding?

The ‘utilitarian answer’ may not be the answer

“Although it is plausible that disease funding and donations should be proportionate to some measure of the harm or damage done by a particular disease or specific tumor type, it is not certain that this will in turn result in the greatest benefit. Making this assumption is a straightforward logical error,” argued hematologist-oncologist Vinay Prasad, MD, MPH, in a commentary article in the Journal of the National Comprehensive Cancer Network.

“Research funding ought to maximize the potential absolute risk reduction from research gains, and need not be strictly proportionate to measures of the severity of disease,” added Dr. Prasad, who is an associate professor of medicine at the University of California San Francisco.

If one approached cancer funding in “the most logical and ethical way,” then the best strategy would not be to save the most lives, but to save the most years of life lost as possible. “This is what philosophers call the utilitarian answer. All things being equal, we should fund projects that will give us the most years of quality life back,” he wrote.

But even the “utilitarian answer” isn’t a perfect one, Dr. Prasad noted. Who can guess which research projects will return the greatest dividends in increasing the years of life for patients?

Also, the “utilitarian answer” would require some authority in place to make decisions for distributing research funds more equitably. But then “the most logical and ethical way” to fund cancer research would be one that takes away, or at least oversees, how individuals choose to make charitable contributions.  

“Many donors choose a cause they are affected by, either personally or through family or friends,” wrote the Northwestern University researchers.

And that’s as it should be. So, ideally, appropriate funding of cancer research would somehow balance the personal preferences of donors with getting the most “bang for the buck” in terms of patient life years.

As Dr. Prasad concluded: “Appreciation of this fact may lead to more constructive debates about equitable cancer research funding and donation by tumor type.”